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| ORIGINAL ARTICLE |
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| Year : 2013 | Volume
: 3
| Issue : 1 | Page : 67-71 |
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Mass drug administration for elimination of lymphatic filariasis: Recent experiences from a district of West Bengal, India
Santanu Ghosh, Amrita Samanta, Seshadri Kole
Department of Community Medicine, Bankura Sammilani Medical College and Hospital, West Bengal, India
| Date of Web Publication | 25-Jun-2013 |
Correspondence Address:
Santanu Ghosh
Department of Community Medicine, Bankura Sammilani Medical College and Hospital, West Bengal
India
 Source of Support: Department of health and family welfare, Govt. of West Bengal., Conflict of Interest: None  | Check |
DOI: 10.4103/2229-5070.113917
 Abstract | | |
Background: Annual mass drug administration (MDA) with diethyl carbamazine (DEC) and Albendazole is the most cost-effective strategy to control lymphatic filariasis (LF). Materials and Methods: The aim of the present study was to assess the coverage and the compliance of MDA, to elicit factors that influenced compliance, to document side-effects reported and to assess the awareness of the community regarding the disease and MDA program in Bankura district, West Bengal after 2012 round of MDA. Multistage cluster sampling method was adopted. Total four clusters; three villages and one urban municipality ward were selected. In each cluster, minimum 30 families were randomly selected and the head or any responsible family member was interviewed using a pre-designed, pre-tested schedule after taking written informed consent. Data were compiled and analyzed using SPSS 19.0. Results: Total eligible population was 683 among which 98.8% received both the drugs. About 5% of the recipients took none of the drugs. More than two-thirds of the families took unsupervised dose. Drug compliance rate was significantly lower in urban (90.7%) than in the rural clusters (95.7%) (z = 2.46, P < 0.05). Effective coverage rate was significantly lower in urban than in the rural clusters (87.4% vs. 95.3%; z = 3.57, P < 0.01). Coverage compliance gap was higher in urban (5.7%) than in rural cluster (3.9%). Fear of side-effects was the main reason for non-compliance. Reported side-effects were few, mild, and transient. Around 60% of the surveyed families were aware about the MDA program whereas, 67% of them heard about LF. Only 41% families were provided information, education, and communication in last 15 days before MDA. Major sources of information for the surveyed families were leaflets (20.3%) and poster (9.8%). Conclusions: Widespread rural urban variation in performance status, poor social mobilization activities, lack of supervised dosing, and lack of knowledge of the community about the disease and the program are the major areas of concern. Keywords: Coverage compliance gap, effective coverage rate, lymphatic filariasis, mass drug administration
How to cite this article:
Ghosh S, Samanta A, Kole S. Mass drug administration for elimination of lymphatic filariasis: Recent experiences from a district of West Bengal, India. Trop Parasitol 2013;3:67-71 |
| Introduction | |  |
Lymphatic filariasis (LF) is the world's second leading cause of long-term disability. The current estimate reveals that 120 million people in 83 countries of the world are infected with LF parasites and more than 20% of the world's population are at risk of acquiring infection. [1] Elimination of lymphatic filariasis (ELF) denotes cessation of LF as a public-health problem, when the number of microfilaria carriers is less than 1% and the children born after initiation of ELF are free from the circulating antigenemia. In India, it is estimated that 554.2 million people are at risk of LF infection in 243 districts. [2] In order to achieve the goal of ELF in India by 2015, National Filaria Day was proposed to be observed every year starting from 2004 in the endemic districts. [2] Control or ELF using an annual mass drug administration (MDA) is one of the cheapest and the most beneficial disease control strategy in the annals of public-health history. [3] MDA in combination with the other techniques has already eliminated LF from Japan, Taiwan, South Korea and Solomon Islands and markedly reduced the transmission in China. [4],[5] The recommended approach is annual supervised MDA through a door-to-door visit by co administration of a single dose of Diethyl carbamazine (DEC) and Albendazole preferably on a single day with two-day mopping up operations. Children below 2 years, pregnant women and seriously ill patients are not eligible for MDA. [6]
In 2012, MDA was completed in 12 filaria endemic districts of West Bengal from 01.03.2012 to 03.03.2012. The post-MDA assessment survey was conducted after MDA in the district of Bankura in the same month. The objectives of the survey were to assess coverage and compliance of MDA, to elicit factors that influenced compliance, to document side-effects reported and to assess the awareness of the community regarding the disease and MDA program.
