Download Community-Based Interventions for the Prevention and Control of

Community-Based Interventions for the
Prevention and Control of Infectious
Diseases of Poverty (IDoP)
Rehana A Salam, Hasina Maredia, Imama Naqvi
Zohra S Lassi, Zulfiqar A Bhutta
Division of Women and Child Health
The Aga Khan University
13 December 2012
Infectious diseases of Poverty
 One of the Millennium Development Goals has underscored the need
for combating HIV/AIDS, malaria, tuberculosis and other diseases.
 Other infectious diseases, by default, have slipped into a ‘neglected’
category. These include most tropical diseases, such as Chagas disease,
dengue, human African trypanosomiasis, leishmaniasis, leprosy,
lymphatic filariasis, schistosomiasis, onchocerciasis etc.
 Given their epidemiology and nature of disease, these infectious
diseases are collectively known as ‘infectious diseases of poverty’.
Infectious diseases of Poverty
 Tuberculosis, malaria and HIV/AIDS accounts for nearly 18% of the
disease burden in the poorest countries.
 One billion people living in low-income countries, comprising 1/6th of
the world’s population, are infected with one or more neglected tropical
disease (NTDs).
 More than 70% of the population affected by NTDs are from low-income
and lower middle-income countries.
 The majority of those affected live in sub-Saharan Africa, where it is
estimated that more than 90% of the total impact of death and disability
caused by NTDs.
WHO. Neglected tropical diseases. 2006
Infectious diseases of Poverty
 The adverse impact of these infectious diseases is the most severe
among the poorest people, who have limited material, physical and
financial resources to draw from and limited or no access to health care.
 Various social determinants also compound the issue. These are areas
where people have no political voice, gender dilemmas, unemployment,
illiteracy, poor nutrition, indoor air pollution and lack of access to proper
sanitation and health education.
 The very fact that the diseases exists among the most deprived, has led
them to be ignored by majority of the institutions.
Rationale and Objective
 A large proportion of infectious diseases are entirely avoidable or
treatable with existing interventions.
 However, the delivery of those interventions to affected populations has
proven very difficult due to weak health system and infrastructure in
many developing countries.
 Thus there is a need to shift focus from institutional care delivery to
community platforms for improved accessibility.
 The objective of this review was to generate evidences from the
evaluation of the effectiveness of community-based interventions for
preventing and controlling IDoP.
CONCEPTUAL FRAMEWORK FOR ICOMMUNITY BASED INTERVENTIONS FOR IDOP
Objectives
Inputs
Process
Outputs
Impacts
Health care delivery facilitated and directed by communities
Training of CHWs/volunteers
Capacity Building
COMMUNITY BASED INTERVENTIONS
Tuberculosis
Malaria
Community
Mobilization
Education & Training
Removal of Financial
Barriers
Preventive and
health promotion
interventions
Curative
interventions
Referral to health
facility
HIV/AIDS
Pneumonia
NTDs
Information and empowerment for communication
and change (IECC)
Support groups
Mass media
Care seeking
Identification of danger signs and complications
Conditional cash transfers
Vouchers
Pay for performance
Antibiotics for case management of pneumonia
Financial incentives
Preventive and health
promotive
Environmental
modification
Sanitation
Vaccination
Health education
Curative and
rehabilitative
Diagnostics
Medicine or drugs
Rehabilitation
Referral for early diagnosis & treatment initiation
Referrals to non-complaints and complicated cases
HOUSEHOLD
•Increased knowledge
and recognition
•Change in Behavior
•Improved care-seeking
OTHER
OUTCOMES:
Improved KAP
Improved
Coverage
Improved Access
Cost effective care
Reduced Inequity
COMMUNITY
•Implementation
Community ownership
•Efficiency
•Quality of Care
•Early Detection and
Management
ENVIRONMENT
•Sustainability
•Improved Environment
•Increased Uptake
HEALTH
OUTCOMES:
Reduction in IDoP
Prevalence
Morbidity
&
Mortality
Methods
Criteria for considering studies for this systematic review
Types of interventions
 All available published and unpublished paper/reports on the impact of
community-based strategies on preventing and controlling IDoP.
