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Estimating Intrinsic Hookworm Transmission Intensity in Areas with Past Mass Drug Administration to Control Lymphatic Filariasis Marleen Werkman1,2*, James E

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Estimating Intrinsic Hookworm Transmission Intensity in Areas with Past Mass Drug Administration to Control Lymphatic Filariasis Marleen Werkman1,2*, James E Werkman et al. Parasites & Vectors (2017) 10:254 DOI 10.1186/s13071-017-2177-6 RESEARCH Open Access The past matters: estimating intrinsic hookworm transmission intensity in areas with past mass drug administration to control lymphatic filariasis Marleen Werkman1,2*, James E. Truscott1,2, Jaspreet Toor1, James E. Wright1,2 and Roy M. Anderson1,2 Abstract Background: Current WHO guidelines for soil-transmitted helminth (STH) control focus on mass drug administration (MDA) targeting preschool-aged (pre-SAC) and school-aged children (SAC), with the goal of eliminating STH as a public health problem amongst children. Recently, attention and funding has turned towards the question whether MDA alone can result in the interruption of transmission for STH. The lymphatic filariasis (LF) elimination programme, have been successful in reaching whole communities. There is the possibility of building upon the infrastructure created for these LF-programmes to enhance the control of STH. Using hookworm as an example, we explore what further MDA coverage might be required to induce interruption of transmission for hookworm in the wake of a successful LF programme. Results: Analyses based on the model of STH transmission and MDA impact predict the effects of previous LF control by MDA over five years, on a defined baseline prevalence of STH in an area with a defined transmission intensity (the basic reproductive number R0). If the LF MDA programme achieved a high coverage (70, 70 and 60% for pre-SAC, SAC and adults, respectively) we expect that in communities with a hookworm prevalence of 15%, after 5 years of LF control, the intrinsic R0 value in that setting is 2.47. By contrast, if lower LF coverages were achieved (40, 40 and 30% for pre-SAC, SAC and adults, respectively), with the same prevalence of 15% at baseline (after 5 years of LF MDA), the intrinsic hookworm R0 value is predicted to be 1.67. The intrinsic R0 value has a large effect on the expected successes of follow-up STH programmes post LF MDA. Consequently, the outcomes of identical programmes may differ between these communities. Conclusion: To design the optimal MDA intervention to eliminate STH infections, it is vital to have information on historical MDA programmes and baseline prevalence to estimate the intrinsic transmission intensity for the defined setting (R0). The baseline prevalence alone is not sufficient to inform policy for the control of STH, post cessation of LF MDA, since this will be highly dependent on the intensity and effectiveness of past programmes and the intrinsic transmission intensity of the dominant STH species in any given setting. Keywords: Soil-transmitted helminths, Lymphatic filariasis, Mass drug administration impact, Interrupting transmission, Transmission models * Correspondence: [email protected] 1London Centre for Neglected Tropical Disease Research (LCNTDR), Department of Infectious Disease Epidemiology, St. Mary’s Campus, Imperial College London, London W2 1PG, United Kingdom 2The DeWorm3 Project, The Natural History Museum of London, London SW7 5BD, United Kingdom © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Werkman et al. Parasites & Vectors (2017) 10:254 Page 2 of 10 Background investigating the possibility of STH transmission interrup- Neglected tropical diseases (NTDs) affect some of the tion through MDA [5, 14, 17]. The current momentum poorest populations in the world [1]. Over the past towards achieving NTD elimination provides an oppor- decade many initiatives have been started to reduce tunity to investigate whether MDA alone can interrupt morbidity induced by NTDs in endemic regions [2]. the transmission of STH. For example, in 2000, the Global Alliance to Eliminate For the STH species, female worms need to find a Lymphatic Filariasis (GAELF) was formed, whose aim male within the host with whom to mate to produce is to achieve elimination of transmission for lymphatic fertile offspring. These exit the host as eggs or larvae filariasis (LF) by 2020 [3]. In 2014, 73 countries were and perpetuate the life-cycle. As such, there exists, within identified as needing mass drug administration (MDA) to the host population, a critical mean adult parasite density control LF. To achieve elimination, community-wide pro- for effective sexual reproduction below which the parasite grammes providing albendazole in combination with iver- population cannot be sustained [18–21]. The inclusion of mectin or diethylcarbamazine, were started in 62 of these this ‘mating function’ within mathematical models of countries. These programmes have been very successful, parasite transmission and MDA creates three