CHARTING A PATH TOWARDS STH ELIMINATION

DeWorm3
CHARTING A PATH TOWARDS STH ELIMINATION
 WELCOME
Welcome to DeWorm3
An estimated 1.5 billion people, representing a
quarter of the world’s population, are infected
with intestinal worms, known as soil-transmitted
helminths (STH)1. These parasites disproportionately
affect disadvantaged populations, particularly
people in impoverished communities living without
access to adequate water and sanitation. People
with heavy or chronic STH infections are at risk of
experiencing significant disease and disability,
particularly children and women of reproductive age. establishing whether the spread of these diseases in
Economic development, improvements in water and specific locations can be stopped and the problem
sanitation, and intermittent targeted mass treatment eliminated. In collaboration with governments,
(deworming) can help prevent the morbidity charities and an international network of universities,
associated with these infections. However, in many a multi-country, community-based trial is underway.
places the reach of these programs is insufficient or DeWorm3 differs from previous initiatives in scale
may need to be continued for the foreseeable future and scope. In sites across Benin, India and Malawi
as infections persist. A fundamental rethink of the not only the children most affected by these
approach to STH infections is needed if we are to infections are being targeted but all members of
develop effective, sustainable and scalable solutions the communities (including adolescents and adults)
to address this enormous public health problem. where these infections occur. DeWorm3 aims to
determine if it is possible to not just control but to
The Natural History Museum, supported by funding eliminate these debilitating infections, removing
from the Bill & Melinda Gates Foundation, launched them from daily life and relegating them to history.
the DeWorm3 project to test a strategy designed
to move beyond the control of these infections, Data collected as part of the DeWorm3 trial are
already shaping how STH and other diseases are
approached globally. We look forward to continued
collaboration with policymakers, organisations and
individuals to achieve the goal of eliminating STH,
changing lives across the world for the better.

Judd Walson
Principal investigator

Judd Walson - Principal investigator

1
World Health Organization (WHO) (2019) Soil-transmitted helminth infections [Online]. Available at:
https://www.who.int/news-room/fact-sheets/detail/soil-transmitted-helminth-infections (Accessed: 10 January 2020).
THE CHALLENGE

STH are transmitted through eggs present infections. Women of reproductive

in the faeces of infected individuals. age and young children with worms
Adult worms live in the intestine, where are at increased risk of malnutrition
thousands of eggs are produced each and anaemia. In addition, these STH
day. In areas where there is open infections also result in lower school
defecation and a lack of access to hygienic attendance and achievement as well as
sanitation, eggs are widely present in the reduced income earning potential when
environment. People unknowingly ingest infected children become adults. The
eggs from contaminated hands and food debilitating effects of worms contribute
that has not been adequately washed. to a cycle of poverty in already deprived
Some worms, such as hookworm, communities.
can also penetrate the skin of people
walking barefoot. Children are especially The current WHO strategy is one of
susceptible as they may be walking or morbidity control, targeting pre-school
playing in contaminated soil. and school-age children, women of
reproductive age, pregnant women and
The four main species of STH— adults in high-risk occupations with repeat
roundworm, whipworm and two treatment of deworming medications2.
species of hookworm—thrive in sub- The strategy has been effective in
Saharan Africa, east and southeast Asia controlling morbidity and spread of the
and Latin America, where people lack disease; however, it is unlikely to break
access to clean water and sanitation transmission of STH. Adults also harbour
is poor.1 While all individuals in some STH infections, particularly hookworm.
communities are at risk of infection, As a result, children are easily re-infected
children and women of reproductive when they return to their households and
age suffer disproportionately from the communities.
negative consequences of these parasite

“STH infections also result in lower school attendance and achievement as well as
reduced income earning potential when infected children become adults.”
DeWorm3:
An International Effort

Without substantial economic development and

improvements to sanitation the current school-based,
targeted strategy supported by drug donation programs
will need to continue for the foreseeable future to control
the negative health effects of these infections.

Using existing tools and novel delivery strategies the

focus of DeWorm3 is to determine whether we can
interrupt the transmission of STH infections sufficiently
to eliminate these diseases.

WHERE TO BEGIN?

The DeWorm3 Project uses a community-wide drug

administration approach to determine whether
deworming both children and adults can begin to disrupt
the STH transmission cycle. We selected sites across
three countries — India, Malawi and Benin — to conduct
community cluster randomized trials comparing the
school-based strategy to community-wide deworming.

Researchers from Imperial College have informed

important aspects of the project’s design. Using data
from previous studies, they have provided evidence-
based estimates of the frequency, duration and scale of
treatment likely to result in transmission interruption. They
have addressed questions including how to interrupt the
infection cycle and how extensive the drug programme
will need to be to suppress STH prevalence, without risk
of bounce back once deworming stops. These analyses
are instrumental to the success of the DeWorm3 project
and any future STH programme guidelines.