 IDoP included malaria, tuberculosis, HIV/AIDS, Neglected Tropical
Diseases (NTDs) (i.e., dengue, trachoma, leprosy, chagas disease,
leishmaniasis, schistosomiasis, and the helminth infections including
hookworm, ascariasis, etc.) and childhood infectious diseases.
 We defined a ‘community-based intervention’ as one which is delivered
by any person within the community, including health care personnel or
lay individuals, and implemented locally at the woman’s home, village or
defined community, but not in a health facility.
 The control received their usual training.
Methods
Criteria for considering studies for this systematic review
Types of studies
 Randomized, quasi-randomized and before/after studies.
Inclusion criteria
 Studies were included if (a) the outcomes considered were those related
to infectious diseases of poverty and (b) studies delivered community
based interventions.
 The main comparisons were between community-based prevention and
control of IDoP compared to no intervention or routine care.
Methods
Data extraction, data analysis and risk of bias assessment
 The abstracts were screened by two authors to identify studies
adhering to the objectives. Each study was double data abstracted into
a standardized form.
 Statistical analyses were performed on the Review Manager software.
 The Cochrane methods were used for risk of bias assessment.
Tuberculosis
 Every year about 9 million people develop tuberculosis globally
and over 2 million die of it.
 The South-East Asia region holds 40% of the global tuberculosis
burden.
 Over 95% of TB deaths occur in LMICs, and it is among the top
three causes of death for women aged 15 to 44 years.
 In recent years there has been a reappearance of TB further
challenged by its changing epidemiology, related to the
emergence of HIV infection.
Tuberculosis
Cure rates
Tuberculosis
Outcome
Cure rates
TB treatment success
TB treatment completion
TB detection
Latent TB detection
Adherence to treatment
Community Based Interventions
RR 1.14 (95% CI: 1.03,1.26)
RR 1.53 (95% CI: 0.97,2.42)
RR 1.09 (95% CI: 0.97,1.23)
RR 2.56 (95% CI: 1.14,5.74)
RR 2.76 (95% CI: 1.64,4.67)
RR 1.86 (95% CI: 1.27,2.74)
Malaria
 Malaria dates back to over 4000 years and is still responsible for a
million deaths globally and over 250 million morbid episodes annually.
 Of various measures in place for malaria prevention, key interventions
include indoor residual spraying, promoting use of Insecticide treated
bed nets (ITN), intermittent preventive therapy for malaria,
presumptive treatment of malaria and education/mass awareness to
reduce exposure through environmental management and skin
repellants.
 Some of these programs have also been integrated with existing
interventions such as antenatal care, immunizations, deworming
campaigns etc.
