Deworming drugs for soil-transmitted intestinal worms in children: effects on nutritional indicators, haemoglobin, and school performance

Abstract

Background: The World Health Organization (WHO) recommends treating all school children at regular intervals with deworming drugs in areas where helminth infection is common. As the intervention is often claimed to have important health, nutrition, and societal effects beyond the removal of worms, we critically evaluated the evidence on benefits.

Objectives: To summarize the effects of giving deworming drugs to children to treat soil-transmitted helminths on weight, haemoglobin, and cognition; and the evidence of impact on physical well-being, school attendance, school performance, and mortality.

Search methods: We searched the Cochrane Infectious Diseases Group Specialized Register (14 April 2015); Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library (2015, Issue 4); MEDLINE (2000 to 14 April 2015); EMBASE (2000 to 14 April 2015); LILACS (2000 to 14 April 2015); the metaRegister of Controlled Trials (mRCT); and reference lists, and registers of ongoing and completed trials up to 14 April 2015.

Selection criteria: We included randomized controlled trials (RCTs) and quasi-RCTs comparing deworming drugs for soil-transmitted helminths with placebo or no treatment in children aged 16 years or less, reporting on weight, haemoglobin, and formal tests of intellectual development. We also sought data on school attendance, school performance, and mortality. We included trials that combined health education with deworming programmes.

Data collection and analysis: At least two review authors independently assessed the trials, evaluated risk of bias, and extracted data. We analysed continuous data using the mean difference (MD) with 95% confidence intervals (CIs). Where data were missing, we contacted trial authors. We used outcomes at time of longest follow-up. The evidence quality was assessed using GRADE. This edition of the Cochrane Review adds the DEVTA trial from India, and draws on an independent analytical replication of a trial from Kenya.

Main results: We identified 45 trials, including nine cluster-RCTs, that met the inclusion criteria. One trial evaluating mortality included over one million children, and the remaining 44 trials included a total of 67,672 participants. Eight trials were in children known to be infected, and 37 trials were carried out in endemic areas, including areas of high (15 trials), moderate (12 trials), and low prevalence (10 trials). Treating children known to be infectedTreating children known to be infected with a single dose of deworming drugs (selected by screening, or living in areas where all children are infected) may increase weight gain over the next one to six months (627 participants, five trials, low quality evidence). The effect size varied across trials from an additional 0.2 kg gain to 1.3 kg. There is currently insufficient evidence to know whether treatment has additional effects on haemoglobin (247 participants, two trials, very low quality evidence); school attendance (0 trials); cognitive functioning (103 participants, two trials, very low quality evidence), or physical well-being (280 participants, three trials, very low quality evidence). Community deworming programmesTreating all children living in endemic areas with a dose of deworming drugs probably has little or no effect on average weight gain (MD 0.04 kg less, 95% CI 0.11 kg less to 0.04 kg more; trials 2719 participants, seven trials, moderate quality evidence), even in settings with high prevalence of infection (290 participants, two trials). A single dose also probably has no effect on average haemoglobin (MD 0.06 g/dL, 95% CI -0.05 lower to 0.17 higher; 1005 participants, three trials, moderate quality evidence), or average cognition (1361 participants, two trials, low quality evidence).Similiarly, regularly treating all children in endemic areas with deworming drugs, given every three to six months, may have little or no effect on average weight gain (MD 0.08 kg, 95% CI 0.11 kg less to 0.27 kg more; 38,392 participants, 10 trials, low quality evidence). The effects were variable across trials; one trial from a low prevalence setting carried out in 1995 found an increase in weight, but nine trials carried out since then found no effect, including five from moderate and high prevalence areas.There is also reasonable evidence that regular treatment probably has no effect on average height (MD 0.02 cm higher, 95% CI 0.14 lower to 0.17 cm higher; 7057 participants, seven trials, moderate quality evidence); average haemoglobin (MD 0.02 g/dL lower; 95% CI 0.08 g/dL lower to 0.04 g/dL higher; 3595 participants, seven trials, low quality evidence); formal tests of cognition (32,486 participants, five trials, moderate quality evidence); exam performance (32,659 participants, two trials, moderate quality evidence); or mortality (1,005,135 participants, three trials, low quality evidence). There is very limited evidence assessing an effect on school attendance and the findings are inconsistent, and at risk of bias (mean attendance 2% higher, 95% CI 4% lower to 8% higher; 20,243 participants, two trials, very low quality evidence).In a sensitivity analysis that only included trials with adequate allocation concealment, there was no evidence of any effect for the main outcomes.

Authors' conclusions: Treating children known to have worm infection may have some nutritional benefits for the individual. However, in mass treatment of all children in endemic areas, there is now substantial evidence that this does not improve average nutritional status, haemoglobin, cognition, school performance, or survival.

