Attempts to Achieve Millennium Development Goals in a Rural Area of Rio de Janeiro : Deworming and Control of Schistosomiasis

In September, 2000, an unprecedented gathering of world leaders attended the United Nations (UN) Millennium Summit in New York, NY, USA and adopted the UN Millennium Declaration committing their nations to a new global partnership to halve the number of people living in poverty by 2015. Several development targets and goals were set, including several in health that are collectively known as the Millennium Development Goals (MDGs). The UN Joint Monitoring Programme estimates that 2.6 billion people – 40% of the world’s population – lack access to sanitation. Inadequate sanitation is one of the biggest contributing factors to child mortality under the age of 5, and yet it remains the most neglected of the MDG sectors. Every year, 10 million children die before reaching their fifth birthday. Improved sanitation could bring the single greatest reduction in these deaths.1 Previous research in Brazil has shown that access to improved sanitation alone reduced the rate of childhood diarrhoea by up to 43%.2 Despite the strong evidence of the impact that increased access to sanitation would have on reducing child mortality, sanitation remains consistently overlooked in the formulation of development policy, and this has led to intense environmental contamination in many territories with helminths. Schistosomiasis and soil-transmitted helminths (STH) are also deeply linked to the absence of sanitation. Human schistosomiasis is a major health problem in many parts of Africa, Asia, and America, and an estimated 200 million people in 76 countries are thought to be infected with one of the schistosome species that cause disease.3 There are http://ijtmgh.com Int J Travel Med Glob Health. 2018 Feb;6(1):30-33 doi 10.15171/ijtmgh.2018.06 TMGH IInternational Journal of Travel Medicine and Global Health J


Introduction
In September, 2000, an unprecedented gathering of world leaders attended the United Nations (UN) Millennium Summit in New York, NY, USA and adopted the UN Millennium Declaration committing their nations to a new global partnership to halve the number of people living in poverty by 2015.Several development targets and goals were set, including several in health that are collectively known as the Millennium Development Goals (MDGs).The UN Joint Monitoring Programme estimates that 2.6 billion people -40% of the world's population -lack access to sanitation.Inadequate sanitation is one of the biggest contributing factors to child mortality under the age of 5, and yet it remains the most neglected of the MDG sectors.Every year, 10 million children die before reaching their fifth birthday.Improved sanitation could bring the single greatest reduction in these deaths. 1 Previous research in Brazil has shown that access to improved sanitation alone reduced the rate of childhood diarrhoea by up to 43%. 2 Despite the strong evidence of the impact that increased access to sanitation would have on reducing child mortality, sanitation remains consistently overlooked in the formulation of development policy, and this has led to intense environmental contamination in many territories with helminths.
Schistosomiasis and soil-transmitted helminths (STH) are also deeply linked to the absence of sanitation.Human schistosomiasis is a major health problem in many parts of Africa, Asia, and America, and an estimated 200 million people in 76 countries are thought to be infected with one of the schistosome species that cause disease. 3There are still around 2.5 million to 6.3 million individuals harboring schistosomes in Brazil. 4In the state of Rio de Janeiro, some areas present low endemicity or isolated foci of Schistosoma mansoni.
Although the definitive resolution for schistosomiasis and STH is sanitation, deworming may be a useful tool in controlling this disease.Helminth control is a crucial, yet neglected, step towards improving public health and to reaching several of the MDGs.According to the World Health Organization (WHO), helminth control could contribute to achieving 7 of the 8 MDGs, 5 although just 3 of the 8 MDGs (4, 5, and 6) are directly related to health, concerning child health, maternal health, and disease control, respectively.
The present study evaluated the impact of deworming on the infection rate of schistosomiasis and the consequences for the MDGs in a rural area of Sumidouro (a county in the state of Rio de Janeiro, Brazil) that is strongly affected by helminths.

Study Population/Recruitment
This descriptive-cross sectional study was carried out in 2 contiguous rural localities (22º 01'S 42º 38'W) in Sumidouro, a county in the Brazilian state of Rio de Janeiro.In the present study, these villages were considered a unique area, since they have very similar physical and population characteristics.This area is surrounded by hills and has waterfalls and rapids as part of its main hydric collections.There are also some remains of the Brazilian Rain Forest on the mountaintops and in small parts along the stream margins.There was no sampling.The whole population of the study area was invited to participate in the study.At the invitation moment, informed consent forms were given to each of the adult subjects and to the parents or guardians of each child living in the locality.The name, age, gender, and address of each subject who decided to join the study were recorded.This is an interventional study carried out in 2 stages: the baseline from 2002 to 2003 and the follow-up from 2005 to 2006.There were 255 participants at the baseline and 224 at the follow-up.

