Rubina Imtiaz – Intestinal Worms

Director, Children Without Worms

Protecting the World’s Children from Parasitic Worms

Rubina Imtiaz, MBBS, grew up surrounded by powerful role models. Her father, Ahmed, was one of Pakistan’s most famous cricket players, known for his formidable hook and pull shot. Her mother was a progressive and pragmatist who taught her and her two sisters the value of self-sufficiency. “She said, ‘Don’t think your husband is going to support you,’” Imtiaz remembers.

That Imtiaz would pursue a career wasn’t debatable. The only question was, which avenue would she choose? Her first aspiration was to be a pilot, but financial logistics got in the way. “I couldn’t afford to go to a private club and take flying lessons,” she says. “Medical school was more affordable.”

Imtiaz started out in internal medicine, but while doing her residency in New Jersey, she learned of the CDC’s Epidemic Intelligence Service (EIS), a fellowship program that trains young doctors to respond to disease outbreaks and other public health threats. In 1984, Imtiaz became the first Pakistani to be inducted into the program. “The rest is history,” she says. “I never turned back.”

From Worms to Global Infections

As a young epidemiologist, Imtiaz joined The Carter Center to help tackle the problem of guinea worm—a parasitic worm that spreads through contaminated water in countries like Pakistan, Ghana, and Nigeria.

It was her first contact with worms professionally, but not personally. As a child, she and the other children in her neighborhood used to eat dirt, a bad habit her mother successfully discouraged by pouring chili powder on the ground. Those grazing sessions were typically followed by the administration of a thick, syrupy deworming liquid. “You were forced to gulp it down, and then the worms came out. I don’t remember having them, but I’m sure other kids did,” Imtiaz says.

From 1992 to 1996, she worked in the UNICEF immunization program in Nepal. Later, she oversaw Field Epidemiology and Laboratory Training Programs (FELTPs) in 26 countries for the Centers for Disease Control and Prevention (CDC), and then served as the CDC’s Associate Director for the Division of Global HIV/AIDS & TB. In 2016, Imtiaz joined The Task Force for Global Health as Program Director of its Children Without Worms (CWW) program.

The Challenges of Eliminating Worms

CWW’s main focus is to eliminate soil-transmitted helminths (STHs), a designation that includes three types of parasitic worms: roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura), and hookworm (Anclostoma duodenale and Necator americanus). These worms thrive in countries with rampant poverty and poor sanitation. They lay their eggs in the intestines of infected people, who then deposit worms and eggs in the ground when they defecate outside. Anyone who touches the contaminated dirt and infected food or drinking water, or who eats fruits and vegetables grown in it ingests the worms’ eggs, and the cycle perpetuates. More than 800 million children live in areas where these parasites spread (WHO).

Trying to kill three different worms at once is “tricky,” Imtiaz says, because they don’t all respond equally to each deworming medication. Combatting STH requires a two-armed approach that involves both preventing transmission, and treating people who live in endemic areas with (usually) donated deworming medicines. “By treating them, you reduce the burden of worms people have in their bellies, and infectious eggs that are being passed out into the soil and water,” Imtiaz says. “Over the long run, if you’re consistently treating a high percentage of infected people, year after year, you’ll theoretically reduce the burden of eggs in the soil.”

Prevention and long-term control efforts rely on sanitation and hygiene—handwashing after people use the toilet, and properly disposing of feces. “You can provide sanitary facilities and clean water, and educate communities about the advantages of taking these precautions to minimize infection and reinfection,” she says.

Measuring Treatment Success

Since 2006, pharmaceutical companies Johnson & Johnson and GlaxoSmithKline have donated millions of doses of anti-parasitic drugs each year to treat STHs, as well as other neglected tropical diseases, such as river blindness. When these donations started, the World Health Organization’s (WHO’s) focus was on getting as many of these drugs as possible to people who needed them. More than a decade and one billion deworming pills later, these companies want to know: Have their donations made a difference?

 

That’s where Imtiaz’s team comes in. CWW surveys countries, assessing whether de-worming drugs were disseminated, and testing residents to see if the drugs effectively reduced the number of parasites and infected people. “That tells us whether the drugs have been impactful in that country,” she says. These surveys also detect “hot spots”—areas where STH transmission continues at high rates. “Then the country is able to go out and start putting out fires in these hot spots.” Identifying areas where STH is already well-controlled frees up drugs for high-risk populations, such as women of childbearing age.

A World Without Worms?

Could we look forward to a day when children in poor areas don’t have to fear parasitic worms? “While elimination of STH (i.e., getting rid of all infections, like we did with smallpox or polio) is so far not possible, what is possible is our goal to control the amount or intensity of these infections, which would essentially eliminate clinical disease and discomfort,” Imtiaz says. Even in poorer areas of the United States like Appalachia, these worms remain a threat, but at a very local and individual level.

To control STH to the point where it is no longer a public health burden requires regular deworming, and teaching people good sanitary practices. In particular, it’s critical to emphasize the use of toilets and make these facilities available.

While that goal may still be some years away, Imtiaz celebrates interim successes. “The biggest accomplishment for us has been changing the mindset from counting pills to counting parasites,” she says. “Making the shift from giving out pills to everyone because they’re free, to actually looking at the disease, mapping patterns, and then targeting pills to the areas and people who need them is the new, more efficient approach.”

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