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Published on: August 22, 2012
Population deworming every 6 months with albendazole in 1 million pre-school children in North India: DEVTA, a
Shally Awasthi1, Richard Peto, Simon Read
1King George's Medical University, Lucknow, Uttar Pradesh, India. shally07@gmail.com
Insights
Regular deworming using albendazole showed minimal impact on mortality rates in north Indian preschool children. The study found no significant reduction in deaths, despite high compliance with the treatment.
Area of Science:
- Public Health
- Pediatrics
- Infectious Disease Epidemiology
Background:
- North India faces significant challenges with underweight preschool children and high rates of intestinal worm infections.
- Mortality rates among children aged 1.0-6.0 years in the region are estimated at 2-3%.
- The Integrated Child Development Service (ICDS) infrastructure was utilized to evaluate the impact of deworming interventions.
Purpose of the Study:
- To assess the effect of regular deworming with albendazole on mortality in preschool children in north India.
- To evaluate the feasibility of using existing ICDS infrastructure for delivering child health interventions.
Main Methods:
- A cluster-randomised trial involving over 1 million children across 8338 ICDS centers in 72 administrative blocks.
- Children received 6-monthly treatments of vitamin A, albendazole, both, or neither (control) over 5 years.
- Mortality data was collected through 6-monthly monitoring of all centers; faecal samples and child weights were assessed in a subset.
Main Results:
- Albendazole compliance was high at 86%, with a reduction in nematode egg prevalence from 36% to 16% in treated areas.
- No significant difference in mortality rates was observed between the albendazole group (3.00 deaths/center) and the control group (3.16 deaths/center).
- Weight-for-age measurements also showed no significant improvement in children receiving albendazole compared to controls.
Conclusions:
- Regular deworming with albendazole had a minimal effect on preschool child mortality in this lightly infected population.
- The ICDS infrastructure is a viable and sustainable platform for delivering child health interventions over extended periods at low cost.
- Targeted deworming strategies may be more effective in areas with higher worm burdens.
Background:
In north India many pre-school children are underweight, many have intestinal worms, and 2-3% die at ages 1·0-6·0 years. We used the state-wide Integrated Child Development Service (ICDS) infrastructure to help to assess any effects of regular deworming on mortality.
Methods:
Participants in this cluster-randomised study were children in catchment areas of 8338 ICDS-staffed village child-care centres (under-5 population 1 million) in 72 administrative blocks. Groups of four neighbouring blocks were cluster-randomly allocated in Oxford between 6-monthly vitamin A (retinol capsule of 200,000 IU retinyl acetate in oil, to be cut and dripped into the child's mouth every 6 months), albendazole (400 mg tablet every 6 months), both, or neither (open control). Analyses of albendazole effects are by block (36 vs 36 clusters). The study spanned 5 calendar years, with 11 6-monthly mass-treatment days for all children then aged 6-72 months. Annually, one centre per block was randomly selected and visited by a study team 1-5 months after any trial deworming to sample faeces (for presence of worm eggs, reliably assessed only after mid-study), weigh children, and interview caregivers. Separately, all 8338 centres were visited every 6 months to monitor pre-school deaths (100,000 visits, 25,000 deaths at age 1·0-6·0 years [the primary outcome]). This trial is registered at ClinicalTrials.gov, NCT00222547.
Findings:
Estimated compliance with 6-monthly albendazole was 86%. Among 2589 versus 2576 children surveyed during the second half of the study, nematode egg prevalence was 16% versus 36%, and most infection was light. After at least 2 years of treatment, weight at ages 3·0-6·0 years (standardised to age 4·0 years, 50% male) was 12·72 kg albendazole versus 12·68 kg control (difference 0·04 kg, 95% CI -0·14 to 0·21, p=0·66). Comparing the 36 albendazole-allocated versus 36 control blocks in analyses of the primary outcome, deaths per child-care centre at ages 1·0-6·0 years during the 5-year study were 3·00 (SE 0·07) albendazole versus 3·16 (SE 0·09) control, difference 0·16 (SE 0·11, mortality ratio 0·95, 95% CI 0·89 to 1·02, p=0·16), suggesting absolute risks of dying between ages 1·0 and 6·0 years of roughly 2·5% albendazole versus 2·6% control. No specific cause of death was significantly affected.
Interpretation:
Existing ICDS village staff can be organised to deliver simple pre-school interventions sustainably for many years at low cost, but regular deworming had little effect on mortality in this lightly infected pre-school population.
Funding:
UK Medical Research Council, USAID, World Bank (albendazole donated by GlaxoSmithKline).
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