Diagnosis and Treatment of Parasitosis
The diagnosis of schistosomiasis was based on coproscopy by Kato-Katz method, 6 using up to 3 faecal samples from each participant and 2 smears per faecal sample.
Each participant whose stool was found positive for S. mansoni eggs submitted to a general clinical examination.Adults and children were treated with a single oral dose of 40 mg/kg praziquantel. 3The tablets were administered with milk to minimize any gastrointestinal side effects.Within this interval, treatment was the only schistosomiasis control method undertaken in the villages, since there were no education measures, snail control, nor improvements to sanitation or access to safe water.

Statistical Analysis
Statistical investigation was confined to individuals who participated in both surveys.Estimates of schistosomiasis infection rate at the 2 surveys were compared, considering the whole population or individuals of different age or gender.
Comparisons used χ 2 or Fisher exact tests, as appropriate. 7A P value of less than 0.05 was considered statistically significant.
In the first survey, there were 41 (25%) persons under the age of 15 years (counted as children), 80 (48.8%) between 15 and 45 years of age, and 43 (26.2%) over the age of 45 years.Three years later, 30 (18.3%) people were under the age of 15 years, 83 (50.6%) were between 15 and 45 years of age, and 51 (31.1%) were over the age of 45 years.There were 36 women of childbearing age (between 15 and 45 years) each time.
The infection rate of schistosomiasis dropped from 28.7% (n = 47) to 6.7% (n = 11).Of these 11 individuals, 6 had been treated in the first study and 5 were "new cases".
The infection rate of each specific group is shown in Table 1.As can be seen, in the more vulnerable groups, such as children and women, the infection rate dropped from 14.6% to 3.3% and from 20.5% to 2.7%, respectively.Among women of childbearing age, the infection rate decreased from 27.8% to 5.6%.No girl under 15 years of age was infected in 2005-2006.
All patients had intestinal or hepatointestinal forms of schistosomiasis, a milder form of the disease.

Discussion
The WHO estimates that helminth control could contribute to achieving 7 of the 8 MDGs: Goal 1 -Eradicate extreme poverty and hunger; Goal 2 -Achieve universal primary education; Goal 3 -Promote gender equality and empower women; Goal 4 -Reduce child mortality; Goal 5 -Improve maternal health; Goal 6 -Combat HIV/AIDS, malaria, and other diseases; Goal 8 -Develop a global partnership for development. 5chistosome infection during childhood causes substantial growth retardation and anemia.Infected children may also have cognitive impairments and memory deficits. 8In the current study, the infection rate of schistosomiasis in children dropped from 14.6% to 3.3%.This supports the argument that deworming would lead to the achievement of Goal 4 of the MDGs.Worm infection weakens very young children in ways that increase their vulnerability to infectious diseases.The benefits of regular deworming in this age group include improvements in iron stores, growth and physical fitness, cognitive performance, and school attendance. 9Deworming in childhood leads to improvements in intellectual development that are related to income in adulthood.Schistosome infection appears to have adverse effects on both maternal health and the fetus. 8A significant drop in helminth infection was seen in women of childbearing age, from 27.8% to 5.6%.Furthermore, a better future can be foreseen, as no girl under the age of 15 years was infected.This could be a contribution to the achievement of Goal 3.For various reasons, anemia may be present in schistosomiasis. 3bundant evidence shows that regular deworming reduces anemia in adolescent girls and women of childbearing age, thus preparing them for a healthier pregnancy. 10ome argue that treatment of sanitation-related disease is a significant drain on scarce financial resources among this section of society, and that the money spent on medicine and healthcare will be at the expense of food, education, and other essentials 1 ; however, worm control is possible with cheap and effective drugs.Praziquantel for schistosomiasis can be given as a single dose according to height, and it costs around $0•20 USD for a school-aged child.1][12][13] Those are the reasons why the authors claim that in situations like that one studied herein, in which a population's needs have been neglected for too long and the environment is strongly contaminated with helminths, the benefits obviously justify the costs of efforts to adopt medication in addition to the improvements achieved in social services.
Indeed, as the current study was not undertaken in an area of high intensity of schistosomiasis, it cannot be predicted whether deworming would have the same effect on a more severely affected area.However, the current study has shown very positive results in controlling infection in the studied area of moderate intensity.It is possible that the interruption of schistosome transmission in high-risk areas will require more complicated, integrated control strategies, i.e. a combination of drug treatment, water management, snail control, and the control or treatment of sewage. 14

Conclusion
Achieving the MDGs will require targeting areas and population groups that have clearly been left behind, like rural communities.In the current study, as there was no improvement to sanitation, deworming might have led to a reduced transmission of schistosomiasis.Although the authors emphasize the fact that treatment cannot replace improvements in sanitation, education, and other services, that drug delivery may be only a stopgap measure, and that the elimination of schistosomiasis will be a long-term process requiring a long-term investment, 14 this study affirms that deworming is an essential tool for achieving the MDGs.

Table 1 .
Distribution of Infection Rate of Schistosomiasis