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Figure 2

Study flow diagram.

Figure 3

Figure 4

Analysis 1.1

Comparison 1 Infected children ‐ Single dose, Outcome 1 Weight (kg).

Analysis 1.2

Comparison 1 Infected children ‐ Single dose, Outcome 2 Height (cm).

Analysis 1.3

Comparison 1 Infected children ‐ Single dose, Outcome 3 Mid‐upper arm circumference (cm).

Analysis 1.4

Comparison 1 Infected children ‐ Single dose, Outcome 4 Triceps skin fold thickness (mm).

Analysis 1.5

Comparison 1 Infected children ‐ Single dose, Outcome 5 Subscapular skin fold thickness (mm).

Analysis 1.6

Comparison 1 Infected children ‐ Single dose, Outcome 6 Body mass index.

Analysis 1.7

Comparison 1 Infected children ‐ Single dose, Outcome 7 Haemoglobin (g/dL).

Analysis 2.1

Comparison 2 Infected children ‐ Multiple dose, longest follow‐up, Outcome 1 Weight (kg).

Analysis 2.2

Comparison 2 Infected children ‐ Multiple dose, longest follow‐up, Outcome 2 Height (cm).

Analysis 2.3

Comparison 2 Infected children ‐ Multiple dose, longest follow‐up, Outcome 3 Body mass index.

Analysis 2.4

Comparison 2 Infected children ‐ Multiple dose, longest follow‐up, Outcome 4 School attendance (days present at school).

Analysis 2.5

Comparison 2 Infected children ‐ Multiple dose, longest follow‐up, Outcome 5 Mid‐upper arm circumference (cm).

Analysis 2.6

Comparison 2 Infected children ‐ Multiple dose, longest follow‐up, Outcome 6 Triceps skin fold thickness (mm).

Analysis 2.7

Comparison 2 Infected children ‐ Multiple dose, longest follow‐up, Outcome 7 Subscapular skin fold thickness (mm).

Analysis 3.1

Comparison 3 All children living in endemic area ‐ first dose, Outcome 1 Weight (kg).

Analysis 3.2

Comparison 3 All children living in endemic area ‐ first dose, Outcome 2 Height (cm).

Analysis 3.3

Comparison 3 All children living in endemic area ‐ first dose, Outcome 3 Mid‐upper arm circumference (cm).

Analysis 3.4

Comparison 3 All children living in endemic area ‐ first dose, Outcome 4 Haemoglobin (g/dL).

Analysis 4.1

Comparison 4 All children living in endemic area ‐ Multiple dose, longest follow‐up, Outcome 1 Weight (kg).

Analysis 4.2

Comparison 4 All children living in endemic area ‐ Multiple dose, longest follow‐up, Outcome 2 Height (cm).

Analysis 4.3

Comparison 4 All children living in endemic area ‐ Multiple dose, longest follow‐up, Outcome 3 Mid‐upper arm circumference (cm).

Analysis 4.4

Comparison 4 All children living in endemic area ‐ Multiple dose, longest follow‐up, Outcome 4 Triceps skin fold thickness (mm).

Analysis 4.5

Comparison 4 All children living in endemic area ‐ Multiple dose, longest follow‐up, Outcome 5 Haemoglobin (g/dL).

Analysis 4.6

Comparison 4 All children living in endemic area ‐ Multiple dose, longest follow‐up, Outcome 6 School attendance (days present at school).

Analysis 5.1

Comparison 5 All children living in endemic area ‐ Single dose (low risk of bias for allocation concealment), Outcome 1 Weight (kg).

Analysis 5.2

Comparison 5 All children living in endemic area ‐ Single dose (low risk of bias for allocation concealment), Outcome 2 Height (cm).

Analysis 5.3

Comparison 5 All children living in endemic area ‐ Single dose (low risk of bias for allocation concealment), Outcome 3 Mid‐upper arm circumference (cm).

Analysis 5.4

Comparison 5 All children living in endemic area ‐ Single dose (low risk of bias for allocation concealment), Outcome 4 Haemoglobin (g/dL).

Analysis 6.1

Comparison 6 All children living in endemic area ‐ Multiple dose (low risk of bias for allocation concealment), longest follow‐up, Outcome 1 Weight (kg).

Analysis 6.2

Comparison 6 All children living in endemic area ‐ Multiple dose (low risk of bias for allocation concealment), longest follow‐up, Outcome 2 Height (cm).

Analysis 6.3

Comparison 6 All children living in endemic area ‐ Multiple dose (low risk of bias for allocation concealment), longest follow‐up, Outcome 3 Haemoglobin (g/dL).

Analysis 7.1

Comparison 7 All children living in endemic area ‐ All multiple ordered by year, Outcome 1 Weight (kg).