In January 2000 the World Health Organization launched a program aimed at global elimination by 2020 of the lymphatic filarial parasites Wuchereria bancrofti and Brugia malayi. These parasites together infect in excess of 120 million people, and cause significant morbidity through elephantiasis. A major stimulus to the implementation of this and other programs, such as those aimed at the elimination of leprosy and Chagas' disease, was the successful global elimination of smallpox in 1977, and major advances in programs to control polio, measles, dracunculiasis (guinea worm) and onchocerciasis (river blindness). So, what of Australian parasite control programs?

In Australia, endemic malaria and lymphatic filariasis have been eradicated, and leprosy, a once feared and politically significant disease, is in decline through sustained control programs conducted by dedicated public health agencies over long periods using effective drugs. However, the same cannot be said for other common parasitic diseases which are still endemic in Australia, including scabies, giardiasis, cryptosporidiosis, hookworm, strongyloidiasis and trichuriasis. These parasite infections have remained highly prevalent among Indigenous Australians living in the tropical north of the country in areas where infrastructure development has lagged, and improvements in living standards have not matched those seen elsewhere.1-3

Rather than being of trivial importance, such parasite infections cause substantial preventable morbidity. Secondary infection of scabies lesions with group A streptococci contributes to the exceptionally high rates of rheumatic fever and renal disease seen in Indigenous people, while enteric parasites cause a range of adverse health effects, including anaemia from hookworm, septicaemia from strongyloidiasis, and malabsorption and diarrhoea in children from giardiasis and cryptosporidiosis. Further, the merit of control programs for geohelminth infection is supported by studies suggesting benefits in educational outcomes among children treated for these infections.4

Despite the progress made in hookworm control during the course of the Australian Hookworm Control Program in the early part of last century, this infection has remained endemic in many Indigenous communities across our tropical north, and contributes to iron deficiency and anaemia in women and children. The limited success of attempts to control hookworm in one remote northern Australian Indigenous community of about 350 people has been published in the Journal (with rates of hookworm infection documented in 1992 of up to 93% in children 5–14 years of age).2 Recently, our group has published the successful outcome of a 78-month hookworm infection control program in the same community.5,6 This program's success was due to close liaison with the community, the setting of clear goals, and a commitment to improve environmental infrastructure and local health education, as well as regular targeted, population-based chemotherapy over a sustained period. The change of anthelmintic from pyrantel (to which parasite resistance had been demonstrated7) to single-dose albendazole was an additional significant factor in the success of the program.

Parasite control programs based on community-wide distribution of albendazole among school-age children have also been implemented in the Northern Territory, and a similar community treatment strategy using permethrin therapy for scabies has recently been shown to reduce the prevalence of scabies in one community from 35% to 3%.3 Such successful programs are useful models for further community programs and national initiatives.

Could and should parasitic disease in northern Australia be controlled more effectively? While the determinants of parasitic disease in northern Indigenous communities are complex, there are common themes. Contributing factors include poverty, lack of health knowledge, poor environmental infrastructure and housing, remoteness from health services, family mobility across health regions, and haphazard opportunistic treatment of parasites as they are encountered in clinical practice. To be successful, parasite control programs must be consistent, coordinated and sustained, and accompanied by local health education and improvements in health infrastructure. At present, regional and State parasite control programs lack a consistent approach across primary and secondary sectors and across State borders, and in some regions are ignored or left largely to enthusiasts.

A more coordinated, national approach to parasite control would have substantial benefits:

• It would allow Aboriginal health organisations to fully participate and "own" the program from the national planning level through to the local community, thus facilitating rational debate on this emotive issue;

• Funding would be made available for nationally agreed strategies and continuing infrastructure improvements in affected communities;

• The use of standard surveillance techniques, reporting and targets would enable monitoring of progress;

• The reduction of parasite burden would be achieved through coordinated, programmed use of proven, safe drugs, including albendazole, ivermectin, tinidazole, and permethrin, at a community level; and

• Programs would be monitored for the development of drug resistance (a problem already present in veterinary practice where related drugs are used8).

Two critical factors for the success of such a program are political will, and a will on the part of the communities themselves, together with local healthcare providers, and government and Indigenous health organisations. While the cost of the drugs is not the major barrier to the implementation of such programs, the positive publicity gained by two pharmaceutical companies from their leadership in donating ivermectin and albendazole to the WHO-sponsored filariasis program could have some local lessons. Leadership in Australian parasite elimination programs should come from both the Indigenous and medical communities through an alliance of Indigenous people and public health, infectious diseases and paediatric practitioners.