|Year : 2022 | Volume
| Issue : 2 | Page : 105-112
Coverage and compliance of mass drug administration in lymphatic filariasis amidst the COVID-19 pandemic: A community based epidemiological study
Sumanta Chakraborty1, Tridibes Bhattacharya2
1 Assistant Professor, Department of Community Medicine, Diamond Harbour Government Medical College and Hospital, Bankura, West Bengal, India
2 Assistant Professor, Department of Community Medicine, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India
|Date of Submission||05-May-2021|
|Date of Acceptance||30-Sep-2021|
|Date of Web Publication||24-Nov-2022|
Department of Community Medicine, Bankura Sammilani Medical and Hospital, Bankura - 722 102, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Despite the target of elimination of lymphatic filariasis by 2015, a few districts of West Bengal including Bankura district failed to achieve it. Under-coverage and unsupervised consumption of medicines during mass drug administration (MDA) campaign were implicated for the failure. Thereby, directly observed therapy (DOT) and mop up by repeated home visits for MDA were adopted.
Objective: The objective of this study is to assess the coverage of anti-filarial medicines distribution and rate of consumption as well as to find out the causes of nonconsumption.
Materials and Methods: A cross-sectional survey was conducted in three sub-centers each of three blocks and three wards of Bankura municipality of Bankura district, WB, India, selected through the stratified random sampling method. Information was collected interviewing inhabitants of the house hold selected through the systematic random sampling technique.
Results: Overall, appropriate medicine distribution was 82.9% with 95.3% of correct consumption of both medicines under supervision. 91.87% of the respondents were aware about Lymphatic filariasis (LF) of which 89.95% reported swelling of leg/foot/hand, 9.57% as pain, 6.22% fever, and 1.44% reported swelling of testis as symptoms of LF. Altogether 10.6% individual, who consumed any medicine (527), reported AEs, out of that 66.1%, 19.6%, and 14.3% complained of dizziness/headache, nausea/vomiting, and drowsiness, respectively, and 28.6% of them sought consultation with health workers.
Conclusion: Substantial supervised consumption in the form DOT in this round too leads to the fact that the effective coverage of MDA has reached the target. It seemed that some segment of the beneficiary is remaining as persistent noncomplaints. Mass mobilization for motivating this persistent defaulter section is the need of the hour.
Keywords: Compliance, coverage, lymphatic filariasis, mass drug administration
|How to cite this article:|
Chakraborty S, Bhattacharya T. Coverage and compliance of mass drug administration in lymphatic filariasis amidst the COVID-19 pandemic: A community based epidemiological study. Trop Parasitol 2022;12:105-12
|How to cite this URL:|
Chakraborty S, Bhattacharya T. Coverage and compliance of mass drug administration in lymphatic filariasis amidst the COVID-19 pandemic: A community based epidemiological study. Trop Parasitol [serial online] 2022 [cited 2022 Dec 7];12:105-12. Available from: https://www.tropicalparasitology.org/text.asp?2022/12/2/105/361953
| Introduction|| |
859 million people in 50 countries worldwide remain threatened by lymphatic filariasis and require preventive chemotherapy to stop the spread of this parasitic infection. Seventeen countries and territory (Cambodia, The Cook Islands, Egypt, Kiribati, Maldives, Malawi, Marshall Islands, Niue, Palau, Sri Lanka, Thailand, Togo, Tonga, Vanuatu, Viet Nam, Wallis and Futuna, and Yemen) are now acknowledged as achieving elimination of lymphatic filariasis as a public health problem. India has about 40% of the global filariasis burden and 50% of the global population at risk of infection. Efforts had been put forward by Government of India by launching the National Filariasis Control Program in 1955 and by the World Health Organization in 1998, in the name of Global Program on Elimination of LF (GPELF), both of them focused to eliminate the disease. One of the goal of India's National Health Policy (2002) is to eliminate LF by the year 2015 and later extended to 2021. The strategies of GPELF are centered around mass-drug-administration (MDA) with appropriate anti-filarial drugs and morbidity management. Under this program, a National Filaria Day is being observed once a year, usually in the month of November for MDA. On that day, a single dose of anti-filarial drug diethylcarbamazine (DEC) along with albendazole (400 mg) is distributed to inhabitants of all age and sex in filariasis endemic areas excluding children below 2 years of age, pregnant women and severely ill-patients. The recommended DEC single dose (at the rate of 6 mg/kg of body weight) is one tablet (100 mg) to children of age group of 2–5 years, two tablets for 6–14 years age group, and three tablets