possible with 18 of these countries now moving to post-MDA equilibria for the mean worm burden, two are stable surveillance once the prevalence of LF had dropped to 1% (endemic infection and extinction) separated by an un- or less [3, 4]. Of the remaining countries, eleven still stable state which is defined as a “breakpoint in trans- needed to start their MDA programme in 2014 [4]. mission” [14, 20]. When this breakpoint is crossed, the LF is frequently co-endemic with soil transmitted parasite population moves towards the stable state of helminths (STH) [5]. These intestinal parasites of extinction in the absence of any immigration of infec- humans are endemic in sub-Saharan Africa, Asia and tion into the human population. No further treatment parts of South America [6]. They comprise of three is required once the breakpoint is crossed. main species, i.e. Ascaris lumbricoides (round worm), Current WHO treatment guidelines for STH are un- Trichuris trichuria (whipworm) and two hookworm spe- likely to result in the interruption of transmission, as cies, Necator americanus and Ancylostoma duodenale. the adult population is not targeted and they create These parasites are transmitted between hosts through reservoirs of infection [21–24]. This is especially true the excretion of eggs or larvae into the environment. for hookworm (Necator americanus)whereamovefrom Re-infection occurs either orally (Ascaris and Trichuris) targeted strategies to community-wide treatment is im- or through the skin (hookworm) [7]. Globally, they are perative to achieve elimination, as the highest prevalence estimated to infect 1.45 billion people, resulting in ap- and intensities of infection are typically found in the adult proximately 5 million years lived with disability [8]. population [11, 12, 25, 26]. Chemotherapeutic treatments exist for all STH species, The success of interventions aimed at transmission although with varying efficacies for the drugs of choice elimination will be highly dependent on the transmission [9, 10]. These are good for hookworm and Ascaris intensity in a given setting, as measured by the basic or in- lumbricoides but less so for Trichuris trichuria.Current trinsic reproductive number, R0. With the use of country- World Health Organisation (WHO) guidelines regard- and site-specific cross-sectional treatment coverage and ing STH focus on drug treatment for preschool-aged chil- hookworm prevalence data it is possible to use mathemat- dren (Pre-SAC: 2–4 year olds) and school-aged children ical models of parasite transmission dynamics, to define (SAC: 5–14 year olds), with the goal of eliminating STH what level of coverage will result in transmission elimin- as a public health problem amongst children [10]. Re- ation in defined transmission intensity settings. These cently, attention and research have started to focus on the models can help inform policy makers on what treatment broader question of whether MDA programmes alone frequency, coverage levels and programme durations will could potentially break the infection cycle for STH para- be necessary to achieve this goal. sites, eventually resulting in parasite elimination [11–14]. The baseline prevalence is highly dependent on the Areas where LF elimination programmes are active are transmission intensity and pattern of parasite aggrega- likely to have achieved a reduction in both prevalence and tion within the human host population, but it is also af- intensity of STH through annual community-wide MDA fected by the past history of MDA treatment programmes. [5, 14, 15] involving the use of albendazole and mebenda- In this paper, we investigate the impact of LF MDA treat- zole, both of which are active against all three major STH ment on the prevalence of hookworm infection, and inves- parasites though with varying efficacy [7, 9, 16]. The po- tigate what regimens of MDA coverage in a subsequent tential for building upon the existing infrastructure for elimination study once LF treatment has ceased will be community-wide MDA programmes in these regions, necessary to achieve the interruption of hookworm combined with the projected reduction in STH prevalence transmission. It is important to note that LF community- and intensity, makes these areas particularly suitable for based coverage is rarely recorded accurately so some Werkman et al. Parasites & Vectors (2017) 10:254 Page 3 of 10 exploration of a range of options about the past history of The parameter σ is the reciprocal of the mean life span MDA coverage is essential in a given location. of an adult hookworm. The parameter Λ defines the force of infection of individuals of age a as, and is de- Methods fined as: We assume a scenario where LF programmes have been Λð Þ¼ ð Þβð Þ active for five consecutive years with a follow-up a L t a programme of three years to treat hookworm infections. where β(a) represents the contact rate of a host with The impact of two LF coverage settings on the preva- age a with the environmental reservoir (Table 1).
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