Malaria
Malaria prevalence
log[Risk Ratio]
Study or Subgroup
10.9.1 Bed nets/ Spraying
SE
Weight
-0.798
-0.734
-0.673
-0.083
-1.897
1.588
0.191
0.137
0.118
0.261
2.4%
11.9%
12.2%
12.3%
11.3%
50.0%
Dapeng 1996
Kuile 2003
Sharma 2009 (1)
Sharma 2009 (2)
Thang 2009
Subtotal (95% CI)
Risk Ratio
IV, Random, 95% CI
Risk Ratio
IV, Random, 95% CI
0.45 [0.02, 10.12]
0.48 [0.33, 0.70]
0.51 [0.39, 0.67]
0.92 [0.73, 1.16]
0.15 [0.09, 0.25]
0.44 [0.24, 0.81]
Heterogeneity: Tau² = 0.35; Chi² = 44.03, df = 4 (P < 0.00001); I² = 91%
Test for overall effect: Z = 2.67 (P = 0.008)
10.9.2 IPTp
Msyamboza 2009
Subtotal (95% CI)
0.0582
0.249
11.4%
11.4%
1.06 [0.65, 1.73]
1.06 [0.65, 1.73]
0.56
8.3%
8.3%
0.03 [0.01, 0.09]
0.03 [0.01, 0.09]
9.2%
9.4%
11.6%
30.3%
0.65 [0.26, 1.62]
0.12 [0.05, 0.29]
1.70 [1.10, 2.63]
0.53 [0.11, 2.61]
Heterogeneity: Not applicable
Test for overall effect: Z = 0.23 (P = 0.82)
10.9.3 IPTc
Ahorlu 2011
Subtotal (95% CI)
-3.507
Heterogeneity: Not applicable
Test for overall effect: Z = 6.26 (P < 0.00001)
10.9.4 Community Promotion
Ayi 2010
Castro 2009 (3)
Castro 2009 (4)
Subtotal (95% CI)
-0.431
-2.12
0.531
0.467
0.447
0.222
Heterogeneity: Tau² = 1.85; Chi² = 28.96, df = 2 (P < 0.00001); I² = 93%
Test for overall effect: Z = 0.79 (P = 0.43)
Total (95% CI)
100.0%
0.42 [0.24, 0.72]
Heterogeneity: Tau² = 0.60; Chi² = 112.67, df = 9 (P < 0.00001); I² = 92%
Test for overall effect: Z = 3.18 (P = 0.001)
Test for subgroup differences: Chi² = 34.39, df = 3 (P < 0.00001), I² = 91.3%
(1) Olyset nets vs. no nets
(2) Untreated nets vs. no nets
(3) Environmental Management Only
(4) Environment+Larvicide
0.01
0.1
1
10
100
Favours Intervention Favours Control
Malaria
Outcome
Community Based Interventions
All-Cause Mortality
Parasitemia
Malaria Incidence
Malaria Prevalence
Mean Hemoglobin
Anemia
RR 0.74 (95% CI: 0.55, 1.00)
RR 0.78 (95% CI: 0.54, 1.11)
RR 0.51 (95% CI: 0.09, 2.89)
RR 0.42 (95% CI: 0.24, 0.72)
MD -0.15 (95% CI: -0.52, 0.22)
RR 0.92 (95% CI: 0.75, 1.12)
Neglected tropical disease
Dengue
 Dengue haemorrhagic fever, a potentially deadly complication, results
from the transmission of a virus by Aedes aegypti mosquitos.
 Dengue is found predominantly in urban and semi-urban areas where
inadequate waste disposal and storage of household water in
containers serve as breeding sites for mosquitoes.
Neglected tropical disease
Dengue: house index
Study or Subgroup
log[Risk Ratio]
20.1.1 Insecticide Treated Materials
Lenhart 2008
Madarieta 1999
Subtotal (95% CI)
Experimental Control
Total Weight
SE
Total
0.5049 0.3493
0.5511 0.2326
450
63
513
Risk Ratio
IV, Random, 95% CI
389
67
456
17.1%
18.4%
35.6%
1.66 [0.84, 3.29]
1.74 [1.10, 2.74]
1.71 [1.17, 2.50]
260
65
325
18.6%
19.5%
38.1%
0.26 [0.17, 0.40]
0.48 [0.41, 0.56]
0.37 [0.21, 0.66]
289
275
59
623
5.8%
5.8%
14.8%
26.3%
0.00 [0.00, 0.04]
0.00 [0.00, 0.04]
1.19 [0.42, 3.32]
0.02 [0.00, 2.71]
1404 100.0%
0.42 [0.19, 0.92]
Risk Ratio
IV, Random, 95% CI
Heterogeneity: Tau² = 0.00; Chi² = 0.01, df = 1 (P = 0.91); I² = 0%