2
WHO (2017) Guideline: Preventive Chemotherapy to Control Soil-Transmitted Helminth Infections in At-Risk Population
Groups. Geneva: World Health Organization.
A NEW APPROACH

Trials for the DeWorm3 Project have now begun in Benin,

Malawi and India. Collaborators include the Ministry
of Health, Institut de Recherche Clinique du Bénin “ Study sites have total
populations ranging from

”
and Institut de Recherche pour le Développement
90,000-140,000 people
in Benin; Blantyre Institute for Community Outreach,
London School of Hygiene and Tropical Medicine,
Ministry of Health and Ministry of Education in Malawi;
and Christian Medical College, Vellore in India. These drug administration. A random sample of individuals
strategic partners have established in-country research in each site was asked to provide stool samples to
sites. Each site has unique epidemiological, cultural, determine the baseline STH infection status in each
socio-economic and geographical differences that will area. These individuals have been asked to continue
enable the study team to determine which factors are providing stool samples annually and again two years
critical to the interruption of STH transmission. after the trial concludes to assess the rate of change of
STH prevalence in each site.
We began by conducting a census at each of the
three study sites to register all residents—more Each study involves a population of over 80,000 people
than 370,000 people—and to assess relevant STH divided into 40 total clusters. Clusters are randomized
transmission factors such as access to clean water to receive either the current WHO approach providing
and sanitation, recent deworming and other key deworming medication to school-aged children, while
demographic characteristics. Using an electronic other clusters receive community-wide deworming
data collection system developed with the LSHTM across all ages. This two-level approach will continue
Data Support Unit, study communities have been for three years. Once this treatment is complete,
mapped in detail, including the coordinates of every no deworming will occur for two years, after which
household. This allows the study team to monitor the prevalence of STH infection at each site will be
the progress of treatment in real-time as we conduct examined to assess success.

MAKING A BIG IMPACT QUICKLY

It can take more than a decade for the results of trials

such as this to be implemented at scale and supported
by policy. The DeWorm3 trials aim to bridge this “know-
do” gap by incorporating implementation science
research to contextualize the clinical research findings.
Collaborators at each of the sites, in collaboration with
the Global Health Implementation Program at the
University of Washington in Seattle (USA) will describe
the implementation environment and conduct
research such as stakeholder mapping, qualitative
interviews and economic evaluations to identify
effective strategies to scale-up and sustain community-
wide deworming programs efficiently. We believe that
these data will help policymakers and implementers
deliver high-quality, effective programmes across all
affected countries.
FUTURE OUTLOOK

The DeWorm3 Project is bringing rigorous research We look forward to continued collaboration with
at scale to address an issue of global public health communities, governments, multilaterals, non-profits
concern. To date, the project has been successful in and individuals as we seek to address one of the most
achieving remarkably consistent and high coverage of common and debilitating human infections across
drug delivery across the study sites. The data collected the globe.
as part of the trial and the associated implementation
science research are already shaping how MDA for
STH and for other diseases is approached globally.
DEAN JAMISON explains the move from control to elimination

In 2013, The Lancet published the report of its drug administrations (MDAs) for control of helminthic
Commission on investing in health, named Global infection in recent years. However, the current focus
Health 2035, in which it argued that a ‘grand on deworming children rather than both children and
convergence’ on infectious disease was technically adults means in many settings, the cycle of infection
and financially feasible. By aligning health investments, may never be broken.
it suggested country governments and donors could
reduce avoidable infectious, maternal and child DeWorm3 is an opportunity for us to test the idea that
deaths to universally low levels in both low-income we might one day actually eliminate these infections—
and lower middle-income countries. in particular Ascaris lumbricoides (roundworm),
hookworm, and Trichuris trichiura,(whipworm). By
In the case of STH infections Global Health 2035 providing a cost-effective solution for the most
identified deworming as a highly cost-effective vulnerable populations, community-wide MDAs offer
intervention, and suggested five years as an impactful the potential to break the deadlock, over a short
timeframe in which to operate such an intervention. period of time, and thereby eliminate future drug
A subsequent report of the Commission, in 2018 expenditure.
reported an impressive 8.3% per year increase in mass

REFERENCES

Jamison, D.T., Summers, L.H., Alleyne, G., Arrow, K.J., Berkley, S., Binagwaho, A., Bustreo, F., et al. (2013). Global
Health 2035: A world converging within a generation, The Lancet, 382 (9908), p1898–1955. https://doi.org/10.1016/
s0140-6736(13)62105-4.

