Residual Human Intestinal Nematode Infections Following Discontinuation of Mass Drug Administration in a Rural South Asian Setting: Implications for Deworming Surveillance.

Prevalence of soil-transmitted helminth (STH) infections in Sri Lanka has declined from 73.3% in 1954 to <1% in 2017, leading to revised deworming policies and discontinuation of routine deworming in three districts, including Anuradhapura, in 2019. As countries approach elimination, this study assessed human intestinal nematode infection (HINI) prevalence in Anuradhapura, a low-endemic setting, using microscopic and molecular methods. From January to November 2023, 967 primary school children were recruited and screened for HINI using direct smears, Kato-Katz, formalin ether concentration, agar plate culture, scotch tape, and qPCR. Combined microscopy and molecular prevalence was 41.2% for STH and 54.1% for HINI. The most prevalent HINI was Enterobius vermicularis (191, 24.5%), followed by Strongyloides stercoralis (120, 19.2%), Ascaris lumbricoides (113, 18.1%), Trichuris trichiura (40, 6.4%), and hookworm (43, 6.9%). Against the composite reference standard, qPCR demonstrated superior diagnostic performance across all species, achieving sensitivities of 86.7% for Ascaris, 85.0% for Trichuris, and 97.7% for hookworm, consistently exceeding those of microscopy-based methods. Correspondingly, qPCR also identified the highest infection prevalences, detecting Ascaris, Trichuris, and hookworm infections in 15.7%, 5.4%, and 6.7% of participants, respectively. All infections were low-intensity as determined by Kato-Katz. Microscopy significantly underestimates STH prevalence. In post-deworming settings, integrated surveillance including molecular diagnostics is essential. The high prevalence of S. stercoralis and E. vermicularis highlights the need for expanded surveillance and targeted interventions to support sustainable control.