Test for overall effect: Z = 2.77 (P = 0.006)
20.1.2 Water Jar Treatment
Neng 1987
Seng 2008
Subtotal (95% CI)
-1.3344 0.2187
-0.7354 0.077
192
249
441
Heterogeneity: Tau² = 0.15; Chi² = 6.67, df = 1 (P = 0.010); I² = 85%
Test for overall effect: Z = 3.36 (P = 0.0008)
20.1.3 Insecticide
Nathan 1982
Pant 1971
Uribe 1984
Subtotal (95% CI)
-6.0242 1.4163
-6.0242 1.4163
0.1712 0.5247
654
247
58
959
Heterogeneity: Tau² = 16.76; Chi² = 30.03, df = 2 (P < 0.00001); I² = 93%
Test for overall effect: Z = 1.55 (P = 0.12)
Total (95% CI)
1913
Heterogeneity: Tau² = 0.84; Chi² = 79.86, df = 6 (P < 0.00001); I² = 92%
Test for overall effect: Z = 2.16 (P = 0.03)
Test for subgroup differences: Chi² = 21.26, df = 2 (P < 0.0001), I² = 90.6%
0.01
0.1
1
10
100
Favours Intervention Favours Control
Neglected tropical disease
Dengue
Outcome
House Index
Positive Serostatus
Mean Breteau Index
Ovitrap Index
Community Based Interventions
RR 0.42 (95% CI: 0.19, 0.92)
RR 0.31 (95% CI: 0.18,0.53)
MD -0.04 (95% CI: -0.28,0.19)
RR 0.76 (95% CI: 0.64,0.91)
Neglected tropical disease
Trachoma
 Trachoma results from infection with Chlamydia trachomatis,
transmitted through contact with eye and nose discharge from those
infected, especially children, and via eye-seeking flies.
 It affects approximately 84 million people globally, and while
mortalities due to trachoma are less than 500 annually, the true
burden of the blinding disease lies in the resulting morbidity, i.e. visual
impairment.
 The largest burden is in Africa, where 28 out of the 46 countries
account for 69% of global active trachoma cases and 47% of global
trichiasis cases.
Neglected tropical disease
Trachoma : Active trachoma (all ages)
Study or Subgroup
Astle 2006 A
Atik 2006 A
Atik 2006 B
Atik 2006-C
Fraser-Hurt 2001 A
Fraser-Hurt 2001 B
Total (95% CI)
log[Risk Ratio]
-2.0787
-0.9046
-0.882
-1.0973
-0.1484
-0.6152
Experimental Control
Risk Ratio
Total Total Weight IV, Random, 95% CI
SE
0.0705
0.2171
0.3672
0.236
0.132
0.1653
3727
896
398
764
571
422
3892
1325
659
1190
947
856
17.3%
16.7%
15.4%
16.5%
17.1%
17.0%
0.13 [0.11, 0.14]
0.40 [0.26, 0.62]
0.41 [0.20, 0.85]
0.33 [0.21, 0.53]
0.86 [0.67, 1.12]
0.54 [0.39, 0.75]
6778
8869 100.0%
0.38 [0.17, 0.87]
Heterogeneity: Tau² = 1.00; Chi² = 213.20, df = 5 (P < 0.00001); I² = 98%
Test for overall effect: Z = 2.29 (P = 0.02)
Risk Ratio
IV, Random, 95% CI
10 100
1
0.01 0.1
Favours Intervention Favours Control
Neglected tropical disease
Trachoma : Active trachoma (children)
Study or Subgroup
Abdou 2010
Astle 2006 B
Biebesheimer 2009
Broman 2006
Edwards 2006 A
Edwards 2006 B
Edwards 2006 C
Emerson 2004
Ewald 2003
Gaynor 2003
Hagan 2009
Huguet 2009
Khandekar 2006 A
Khandekar 2006 B
Kumaresan 2003 A
Kumaresan 2003 B
Schemann 2007 A
Schemann 2007 B
Schemann 2007 C
West 2007
Total (95% CI)
log[Risk Ratio]
SE
0.0922
-1.7019
-1.3652
-0.2908
-0.1567
-0.1285
-0.0438
-0.3104
-0.0715
-1.1705
-1.0403
-1.58
-1.8046
-0.6384
-0.2533
-1.2521
-1.3036
-1.1186
-0.8631
-1.683
0.082
0.0847
0.0735
0.0609
0.031
