The Costs and Cost-Effectiveness of Mass Treatment for Intestinal Nematode Worm Infections Using Different Treatment Thresholds

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Abstract
It is estimated that almost a half of all of people living in developing countries today are infected with roundworms, hookworms, or whipworms or combinations of these types of intestinal nematode worms. They can all be treated using safe, effective, and inexpensive single-dose generic drugs costing as little as USD 0.03 per person treated when bought in bulk. The disease caused by intestinal nematodes is strongly related to the number of worms in the gut, and it is typical to find that worms tend to be aggregated or clumped in their distribution so that 80% of all worms. This clumping of worms is greatest when the prevalence is low. When the prevalence rises above 50%, the mean worm burden increases exponentially, worms are less clumped, and more people are likely to have moderate to heavy infections and may be diseased. Children are most at risk. For these reasons, the World Health Organization (WHO) currently recommends mass treatment of children ≥1 year old without prior diagnosis when the prevalence is ≥20% and treatment twice a year when the prevalence is ≥50%. The risk of moderate to heavy infections with intestinal nematodes was estimated by applying the negative binomial probability distribution, then the drug cost of treating diseased individuals was calculated based on different threshold numbers of worms. Based on this cost analysis, a new three-tier treatment regime is proposed: if the combined prevalence is >40%, treat all children once a year; >60% treat twice a year; and >80% treat three times a year. Using average data on drug and delivery costs of USD 0.15 to treat a school-age child and USD 0.25 to treat a pre-school child (with provisos) the cost of treating children aged 2–14 years was calculated for 105 low- and low-middle-income countries and for constituent regions of India and China based on estimates of the combined prevalence of intestinal nematode worms therein. The annual cost of the three-tier threshold was estimated to be USD 224 million compared with USD 276 million when the current WHO recommendations for mass treatment were applied. The three-tier treatment thresholds were less expensive and more effective as they allocated a greater proportion of expenditures to treating infected individuals when compared with the WHO thresholds (73% compared with 61%) and treated a larger proportion of individuals with moderate to heavy worm burdens, arbitrarily defined as more than 10 worms per person (31% compared with 21%). Almost one in every two people in the developing world is infected with one or more types of intestinal nematode worms. When fewer than 50% of people are infected, most carry only a few worms; but when more than 50% are infected, the number carrying moderate to heavy numbers increases markedly, as does the risk of disease. The WHO recommends annual mass deworming of children when 20% or more are infected and twice a year if 50% or more are infected. We estimated the cost of this to treat children with 10+ worms, an arbitrary moderate to heavy infection. We concluded that it is not cost-effective to mass treat children when fewer than 40% are infected because the majority are uninfected and few are likely be diseased. We propose annual treatment when 40% or more children are infected, twice a year at 60%, and three times a year at 80% or more. This would cost USD 224 million annually to treat all children aged 2–14 years in 107 developing countries compared with USD 276 million using current WHO guidelines. The new three-tier guidelines also treat a larger proportion of infected children and treat children with moderate to heavy worm burdens more often.