Watkins, D.A., Yamey, G., Schäferhoff, M., Adeyi, O., Alleyne, G., Alwan, A., Berkley, S., et al. (2018). Alma-Ata at 40
years: reflections from The Lancet Commission on Investing in Health, The Lancet, 392 (10156), p1434–60. https://
doi.org/10.1016/s0140-6736(18)32389-4.

Anderson, R.M. and May, R.M. (1991). Infectious Diseases of Humans. Oxford University Press, p.478-484, 517-529.
NILANTHI DE SILVA explains how WHO might use the findings of DeWorm3
Professor of Parasitology at the University of Kelaniya, Sri Lanka, serves on the World Health
Organisation’s Expert Advisory Panel on Parasitic Diseases and is a member of the DeWorm3
Strategic Advisory Group.

The World Health Organization (WHO) If DeWorm3 can demonstrate that transmission can
recommendations to combat STH infections currently be interrupted through deworming programmes
focus on control and reduction of morbidity, in the that target the entire community rather than selected
knowledge that deworming is known to dramatically populations, and that this is also programmatically
reduce the number of adult worms, and therefore to feasible, that would lead to a major shift in WHO
reduce the risk of illness such as anaemia, intestinal recommendations to member states. A time-bound
obstruction, dysentery and more. target that requires periodic deworming for a limited
number of years, followed by cessation of the
However, because environmental contamination deworming programme, will always be the preferred
and re-infection are so common, deworming needs option. But whatever the results from DeWorm3,
to be repeated every four to 12 months, to keep even if they indicate interruption of STH transmission
the worm count low. With the current strategy of through mass deworming alone is not really feasible,
targeting only at-risk groups, it is inevitable that the data generated will certainly help to fill current
environmental contamination and re-infection will gaps in knowledge, helping WHO to make better,
continue. Therefore, the need for periodic, large-scale more evidence-based recommendations.
deworming will also continue, as will the risk of donor
fatigue or anthelmintic resistance.

“ deworming is known to dramatically

reduce the number of adult worms,
and therefore to reduce the risk of
illness such as anaemia, intestinal
obstruction, dysentery and more.
”
KHUMBO KALUA describes the census process in Malawi
Principal Investigator for the Malawi DeWorm3 site researches neglected tropical diseases,
focusing on trachoma, schistosomiasis and STH

Conducting a census is no easy task at the best of Once all households in the location had been visited
times. In Malawi we faced many obstacles, including and information on household members’ age, sex,
unseasonably heavy rainfall. We also began our education and toilet access had been collected, the
DeWorm3 efforts during farming season, when many teams reported back to the office to meticulously
families were already out in their fields. We knew we upload data from the consent forms—and to make
had many households to visit and because many note of all the households we would need to revisit!
people were not at home, we often needed to visit It was a monumental task that could not have been
households several times to ensure every person was achieved without the tireless work of our staff and
reached. volunteers.

We began by identifying 40 locations in the study

site and employed 10 teams of four to visit each
site. These teams were equipped with a Samsung
Galaxy J2 phone, log forms, consent forms, a pen, a
bag for carrying supplies and a vehicle. Leaving the
office at 7am each day, they began by meeting a
village volunteer to guide them around the various
households at their location. As was custom, our teams
always started at the chief’s house as a way to ensure
community-leader buy-in. These volunteers also acted
as a witness if there was no-one literate over the age of
16 living at the address to sign the consent form.
MOUDACHIROU IBIKOUNLÉ
talks about mass drug administration (MDA) in Benin.
Principal Investigator for the Benin DeWorm3 site; neglected tropical disease research
focuses on lymphatic filariasis, schistosomiasis and STH control and elimination.

Several successful mass drug administration (MDA) work smoothly, through what’s known as sensitisation.
treatments for lymphatic filariasis, caused by a thread We’ve identified people who can help influence the
like worm, have been carried out in Benin. Prior to community to accept this approach and therefore
DeWorm3, there have been as many as six rounds of help ensure consistent data collection between the
MDA in the Comé district providing a good foundation community clusters.
for the project trials.
Sensitisation activities are jointly led by an advisory
Although the Comé community is familiar with board and the project core team. The board is made up
deworming, the challenge of the DeWorm3 project of local authorities, traditional leaders and local health
will be to manage the two-level approach within the centre managers. Together the teams help prepare
same community: the one that works across many communities for the census, trial monitoring and drug
ages, and the one focused on children. We’ve sought administration. This might involve broadcasts on local
help from all levels of village administration to make it radio, in the churches or in the mosques.
HOW CAN SENSITISATION ENCOURAGE PEOPLE
TO TAKE PART IN THE TRIAL?