0.0439
0.0431
0.1043
0.1413
0.2201
0.0616
0.3102
0.3205
0.2455
0.3102
1.5457
0.1574
0.1381
0.1504
0.1418
Experimental Control
Total Weight
Total
5.6%
273
284
5.5%
1448
1393
5.6%
758
758
5.6%
268
292
5.7%
998
998
5.6%
509
509
5.6%
502
502
5.5%
2203
1975
5.3%
234
123
4.9%
243
175
5.6%
6241
9288
4.3%
793
154
4.3%
447
482
4.7%
463
429
4.3%
222
286
0.6%
222
155
5.2%
727
716
5.3%
942
912
5.3%
658
645
5.3%
462
607
20683
18613 100.0%
Heterogeneity: Tau² = 0.31; Chi² = 928.97, df = 19 (P < 0.00001); I² = 98%
Test for overall effect: Z = 6.02 (P < 0.00001)
Risk Ratio
IV, Random, 95% CI
Risk Ratio
IV, Random, 95% CI
1.10 [0.93, 1.29]
0.18 [0.15, 0.22]
0.26 [0.22, 0.29]
0.75 [0.66, 0.84]
0.85 [0.80, 0.91]
0.88 [0.81, 0.96]
0.96 [0.88, 1.04]
0.73 [0.60, 0.90]
0.93 [0.71, 1.23]
0.31 [0.20, 0.48]
0.35 [0.31, 0.40]
0.21 [0.11, 0.38]
0.16 [0.09, 0.31]
0.53 [0.33, 0.85]
0.78 [0.42, 1.43]
0.29 [0.01, 5.91]
0.27 [0.20, 0.37]
0.33 [0.25, 0.43]
0.42 [0.31, 0.57]
0.19 [0.14, 0.25]
0.45 [0.35, 0.59]
0.01 0.1
1
10
100
Favours Intervention Favours Control
Neglected tropical disease
Trachoma : Active trachoma (children)
Outcome
Chlamydia Trachomatis (all ages)
Chlamydia Trachomatis (Children)
Community Based Interventions
RR 0.20 (95% CI: 0.11,0.38)
RR 0.13 (95% CI: 0.06,0.28)
Neglected tropical disease
Leprosy
 Leprosy is caused by bacterial infection and results in skin sores, nerve
damage, and muscle weakness with the potential for permanent
damage and disability if left untreated.
 Remarkable success has been achieved globally since 1985 with a 90%
reduction in prevalence and more than 15 million patients cured.
 Currently, the prevalence rate is estimated to be 400,000, with 6,000
deaths per year due to leprosy, with the Southeast Asia region
reporting the highest cases.
Neglected tropical disease
Leprosy : Incidence of Leprosy
Study or Subgroup
Bakker 2005 A
Bakker 2005 B
Cunhon 2008
Idema 2010 (1)
Moet 2008
Namadi 2002
Rahim 2004
Schuring 2009 A
Schuring 2009 B
Schuring 2009 C
Sharma 2005 A (2)
Sharma 2005 B (3)
Sharma 2005 C (4)
Total (95% CI)
log[Risk Ratio]
0.0445
-1.515
0.0454
-0.833
-0.4336
-0.1321
-2.1928
-1.5953
-0.867
-0.8406
-0.1649
-0.2601
-0.0141
Experimental Control
Risk Ratio
Total Weight IV, Random, 95% CI
Total
SE
1.05 [0.48, 2.27]
626 7.3%
1633
0.3952
0.22 [0.06, 0.79]
626 5.9%
1080
0.65
1.05 [0.30, 3.61]
8176 6.0%
39067
0.6323
0.43 [0.28, 0.67]
10038 8.0%
9994
0.2218
0.65 [0.47, 0.90]
9385 8.2%
9388
0.1665
0.88 [0.79, 0.98]
36347826 29869565 8.4%
0.0546
0.11 [0.10, 0.12]
19607000 12304665 8.4%
0.0528
0.20 [0.09, 0.45]
2139 7.2%
4259
0.4021
0.42 [0.26, 0.69]
2139 7.9%
6462
0.2537
0.43 [0.24, 0.77]
2140 7.7%
4291
0.2924
0.85 [0.72, 0.99]
1729 8.3%
4889
0.0807
0.77 [0.65, 0.92]
1729 8.3%
5410
0.0887
0.99 [0.87, 1.12]
1730 8.3%
4969
0.0656
56046268 42214687 100.0%
Heterogeneity: Tau² = 1.03; Chi² = 1098.87, df = 12 (P < 0.00001); I² = 99%
Test for overall effect: Z = 2.26 (P = 0.02)
(1) incidence amongst contacts of those with leprosy; control is standard treatment.
