The Pediatric Infectious Disease Journal •  Volume 32, Number 9, September 2013 www.pidj.com | 931 OPINION & ANALYSIS Abstract: The World Health Organization advocates mass antihelminthic treat- ment of school-age children in areas of high prevalence of soil-transmitted hel- minths. Soil-transmitted helminths prevalence in Afghanistan is 20–50%, but a high proportion of children do not attend school, so may be missed by deworm- ing programs. The primary function of military medical assets in a theater of war is to provide life, limb and eyesight saving treatment. Additional humanitarian aid in the form of nonemergency treatment has also been provided in Afghani- stan for thousands of civilian children. Children represent 3–15% of the patients treated at deployed military medical facilities. We report on recent experience of deployed surgical teams in southern Afghanistan who have noticed high levels of soil-transmitted helminths in war-injured patients. Military medical assets may provide an opportunity to integrate a policy of deworming of children into existing programs of humanitarian support. This would not be a substitute for mass deworming programs, but a supplementation. Key Words: deployed military facilities, deworming, children M ore than a billion people in the world are infected by soil- transmitted helminths (STH), 1 and these constitute one of the “neglected tropical diseases” that have recently become the focus of international public health prioritization. 2 The most widespread STH are roundworms, whipworms and hookworms. Infection results from feco-oral transmission of eggs or direct skin contact with larvae. These infections thrive where there is poverty, poor water quality and sanitation, especially in remote rural areas, urban slums and areas of conflict. 3 The World Health Organization (WHO) recommends annual mass antihelminthic treatment of all school-age children in areas where the prevalence is >20% or twice a year when the prevalence is >50%, with the goal of preventing adverse effects on nutritional status, hemoglobin concentration and cognition in order to improve health, intellect and school attendance. 3 The evidence that routine deworming demonstrates substantial benefits in relation to cognition, school attendance and school perfor- mance is conflicting, with evidence of benefit in some studies but not others. 4 Treating children for STH is strongly advocated by the WHO and, if combined with micronutrient supplementation, appears to offer the prospect of major health benefits to vulnerable communities. 5 TREATMENT OF WORMS Improvements in sanitation and health education are impor- tant interventions required in order to change practices and behaviors that reduce the transmission of STH. 6 Periodic mass deworming pro- grams have been recommended by the WHO. Most mass deworming programs have been school-based because children tend to have the highest prevalence and intensity of infection. 7 The programs focus on geographic areas with a high prevalence, using drugs recom- mended by the WHO. 8 Effective chemotherapy includes the use of mebendazole or albendazole, and occasionally pyrantelpamoate or levamisole. 9 These drugs are cheap when purchased in large quanti- ties (0.03–0.07 USD per child), 10,11 readily available even with lim- ited resources, 12 safe and effective against the most common STH. 13 WORMS IN AFGHANISTAN Chronic malnutrition in children is a major public health prob- lem in Afghanistan, with a lack of adequate household food intake and suboptimal infant and young child feeding and hygiene practices contributing to poor nutritional outcomes. 14 STH infestation may compound deficiencies in vital micronutrients and the physical and cognitive development of children may be impaired, 15 with poten- tial long-term effects on educational achievement and economic productivity. 16 Afghanistan’s relatively poor, remote, rural areas are ideal environments for opportunistic parasites; the effects of poor sanitation and infrastructure have been exacerbated by the enduring conflict that has troubled the country for many years. Survey data indicate that STH prevalence in several regions of the country is 20–50%, with some areas around Kabul >50%. 17 A high proportion of Afghans are children, and they continue to suffer the consequences of repeated infestation despite recent eradication programs. 18 The biggest deworming campaign in Afghanistan to date was undertaken in 2004, when the United Nations World Food Programme in collaboration with the WHO, UNICEF and the Afghan Ministries of Health and Education were able to treat 4.5 million children. 19 This fell short of the total number of school-age children (approximately 9 million) because a large proportion of these children do not attend school, as circumstances may miti- gate against attendance. School attendance is poor primarily due to problems with accessibility and security; however, there is gender imbalance and school restriction due to poverty, with children hav- ing to work or being excluded from education due to marriage. 20 TREATMENT OF CHILDREN AT INTERNATIONAL SECURITY ASSISTANCE FORCE MEDICAL FACILITIES As well as treating International Security Assistance Force personnel, deployed military medical facilities in Afghanistan pro- vide emergency medical support for civilians, including children. During the recent conflict, children have represented approximately 3–15% of the number of patients treated at deployed military hos- pitals 21–23 and contribute up to 25% of the bed occupancy. These children have often sustained battle trauma including blast and mis- sile injuries, and the majority require surgical intervention 24 with as many as 40% requiring admission to critical care. 25 Although the primary function of deployed medical assets in a theater of war is to provide life, limb and eyesight saving treatment, Copyright © 2013 by Lippincott Williams & Wilkins ISSN: 0891-3668/13/3209-0931 DOI: 10.1097/INF.0b013e31829e4551 Routine Deworming of Children at Deployed Military  Healthcare Facilities David N. Naumann, MRCS,* Jonathan Lundy, MD,† Daniel S. Burns, MRCP,* Mark S. Bailey, MD,* and Douglas M. Bowley, FRCS† Accepted for publication May 30, 2013. From the *Department of Military Medicine, Royal Centre for Defence Medi- cine, Birmingham; and †Department of Surgery, Role 3 Hospital, Camp Bas- tion, Joint Medical Group, Afghanistan. The authors have no funding or conflicts of interest to disclose. Address for correspondence: David N. Naumann, MRCS, Department of Mili- tary Medicine, Royal Centre for Defence Medicine, Birmingham, B15 2SQ. E-mail: david.naumann@cantab.net. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.pidj.com).