| Materials and Methods | | |
Multistage cluster sampling method was adopted. There are 22 blocks in Bankura district. According to the Guidelines of Government of India, three blocks, one from >80% coverage, one from 50% to 80% coverage and one from <50% coverage in the rural areas and one municipality ward were to be selected randomly. [6]
However, all blocks of Bankura had >80% coverage according to the district authority except one (Barjora) that was selected. The blocks with >80% coverage were further stratified into blocks with 80% to 90% and >90% coverage. One block with 80%-90% (Bankura-I) and the other with >90% (Ranibandh) were randomly selected. From each selected block, one Primary health center (PHC) was randomly selected. From each selected PHC, one sub center and from each selected sub center, one village was selected randomly. Ward no 19 was randomly selected from the list of the wards of Bankura Municipality as the urban cluster. Therefore, the survey was conducted in four clusters; three villages, namely Badulara (Bankura-I block), Baharboal (Barjora block) and Sonardihi (Ranibandh block) and one urban ward, ward no. 19 of Bankura Municipality. From each cluster, at least 30 families were surveyed as per Guidelines of Government of India. [6] Each cluster was divided into three areas, and ten families from each area were selected. The first family in each area was selected randomly, and the other nine families were selected serially from the first family. In case of a closed house, the adjacent house was selected. The head of the family or other responsible adult member present at the time of the survey was interviewed with the help of a pre-designed, pre-tested schedule after taking written informed consent. Data were compiled and analyzed using the SPSS 19.0.
| Results | | |
Background characteristics
Total number of families surveyed was 133, and total surveyed population was 750. Total number of the eligible population surveyed was 683 (91%) out of which 53.7% were men and 46.3% were women. About 75% of the eligible population was aged 15 years and above.
Results of mass drug administration survey
About 98.8% of the population (675/683) were drug recipients who were distributed with both the drugs. The treatment coverage was low in the urban cluster (96.4%) compared to other clusters. Around 5% (35/675) of the recipients had taken none of drugs and 0.29% (2/675) had taken only DEC [Table 1]. Those who took both DEC and Albendazole were considered compliant. Overall drug compliance rate was 94.8% (95% confidence interval [CI]; 93.1, 96.5). Drug compliance rate was low in urban cluster (90.7%) than in the rural clusters, (95.7%) and the difference between urban and the rural clusters was significant (z = 2.46, P < 0.05). Intercluster variation among rural clusters were not significant (Chi-square = 2.33, df = 2, P > 0.05). Effective Coverage Rate was estimated as a product of coverage and compliance and coverage compliance gap (CCG) was estimated as the difference between coverage and compliance rate. [7] Overall, effective coverage rate was 93.7% (95% CI; 91.9-95.5). Effective coverage rates were 87.4% in urban cluster and 95.3% in rural clusters, and the difference was highly significant (z = 3.57, P < 0.01). CCG was 5.7% in urban cluster, and 3.9% in rural cluster whereas overall CCG was 4% [Table 2]. Most (66.9%) of the families were not administered supervised dose. Most of the unsupervised families (72.6%) consumed the drugs after taking dinner as advised by the local drug distributors. No empty blister pack was found in any house during the survey. | Table 2: Effective coverage rate and coverage compliance gap in rural and urban clusters
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Those who did not take both the drugs were considered non-compliant. Among 35 non-compliant people, 21 (60%) were males and 14 (40%) were females. The main reasons for non-compliance were "fear of side-effects" (54.3%), "not present at home" (42.8%) and "no counseling for MDA" (2.9%).
Fifteen (2.3%) recipients experienced side-effects of drugs; among them 4 (0.6%) had vomiting, 4 (0.6%) had dizziness, 1 (0.2%) had a fever, and 6 (0.9%) complained of other side-effects after drug intake.
Around 60% (80/133) of the surveyed families were aware about the MDA program whereas 66.9% (89/133) of families heard about LF. Out of those 89 families, 73 (82.0%) knew one or more symptoms/signs of LF and 47 (52.8%) were aware about the mode of transmission of LF [Table 3]. | Table 3: Awareness of the surveyed families regarding MDA programme and disease
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It was noted that 79 (59.4%) out of 133 families were not provided information, education, and communication in last 15 days before MDA and 57 (42.9%) families were informed by personal communication only on the day of drug distribution. In the urban ward, not a single family was contacted in the last 15 days before MDA. Major sources of information for the surveyed families were leaflets (20.3%) and poster (9.8%) followed by the microphone campaign (5.3%).
