Anthelmintic resistance in Southeast Asia (AHR-SEA): implications for control and elimination of intestinal helminths

Soil-transmitted helminth (STH), or intestinal worm infections, are a major health burden worldwide, particularly in rural and poor urban areas of low- and middle-income countries, including in Southeast Asia. They infect over 1 billion people worldwide, causing considerable disease including anaemia and stunting and wasting in children. They can also significantly exacerbate poverty, particularly in marginalised communities. In the Philippines nearly 30% of school-aged children are infected with STHs, whereas in Malaysia and Thailand infections are particularly common in indigenous communities, refugees and migrants. The diseases caused by STHs are classified as Neglected Tropical Diseases by the World Health Organization (WHO). In its Roadmap for Neglected Tropical Diseases, WHO targets STH diseases for elimination as a public health problem by 2030. The main approach for STH control is regular distribution of deworming drugs to individuals living in endemic areas. However, there are concerns that resistance will arise to deworming drugs in human STHs, as is common in similar worm infections in animals, thus jeopardising control programmes. Therefore, there is an urgent need to understand how effective deworming drugs are in treating STHs, what the impacts would be on WHO elimination targets if resistance does emerge and explore alternative control approaches. Our project brings together an interdisciplinary team of expert researchers from Malaysia, the Philippines, Thailand and the United Kingdom and aims to address current knowledge gaps in relation to performance of deworming drugs in treatment of STHs and to identify alternative control strategies for STHs which are acceptable to communities. We will do this by undertaking field studies to assess performance of deworming drugs in treatment of STHs in areas of the three countries where high levels of STHs persist despite deworming treatment. We will use cutting edge genomics approaches to determine whether there are genetic variations associated with resistance to deworming treatment in the STHs circulating in the study sites. We will also investigate interactions between STHs and deworming treatment and people’s gut microbial community (microbiome) to propose alternative STH treatment options and to explore if gut microbes might influence treatment responses. Furthermore, we will employ machine learning methods to predict emergence of resistance to deworming drugs and use mathematical modelling and health economics approaches, informed by preference, symptoms and health-related quality-of-life data collected during the field studies, to determine what impact emergence of resistance will have on STH control and identify alternative control approaches which are acceptable to communities. Finally, we will design a strategy to monitor for emergence of deworming resistance. Integrated into the project will be a programme of knowledge exchange and research capacity building activities including training courses, researcher exchanges and field-based training. By embracing a collaborative interdisciplinary approach, this project will shed new light on the issue of STH resistance to deworming drugs and the effect that emergence of resistance will have on STH control and elimination. Ultimately, the project will deliver evidence-based strategies to monitor for resistance emergence and minimise the impact of resistance emergence on achieving the WHO 2030 targets, crucial information for public health policy makers.