Equitable control of schistosomiasis and helminthiasis.

Over the past decade, the continued high prevalence of some neglected tropical diseases (NTDs) has necessitated a revision of where and what kind of intensive control interventions are needed and what the associated targets are. Set within a global strategy of preventive chemotherapy, as endorsed by WHO, the frontline public health method is routine co-administration by mass drug administration (MDA), of the anthelmintics praziquantel against schistosomiasis and albendazole against soiltransmitted helminth iasis. In 2001, an ambitious target was set within resolution 54.19 of the World Health Assembly to attain regular treatment coverage of at least 75% in all school-age children at risk of morbidity. With noted progress falling short of this target by 2010, in January, 2012, several substantial pledges and commitments were made at the London Declaration on NTDs with an additional World Health Assembly resolution 65.21, and both called for intensifi cation of eff orts to better rally resources and to ensure an adequate provision of medications. In The Lancet Infectious Diseases, Nathan Lo and colleagues show that striving towards 75% coverage should now be considered as the minimum standard of care in those communities targeted or deemed eligible for praziquantel and albendazole treatment. They describe novel cost-eff ectiveness analyses of current MDA strategies, based on infection prevalence thresholds to explore putative outcomes of alternative prevalence thresholds as summed over a period of 5 years, assuming 75% treatment coverage. Most interestingly, they show that, if 21·3% of the population shifted to integrated treatment with praziquantel and albendazole, programme synergies would lead to a 40% reduction in implementation costs (as noted in the Article’s appendix). Moreover, their analyses show annual preventive chemotherapy against schistosomiasis to be highly cost-eff ective in treatment of school-aged children at a prevalence of 5% (95% uncertainty interval [UI] 1·7–5·2; current guidelines state 50%) and of the entire community at 15% (7·3–18·5). Annual MDA against soil-transmitted helminthiasis was highly costeff ective in treatment of school-aged children at a prevalence of 20% (95% UI 5·4–30·5%; current guidelines state 20%) and for the entire community at 60% (35·3–85·1). Furthermore, Lo and colleagues show that earlier approaches have not improved equity of access to treatment. Nor would these lead to substantial disability-adjusted life-years averted. By investigation of the diff erent scenarios, they surmise that much lower prevalence thresholds than WHO norms are more sensible. These could be used at international and national levels. However, whether these new norms for control eff orts are entirely practical is not yet clear, because if their advice was closely followed, overestimation of the bottlenecks and strictures in logistics that need to be overcome in this new logical chain of events is likely. Without doubt, more information on best implementation strategies is needed to sensibly guide its transition and application such that expanded access is not counterproductive. Foremost, dramatic change is needed in our appraisal of these diseases by reducing existing barriers to expansion of treatment, irrespective of age, sex, and disability. Using their analytical framework, Lo and colleagues estimate that treatment needs for Africa are six times higher than current guidelines for praziquantel and two times higher for albendazole. Thus, the consequences for country programming are immense; the MDA strategies might prove to be cost-eff ective, but the involved total budgets and other investments needed will be substantial in absolute terms for each country involved. Implementation of the suggested framework is a major undertaking, in view of the paucity of resources in other priority areas within NTD programmes and other health domains. From a budgetary perspective, a realistic limited budget might actually facilitate up-scaled, stepwise implementation and prevent rejection as unrealistic in real life. In their analyses, Lo and colleagues used county-specifi c aff ordability standards related to their available national income. In all scenarios, increased drug subsidies and donations from pharmaceutical companies, strong political will, increased logistical support, and improved epidemiological surveillance to monitor for drug resistance are needed. At lower prevalence levels, the at-risk vulnerable populations may be living in poverty and be harder to reach and lower compliance will lead to lower returns. Additionally, Lo and colleagues note the extra eff ort and resources needed nationally Lancet Infect Dis 2016