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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