(2) all groups including control received MDT.
(3) all groups including control received MDT.
(4) all groups including control received MDT.
Risk Ratio
IV, Random, 95% CI
0.51 [0.29, 0.91]
0.01 0.1
1
10
100
Favours Intervention Favours Control
Neglected tropical disease
Chagas Disease
 Chagas disease is caused by contact of any break in the skin, eyes, or
mouth with the parasite Trypanosomacruzi, present in the feces of a
triatomine bug.
 Parasitic bugs results in the infection of 8.5 million of the population,
and being the cause of death for 14,000 people a year.
 Chagas disease occurs in two phases, namely, acute followed by
chronic, and can ultimately result in death due to arrhythmias.
 In areas with domiciliary vector transmission, children younger than 5
years are commonly infected, while in areas without domiciliary
transmission, older ages are more commonly affected due to exposure
to wild life vectors present while engaging in agricultural, fishing, and
hunting activities.
Neglected tropical disease
Chagas disease: Pre-domiciliary infestation Rate
Neglected tropical disease
Leishmaniasis
 Leishmaniasis is caused by parasites transmitted through the bite
of infected sand flies, and can manifest as visceral or cutaneous.
 Approximately 51,000 deaths occur globally due to
leishmaniasis.
 With the spread of HIV, people are more susceptible to co-
infection of Leishmania and HIV, and despite proper treatment,
relapse is common and often results in death.
Neglected tropical disease
Leishmaniasis: Incidence of Cutaneous Leishmaniasis
Neglected tropical disease
Leishmaniasis: Incidence of Visceral Leishmaniasis
Study or Subgroup
Dietze 1997
Gavgani 2002
Picado 2010
log[Risk Ratio]
Experimental Control
Risk Ratio
SE
Total Total Weight IV, Fixed, 95% CI
-0.4817 0.309
0.007 0.0993
-0.0026 0.1423
Total (95% CI)
Heterogeneity: Chi² = 2.31, df = 2 (P = 0.31); I² = 13%
Test for overall effect: Z = 0.35 (P = 0.73)
209
1141
6372
149 6.5% 0.62 [0.34, 1.13]
1078 62.9% 1.01 [0.83, 1.22]
6319 30.6% 1.00 [0.75, 1.32]
7722
7546 100.0% 0.97 [0.83, 1.14]
Risk Ratio
IV, Fixed, 95% CI
0.01 0.1
1
10 100
Favours Intervention Favours Control
Neglected tropical disease
Schistosomiasis
 Schistosomiasis is a helminth infection transmitted through
contaminated water consisting of skin-penetrating parasites.
 Schistosomiasis can be intestinal or urogenital, and results in severe
organ pathology, anemia, malnutrition, and can also increase risk of
HIV infection.
 Globally, between 150,000-200,000 deaths occur annually due to
schistosomiasis.
 The primary intervention to control schistosomiasis is treatment with
praziquantel supplemented by provision of safe water and adequate
sanitation.