| Discussion | | |
MDA should be implemented in >85% of the population in endemic areas and must be sustained for 5 years to be successful. [2] In Bankura, drug distribution rate (99%) was satisfactory. However, even after 4 years of MDA, non-compliance for both DEC and Albendazole was found to be about 5%. Post-MDA survey conducted in 2010 in North 24 Paraganas, another endemic district in West Bengal by Karmakar et al. reported only 55.9% coverage and 69.4% compliance making effective coverage rate 38.8%, much lower than that of the present study. [8] Significant difference in effective coverage rates were found between urban and rural clusters (z = 3.57, P < 0.01) in the present study. Inadequate and improper social mobilization by Municipality and urban health workers were the probable reasons. In North 24 Paraganas, percentages of coverage, compliance and effective coverage were 72.9, 70.5 and 51.4 respectively in the rural areas whereas in urban areas, the corresponding figures were 14.2, 56.3 and 8.0, much lower than the present study. [8] The probable reason for better performance in Bankura is strengthening of awareness campaigns in last 2 years. In North 24 Paraganas, no supervision of drug consumption was conducted in any family, and families were advised to take the drug at night after dinner. Similar findings from our study indicate the need for systematic and focused training of health workers all over the state. In Andhra Pradesh, Mukhopadhyay et al., reported only 64.6% consumption among those who received drugs. [9] Babu in Orissa reported 83% of drug coverage and only 49.5% people actually consumed the drug. [10] Philippines study showed that 63.3% of the population received the antifilarial drugs. Knowledge on LF and perceived benefits of antifilarial drugs were found to be associated with MDA acceptance (P = 0.08). [11]
In North 24 Paraganas, the most frequent causes for non-compliance were fear of side-effects (36.8%) followed by inadequate counseling about the use of the drug (27.8%). Similar reasons were elicited in the present study also. [9] Babu reported that the fear of side effects was the predominant reason for non-consumption in Orissa which is similar to the finding of the present study. [10] On the contrary, Mathieu et al. reported that the primary reason for non-compliance was absenteeism during the distribution (17%) In Haiti. In a multivariate analysis, being male (odds ratio [OR] = 3.3; 95% CI = 1.5-7.4), knowing that a mosquito transmits the disease (OR = 2.6; CI = 1.2-5.4), and having learned about the MDA through posters and banners (OR = 2.9; CI = 1.2-7.5) were found to be positively associated with taking the drugs. However, no such association was found in the present study. [12] Njomo et al. in Kenya reported "feeling that the drugs were not necessary," being absent and thinking that the drugs were meant for only patients with LF as major causes of non-compliance. [13] Weerasooriya et al. reported that use of other medicines, a lack of feeling of the necessity for them and forgetting among reasons of non-compliance in Sri Lanka in 2007. [14]
The prevalence of reported side-effects in the present study was around 2% only. In North 24 Paraganas, too, drug was well-tolerated and vomiting was reported by only one recipient. Experience of side-effects including giddiness, fever, headache, and vomiting influenced compliance in Kenya (P < 0.001). [13]
In spite of 95% compliance in the present study, about 40% of the families were not aware about the MDA program, and about 33% did not hear about LF which implies that a considerable proportion of people were taking drugs without understanding the reason. This is not at all desirable because only provider initiated programs cannot be sustainable in the long run. In North 24 Paraganas, only 55.4% had heard about LF. [8] Awareness status was better in urban ward (88.9%) compared to villages (43.0%) in North 24 Paraganas. Only 17.4% in a rural area and 42.2% in an urban area were aware about presenting symptoms of LF, lower in comparison to the present study. In the same study, only 13.9% knew the mode of transmission of filariasis correctly; few had incorrectly identified direct contact, water, and air as routes of transmission. Mukhopadhyay reported that 53.7% heard about LF, lower than that in the present study. In the same study, 72.9% were found to be aware about the symptoms and 65% knew about transmission. [7] Similar low awareness was reported by Eberhard et al. in an endemic area in Haiti. [15] According to Krentel et al., only 54% have heard the name of filariasis in Indonesia. [16] However, Mathieu et al. reported that 93% of the interviewees were aware of filariasis and 72% knew at least one clinical sign of the disease in Haiti. [12]
The present study, though representative of the eligible population in Bankura district, was not free of limitations. First of all, there was a possibility of recall bias as the survey was not conducted immediately after MDA. Secondly, supervised drug administration could not be observed for the same reason. Finally, qualitative research techniques, like in-depth interviews of recipients could not be undertaken. The future surveys will be more informative if abovementioned issue can be properly addressed.
| Conclusion | | |
In spite of satisfactory coverage and compliance, widespread rural urban variation in performance status, poor social mobilization activities, lack of supervised dosing, and lack of knowledge of the community about the disease and the program as revealed by the present study remain the major areas of concern. Timely and adequate training of the drug distributors strengthening of pre-MDA motivational campaigns, and greater involvement of the local community mobilizers with special emphasis on urban areas are the needs of the hour.
| Acknowledgement | | |
The authors acknowledge the financial support obtained from Dept. of Health and Family Welfare, Government of West Bengal for the study. The authors are also expressing their heartfelt thanks to Dr. Gautam Narayan Sarkar, Prof and Head, Dept. of Community Medicine, Bankura Sammilani Medical College and Hospital, Dr. Jagannath Dinda, CMOH, Bankura and Dr. Debasish Roy, Deputy CMOH-II, Bankura for his extensive co-operation in conducting the survey.
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[Table 1], [Table 2], [Table 3]
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