Moudachirou Ibikounlé and Adrian Luty, the Benin site

principal investigators, have experience in preparing,
or sensitising, their local communities to large-scale CHORUS
treatment campaigns. Their efforts ensure the required
number of individuals across a large age range agree
Cette mauvaise maladie
to take medication, and in some cases provide urine On doit éliminer.
and stool samples, during the trial period.
On doit se faire soigner (x3)
To help launch the Benin DeWorm3 project, they
worked with a local youth group, creating an awareness Dans tout Comé
song that was launched at a community event in front Dans tout le Benin
of a live crowd. The chorus says, ‘we need to eliminate’
and ‘we need to get treatment’ while the main lyrics
talk about the DeWorm3 project, the effects intestinal
worms may have on people’s health and urges English translation:
people to listen to experts for a better future. The
This nasty sickness
piece was so well received that it was professionally
recorded by the youth group members and is now We must eliminate.
regularly played across Comé district. Feedback
from community members revealed that it has led to We need to get treated (x3)
increased education, especially among teenagers,
In the whole of Comé
about intestinal worms and the aims of the deworming
campaign. In the whole of Benin

Above: Members of Carrefour Jeunesse

Comé performing the DeWorm3 song
at a community event.
SITARA SR AJJAMPUR talks about parasite survey techniques in India
Principal Investigator for the India DeWorm3 site, researches diarrheal diseases and
oversees a busy parasitology diagnostics laboratory.

Collecting and examining stools is how we assess the

“
number of worms in a population. For the DeWorm3
trial in India these are assessed at Christian Medical
More than
College (CMC), Vellore and at a “field lab” in Jawadhu 100 samples screened
Hills.

Once a participant has been recorded on the census

each day
”
and selected for a survey, they are asked if they are
willing to provide stool samples. They are then given this scale (more than 100 samples screened each day)
a questionnaire and a home stool collection kit with a we rely on a large number of well-trained technical
unique barcode. These are later scanned and carefully staff. Stool sampling is critical to the Deworm3 project
transported in a cooler box to one of our laboratories. objectives, particularly in understanding prevalence of
each STH species and determining if STH transmission
Rapid and appropriate sample transport is vital to has been successfully interrupted.
the success of a project, as is effective and precise
examination. Once the samples reach the lab they are WHO 2017. Guideline: Preventive Chemotherapy
scanned, then screened. We test the samples for soil- to Control Soil-Transmitted Helminth Infections in
transmitted helminths and other helminth ova, and At-Risk Population Groups. Geneva: World Health
meticulously record anything we find. With a study of Organization.
CONCLUSION
The Natural History Museum (NHM) is proud to
have been invited to develop and lead DeWorm3
on behalf of the Bill & Melinda Gates Foundation.
United towards eliminating infections of intestinal
worms across the world, DeWorm3 has become
more than the sum of its parts yet firmly focused on its
goals. DeWorm3 focuses on sites in Benin, India and
Malawi, but its partnerships and tireless collaborators
span the globe; representing expertise in clinical
trials, public health, epidemiology, modelling, social loss to an ever-growing human population we must
sciences, molecular biology, diagnostics and many respond collaboratively and effectively if we are to
other disciplines. secure a future where both people and planet thrive.
DeWorm3 is a prime example of our commitment
Over 300 people are involved in delivering this to attaining the United Nations Sustainable
investment. I applaud the PIs and their teams Development Goals – especially SDG 3 ‘good health
across all the institutions delivering and supporting and well-being’.
DeWorm3. To date the project has been an
unprecedented success with sustained, and even The NHM’s science has long focused on agents
improved performance across the board. Without of disease and how they interact in the natural
the generous drug donations from GlaxoSmithKline environment; whether identifying parasites or
DeWorm3 would not be able to implement such an vectors, uncovering parasite and pathogen life
enormous clinical trial and we thank them for help in cycles, revealing patterns of evolutionary radiation
treating over 300,000 people for STH. or ecological dispersal, or engaging with elimination
and control programmes. The NHM’s 80 million
In January 2020 the NHM launched its new strategy natural history specimens represent a global
in response to a growing planetary emergency. From resource tracking global change. We host over
climate change, pollution, habitat and biodiversity 15,000 science visitor research days, loan over
40,000 items and engage with well over 5 million
visitors to our galleries each year. Our digital reach is
global and growing via the internet, social and other
media. Our new collections enable genetic, genomic
and environmental analyses, drive discovery and
help track change in a rapidly changing world.

What we collect and share today — samples,

specimens, data, information, knowledge — will
help shape our tomorrow. DeWorm3 is providing a
platform for positive change.

Tim Littlewood
Executive Director of Science, NHM

Tim Littlewood
Executive Director of Science, NHM
 CHARTING A PATH TOWARDS STH ELIMINATION

@deworm3_NHM www.nhm.ac.uk/deworm3
A SPECIAL THANK YOU TO ALL OF OUR COLLABORATORS