Neglected tropical disease
Schistosomiasis: Prevalence of S haematobium
Study or Subgroup
Ageel 1997
Nsowah-Nuamah 2001 A
Nsowah-Nuamah 2001 B
Nsowah-Nuamah 2001 C
log[Risk Ratio]
-4.4268
-1.114
-0.4196
-1.1419
Experimental Control
Risk Ratio
Total Total Weight IV, Random, 95% CI
SE
1.4215
0.0825
0.0491
0.0815
Total (95% CI)
2579
784
1075
731
2867 3.3%
697 32.0%
1090 32.7%
775 32.1%
0.01 [0.00, 0.19]
0.33 [0.28, 0.39]
0.66 [0.60, 0.72]
0.32 [0.27, 0.37]
5169
5429 100.0%
0.37 [0.22, 0.62]
Heterogeneity: Tau² = 0.22; Chi² = 93.83, df = 3 (P < 0.00001); I² = 97%
Test for overall effect: Z = 3.71 (P = 0.0002)
Risk Ratio
IV, Random, 95% CI
0.01 0.1
1
10
100
Favours Intervention Favours Control
Prevalence of S. mansuni
Study or Subgroup
Gryseels 1991 A
Gryseels 1991 B
Gundersen 1990
Zhang 2007 B
Total (95% CI)
log[Risk Ratio]
SE
-0.8377
-0.2787
-1.3111
-1.7646
0.0698
0.0832
0.1167
0.1547
Experimental Control
Total Weight
Total
748
857
735
397
2737
Risk Ratio
IV, Random, 95% CI
25.6%
25.4%
24.9%
24.1%
0.43 [0.38, 0.50]
0.76 [0.64, 0.89]
0.27 [0.21, 0.34]
0.17 [0.13, 0.23]
2572 100.0%
0.35 [0.21, 0.61]
634
594
441
903
Heterogeneity: Tau² = 0.30; Chi² = 97.38, df = 3 (P < 0.00001); I² = 97%
Test for overall effect: Z = 3.71 (P = 0.0002)
Risk Ratio
IV, Random, 95% CI
10
100
0.1
1
0.01
Favours Intervention Favours Control
Neglected tropical disease
Soil transmitted helminthiases
 The soil-transmitted helminth infections, hookworm, ascariasis, and
trichuriasis are often co-infectious and linked in transmission through
eggs in contaminated water, although the biology of each disease
differs.
 The primary morbidity resulting from STH is malnutrition, with grave
consequences to the physical growth and cognitive development of
children, as well as to the health and pregnancy outcome of
childbearing women due to resulting iron deficiency and anemia.
Neglected tropical disease
Soil transmitted helminthiases: anemia prevalence
Study or Subgroup
Abel 2000 t
Larocque 2006 B
Larocque 2006 C
Nbidazza 2010 A
Nbidazza 2010 B
Nbidazza 2010 C
Total (95% CI)
log[Risk Ratio]
SE
-0.4051
-0.3401
-0.3967
-0.0154
0.018
-0.0338
0.0566
0.0816
0.0822
0.0882
0.0884
0.0882
Experimental Control
Risk Ratio
Total Total Weight IV, Random, 95% CI
403
479
471
488
458
500
2799
18.1%
16.6%
16.6%
16.2%
16.2%
16.2%
0.67 [0.60, 0.75]
0.71 [0.61, 0.84]
0.67 [0.57, 0.79]
0.98 [0.83, 1.17]
1.02 [0.86, 1.21]
0.97 [0.81, 1.15]
1847 100.0%
0.82 [0.69, 0.97]
425
479
471
157
157
158
Heterogeneity: Tau² = 0.04; Chi² = 34.11, df = 5 (P < 0.00001); I² = 85%
Test for overall effect: Z = 2.38 (P = 0.02)
Risk Ratio
IV, Random, 95% CI
100
0.01 0.1
1
10
Favours Intervention Favours Control
Neglected tropical disease
Soil transmitted helminthiases: mean hemoglobin
Study or Subgroup
Abel 2000 i
Abel 2000 ii
Abel 2000 iii
Atukorala 1994 A
Atukorala 1994 B
Nbidazza 2010 A
Nbidazza 2010 B
Nbidazza 2010 C
Torlesse 2001 A
Torlesse 2001 B
Total (95% CI)
Mean Difference
SE
0.84
0.9
0.64
1.7
-0.8
0.04
0.2
0.15
2.01
0.17
0.3177
0.112
0.1338
0.4559
0.4246
0.1262
0.1263
0.1264
0.5949
0.3127
Experimental Control
Total Weight
Total
30
229
166
51
64
472
472
472
29
29
8.9%
13.0%
12.6%
6.5%
7.0%
12.7%
12.7%
12.7%
4.7%
9.0%
0.84 [0.22, 1.46]
0.90 [0.68, 1.12]
0.64 [0.38, 0.90]
1.70 [0.81, 2.59]
