Outline Deaths and DALYs in 514 yr olds Enteric infections Three stories An enteric virus An enteric parasite An enteric bacterium Prevention and the environment Management of illness Core competencies of School health programs ID: 911920
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Slide1
School based prevention and management of enteric infections in children
Slide2Outline
Deaths and DALYs in 5-14
yr oldsEnteric infectionsThree storiesAn enteric virusAn enteric parasiteAn enteric bacterium Prevention and the environmentManagement of illness Core competencies of School health programs
Slide3Deaths in 5-14 years
Slide4Disability adjusted life years lost (DALYs) in 5-14 years
Slide5India’s place in the world
Slide6Enteric infections
Water borne infections
Foodborne infectionsPerson-to person infections
Enteric infections affect
The gut (diarrhoea, dysentery
etc
)
The liver (hepatitis A and E)
The body (typhoid, paratyphoid)
The brain (cysticercosis)
……..
Slide7Recently identified waterborne infections
Cryptosporidiosis 1984
Cyclospora 1989Campylobacter 1978E. coli O157 1990Yersinia 1982
P.
shigelloides
1978
Aeromonas
1984
Legionnaires
’
disease 1981
Helicobacter 1991
Hepatitis E 1988
Norwalk virus 1978
Acanthamoeba
Toxoplasmosis 1984
V.
cholerae
O139 1991
Microsporidiosis
2000
SARS 2003
Slide8A partial list of causative agents
Water
Cholera CryptosporidiosisCyclospora Campylobacter
E. coli
O157
Yersinia
P.
shigelloides
Aeromonas
Helicobacter
Hepatitis E
Norwalk virus
Acanthamoeba
Toxoplasmosis V. cholerae O139
Microsporidiosis
Food
Norovirus
S
aureus
B cereus
C
perferingens
Shigella
Salmonella
V
parahaemolyticus
Y
enterocolitica
C
botulinum
E coli O157:H7
L
monocytogenes
Trichinella
spiralis
Giardia
lamblia
Brucella
abortus
Campylobacter
jejuni
Cryptosporidium
parvum
Aeromonas
hydrophilia
Slide9Three stories-Hepatitis A virus
Faeco
-oral
Hepatitis A
Hepatitis E
Parenteral
Hepatitis B
Hepatitis C
Hepatitis D (delta agent)
Hepatitis G
Slide10Hepatitis A is a vaccine preventable disease.
But do we need a vaccine?
Age in years
% positivity
Serosurvey
in Vellore, 2003
Slide11The changing picture of hepatitis A
Anti-hepatitis A antibodies in children 6-10 years of age in Pune (
Deoshatwar
et al,
Epidemiol
Infect 2020)
57/58 cases in children < 15 years, 31/58 cases from 8 streets, Srinivasan et al, AJTMH 2020)
We did not need a vaccine in 2003. Do we need a vaccine now?
Slide12Pullan
et al.
2014.
Parasit
Vectors. 7: 37
Global distribution of STH infection
An estimated 1.5 billion people are infected with STH globally
Approximately one-in-five individuals infected with STH reside in India
Current WHO strategy for STH control is targeting pre- and school-age children and at-risk populations with MDA
Untreated adults may contribute to reinfection of at risk populations by serving as reservoirs of infection
Three stories-soil transmitted
helminths
Slide13Impact of deworming on growth and nutrition
Hookworm and whipworm are associated with iron deficiency anaemia
STHs are associated with malnutrition
possibly mediated through impaired fat digestion, reduced vitamin A absorption, and temporary lactose intolerance
Effects on nutrition are through appetite suppression, increased nutrient loss, and decreased nutrient absorption
Image: NDD India, MOHFW
Slide14Benefits of targeted deworming on cognition and school performance
MDA associated with gains in educational outcomes
Children living in treatment communities had test scores 0.2-0.4 standard deviations higher than those in control areas (2014 long-term evaluation of Ugandan RCT)
MDA considered the most cost-effective child development intervention (2018 Evidence Review)
Slide15The age distribution of all worms is not the same
Slide16But current control strategies may not interrupt transmission of all STH species
Anderson
et al
.
PLoS
Negl
Trop Dis. 2015. 9: e0003897
Slide17What is elimination and how do we measure it?
Year
Disease prevalence
Baseline prevalence assessment
NB. Hypothetical scenarios, based on models provided
MDA
MDA
MDA
MDA
MDA
LF MDA
MDA
MDA
MDA
DW3 MDA
Interim
prevalence assessment:
6 months post final round of MDA
Endline
prevalence assessment
Scenario 4: TRANSMISSION INTERRUPTION
Prevalence falls below ≤2% six months post-MDA, and maintains or continues to decrease over two years of surveillance
Surveillance
4
Scenario 2: BOUNCEBACK
Prevalence falls below ≤2% six months post-MDA, but then increases above 2% over two years of surveillance
Scenario 3: TRANSMISSION INTERRUPTION
Prevalence does not fall below ≤2% six months post-MDA, but falls below 2% over two years of surveillance
Scenario 1
Prevalence never falls below the ≤2% prevalence threshold
1
3
2
DeWorm3 Endpoint Scenarios
STH transmission models suggest reaching a
2% prevalence of STH (for any species) 24 months after stopping MDA reliably predicts
transmission interruption
Slide18Three stories-typhoid
A 250-year-old debate: is typhoid a problem in India?
18
Slide19Does India need typhoid vaccines? In schools?
Decline in culture-confirmed typhoid, complication & mortality in the last decade
Has the burden of typhoid been masked by increased antibiotic use in the community?Will the emergence of antimicrobial resistance lead to resurgence?
Are vaccines needed? Could disease be going away?
19
John J, et al.
PLoS
NTDs 2016
Gadhra
S CDDEP (unpublished)
Slide20Improvements in
WaSH
20
Improved
≠
safe
Slide2121
Slide22Incidence of typhoid fever in Delhi, Kolkata, Pune and Vellore by age
22
Age group
(Years)
Person-time (years)
Number of typhoid cases
Incidence per 100,000 child year
(95% CI)
0.5 to < 5
3788·3
39
1029·5
(752 – 1409)
5 to <10
5953·0
86
1444·7
(1169– 1785)
10 to <15
5076·2
51
1004·7
(764– 1322)
0.5 to <15
14817·5
176
1187·8
(1025– 1377)
WHO calls a country highly endemic if incidence per 100,000 child year is over 200!!!
We have a vaccine made in India and do not use it
Slide23Prevention and the environment
Clean water
Clean foodClean environment NutritionVaccinesPromotion of health-education, screening (deficiencies and infections), referral
Slide24Management of illness
When is what required and where?
Early detectionReferral systemsThe case for education-Antibiotic abuse
Slide25Core competencies for school health services
Access
Student focusPromotion of wellnessPrevention and management of illnessSystem integration and coordinationSustainable Accountable
Slide26Summary
Deaths and DALYs in 5-14
yr oldsEnteric infectionsThree storiesAn enteric virusAn enteric parasiteAn enteric bacterium Prevention and the environmentManagement of illnessCore competencies of School health programs