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Regular mass anthelminthic therapy of children with parasitic worms is still controversial
- Luis Huicho (24 August 2003)
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helminths in surgical practice
- dr singh sheetal sheetal (25 August 2003)
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Surgical problems due to the helminths
- Amar D Deshpande (28 August 2003)
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poverty and illiteracy major hurdles in eradication of helminthic infection
- koteshwara muralidhara (28 August 2003)
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OTHER SIDE OF THE COIN ? IN ASTHMA
- DR UMESH CHANDRA OJHA (29 August 2003)
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Luis Huicho, Professor of Paediatrics, Universidad Nacion al mayor de San Marcos and Instituto de Salud del Niño Av. Brasil 600, Lima, LI05, Peru
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The article of Awasthi et al. (1) addresses a highly relevant problem, particularly for developing countries. The authors rightly argue that, although parasitic worms do not represent a substantial burden of disease regarding mortality, they can substantially affect the growth and development of affected children. However, the emphasized statement “Parasitic worms have largely been overlooked by medicine, but attitudes are changing with the realisation that they can seriously affect child development and that treatment is easy and cheap” implies that treatment is effective for overcoming the negative effect of parasitic worms on child growth and development. The authors do not mention that this issue is currently under debate. Furthermore, they formerly performed a systematic review where the evidence of effectiveness of regular and widespread antihelminthic therapy for parasitic infections in children to overcome their negative impact on growth and development was questioned (2). A useful discussion followed to this systematic review. But the arguments raised throughout the discussion were insufficient to change the conclusion that evidence is weak. Thus caution must be exercised before adopting and scaling up such a strategy throughout countries. Explicit evidence should be stated to defend the strength of mass regular antihelminthic therapy. Awasthi et al., quote now two additional studies (3,4) which show that “children with chronic infection, and the constrained development that results from this, will need not only improved health but also a good education to catch up”. This is right, but it does not constitute substantive new evidence in favor of routine regular mass anthelminthic therapy. Children of the developing world desperately need well designed trials to assess the real effect of regular treatment on growth and development. The Lancet series on Child Survival rightly points out that child health has been neglected and that there is the need to act now applying existing effective and non-costly interventions to avoid about 6 million deaths each year, mostly in poor countries (5-9). For this, the scientific community, the donors, and the governments must recover the child health survival as a high priority agenda. Maybe it is time to discuss more openly on the scientific evidence of several public health interventions promoted by world leading organizations. Only in this way we can continue adding cost-effective interventions to the already available armamentarium. Otherwise, we risk continuing inducing poor countries the adoption of health interventions without sufficient evidence on effectiveness at public health level. And the scarce money may continue being diverted. We can not afford that. References 1. Awasthi HS, Bundy DAP, Lorenzo Savioli L. Helminthic infections. BMJ 2003; 327:431-433. 2. Dickson R, Awasthi S, Demellweek C, Williamson P. Anthelmintic drugs for treating worms in children: effects on growth and cognitive performance (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software. 3. Partnership for Child Development. Heavy schistosomiasis associated with poor short-term memory and slower reaction time in Tanzanian school children. Trop Med Int Health 2002;7: 104-17. 4. Hadidjaja P, Bonanag E, Suyardi MA, Abidin SA, Ismid IS, Margono SS. The effect of intervention methods on nutritional status and cognitive function of primary school children infected with Ascaris lumbricoides. Am J Trop Med Hyg 1998;59: 791-5. 5. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year?. Lancet 2003;361:2226-34. 6. Jones G, Richard W Steketee RW, Black RE, Bhutta ZA, Morris SS and Bellagio Child Survival Study Group. How many child deaths can we prevent this year?. Lancet 2003; 362: 65-71. 7. Bryce J, el Arifeen S, Pariyo G, Lanata CF, Gwatkin D, Habicht JP and Multi-Country Evaluation of IMCI Study Group. Can public health deliver?. Lancet 2003;362:159-64. 8. Victora CG, Wagstaff A, Armstrong Schellenberg J, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003;362:233-241. 9. D Gillespie D and The Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003;362:323-7. Competing interests: None declared |
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dr singh sheetal sheetal, chief cosultant in surgery lochan nursing home jammu j&k state india jammu j&k state india 180012
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i fully agree with the authors of this article that the the problems caused by the helminths are underpublished and underdiscussed.in my surgical experience of more than thirty years in various medical colleges of jammu and kashmir i have encounterd the following surgical problems due the worms a]subacute and acute intestinal obstruction in children.this group forms one of the commonest paediatric emergencies.interestingly any attempt to treat them with antihilminthics drugs precipitates tho luminal block. b]worms particularily ascariasis have been found to be closely associated with biliary lithiasis and at times obstructive jaundice due choledochal worms Competing interests: None declared |
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Amar D Deshpande, Specialist Registrar Cheltenham General Hospital
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I agree with the authors that worm infestations are generally underdiagnosed and casually treated. Especially in the third world countries the worm infestations are very common. Though surgical complications following worm infestation are uncommon, during my surgicla training in Mumbai (Bombay), I have come across many cases like 1)intestinal obstruction in children as well as adults, 2) Obstructive jaundice due to blockade of CBD due ascaris, 3)Ascaria perforating the typhoid enteric ulcers causing peritonitis, 4)Gastric outlet obstruction due to a ball of roundworms in the duodenum. Treating these patients with antihelminthetics pose a risk of aggravating these problems. Any type of bowel surgery in these patients pose a danger of anastomotic failures due to worms burrowing their way through the anastomoses. Competing interests: None declared |
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koteshwara muralidhara, senior house officer Central Middlesex Hospital,London,NW10 7NS
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Awasthi et al have rightly raised the some what neglected issue of importance of education in prevention and protection from helminthic infections. It is important to note that the prevalance of these infections is high in countries of the third world with raging poverty and illiteracy. Unfortunately, helminthic infections are not given much importance by the concerned governments. More international funding and involvement by the international health agencies and research organizations may take us some distance towards eradication of helminthic infections. Competing interests: none |
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DR UMESH CHANDRA OJHA, pulmonologist new delhi
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I fully agree with the author but in asthma it is most unlikely that the rising trends seen world-wide has one single reason. In both developing and developed countries, environmental factors present during pregnancy and in the first 3 years of life are most relevant to the observed increase in asthma and allergy. The study of Lynch and coworkers (cited in a review article by S. T. HOLGATE IN Q.J.Med. 1998; 91:171–184) has shown that from a public health standpoint, high levels of non-specific IgE may prove to protect rural dwellers who are exposed to parasites from allergy and asthma. Competing interests: None declared |
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