-0.80 [-1.63, 0.03]
0.04 [-0.21, 0.29]
0.20 [-0.05, 0.45]
0.15 [-0.10, 0.40]
2.01 [0.84, 3.18]
0.17 [-0.44, 0.78]
2014 100.0%
0.49 [0.17, 0.80]
36
191
176
51
64
488
458
500
32
29
2025
Mean Difference
IV, Random, 95% CI
Heterogeneity: Tau² = 0.18; Chi² = 63.40, df = 9 (P < 0.00001); I² = 86%
Test for overall effect: Z = 3.06 (P = 0.002)
Mean Difference
IV, Random, 95% CI
-4 -2 0 2 4
Favours Control Favours Intervention
Summary – Tuberculosis
 This systematic review shows that community based interventions are
overall associated with a significant increase in cure, TB and LTB
detection.
 When compared by delivery strategy, care delivered by CHW’s showed
significant impacts on cure, success and adherence to treatment.
 However, delivery through HCW’s improved the adherence to
treatment.
Summary – Malaria
 Community based interventions have shown to be effective in
reducing malaria prevalence and all-cause mortality. However, these
results should be interpreted with caution due to limited number of
studies and considerable heterogeneity.
 The range of outcomes reported for specific interventions were limited
hence considerable heterogeneity exists in the subgroup analysis and
the findings are inconclusive.
Summary – NTDs
 For most of the NTD outcomes, community based interventions were
found to be effective compared to routine care.
 For some NTD’s there was no quantifiable data for the pooled analysis.
These included buruli ulcer, human african trypanosomiasis,
dracunculiasias, lymphatic filariasis and Onchocerciasis.
 NTD’s pose great economic burden and still are neglected in terms of
research work done.
Limitations
 It must be noted that most of the studies included in the review were
conducted in various parts of South Africa, limiting its generalizibility.
 Moreover, tuberculosis has highest burden of co-existent cases of
HIV/AIDS, of up to 80%, making the region different from other
developing countries where HIV/AIDS is not as prevalent.
Recommendations
 As a disease of poverty, progress towards eradication of these remains
hampered by economic constraints.
 Steps can be taken to reduce the barriers that are social and health
system related, by taking a flexible approach to prevention and control.
 The major challenge remains the design and implementation of
effective population based intervention programs since these infectious
diseases affects the poorest sections of the population with limited
access to health services.
 Essential interventions that need to be packaged include communitybased early detection and health education efforts, CHW training,
provision of medical and surgical treatment and rehabilitation for
deformities.
Recommendations
 Combination of interventions including community-based surveillance
systems, intensified case-containment measures, and access to safe
drinking water have been elements of the successful programs.
 Special emphasis needs to be given to educating and counseling the
masses.
 Parallel education programs should also be run along with the
interventions so that the usage rate can be increased.
 Follow up campaigns need to be ensured through different channels to
increase the reach and efficacy of these program to larger populations.
Thanks
Acknowledgements:
TDR- WHO for funding this review