for those ≥15 years of age along with fixed single dose Albendazole 1 tablets of 400 mg. The aim of the strategy is cessation of transmission of filariasis by curbing the microfilaria (Mf) load in the community to <1%. As of 2015, 18 LF endemic countries globally had reduced infection prevalence to levels at which transmission is assumed to be unsustainable. Six of these countries have now been acknowledged as achieving the elimination of LF as a public health problem. Since 2004, India is implementing the MDA strategy in all its LF endemic states including West Bengal. However, different post-MDA coverage evaluation surveys (CESs) highlighted low coverage as well as unsupervised consumption of anti-filarial medicines. Later, it was found that swallowing of anti-filarial medicines under supervision has not been emphasized and may be a reason for low coverage. Moreover, independent appraisal carried out by vector control research center, Pondicherry, in the district of Birbhum and Bankura of WB in July, 2014 revealed Mf rate well over 1% (contrary to the target of <1%) in most of the sites of Night Blood Survey. Being stricken by abysmal high Mf rate and the deadline of LF elimination by 2015 the vector borne disease control division of Department of Health and Family Welfare, Government of West Bengal first put emphasis on directly observed therapy (DOT) and repeat house-to-house visit, a paradigm shift in the strategy of MDA implementation since the round held in April, 2015. However, in its debut, the pincer attack of DOT and repeat home visits could not make much impressive dent in to the problem of low coverage and or unsupervised consumption. However, the emphasis on DOT and repeat home visits were also practiced in subsequent MDA rounds including the last one held in the backdrop for the severe acute respiratory syndrome coronavirus 2 pandemic in the month of March 2021.
- To determine the coverage of MDA in February 2021 round
- To assess the causes of noncompliance, if any
- To evaluate the strength, weakness, opportunity, and threats analysis of the MDA program.
| Materials and Methods|| |
A descriptive evaluation study was done in the form of community-based cross-sectional survey carried out after the implementation of last round of MDA in the district of Bankura. For this purpose, multistage random sampling method was adopted. First, the district Bankura of WB, India was allotted to Bankura Sammilani Medical College. Baseline details such as number of block primary health centers and sub-centers (sc) under their jurisdiction, municipalities and wards, total eligible population, reported coverage rates of last round of MDA in these blocks/municipalities, and the district etc., were collected from office of Deputy Chief Medical Officers of Health-II, Bankura district. Bankura district with overall coverage 87.32% comprises of 16 blocks and 1 municipality. The assessment was conducted in four areas (clusters) – Three (3) rural and one (1) urban. Based on the reported coverage of district health authorities, three blocks was selected – one each from highest coverage, medium coverage, and lowest coverage. The municipality with lowest coverage was selected, as there was only one municipality, Bankura municipality stood selected by default. From each of the selected blocks, three (3) subcenters were selected randomly and then one random village from each of the selected sub-centers (preferably avoiding the village where subcenter is placed). In the selected municipality, three (3) wards were selected randomly. From each village and ward at least 10 households (HHs) to be selected randomly. The selected blocks were Raipur, Ranibandh, Sarenga, and Bankura Municipality from Bankura District. In the next stage, three sub-centers from each of the selected block were chosen by simple random sampling, and similarly, three wards of Bankura municipality were chosen for the survey. The Akhuta, Puranpani and Haludkanali sub-centers from Ranibandh block, Raipur bazar, Raipur GP, Raipur RH sub-centers of Raipur block and Penchara Deuli, Taldiha, and Bikrampur sub-centers of Sarenga block, respectively, and ward no. 1, 3, and 5 of Bankurai Municipality were chosen as the cluster for the CES. Then, from each selected sub-center/municipal ward, three villages/hamlets were chosen by the simple random sampling. A HH list of the selected villages/wards was collected from the concerned sub-centers. Subsequently, H-Hs were included following a systematic random sampling technique in such a manner that the criteria of both 10 H-Hs and 50 individuals from each village/ward were fulfilled. A total 30 HHs and 150 individuals from each block/Municipality (cluster) were the required sample size. Thus, total 662 individuals were surveyed from 132 selected HHs with breakup of 158, 175, 161 and 168 individuals from 31, 33, 32, and 36 HHs from the villages of Ranibandh block, Raipur block, Sarenga block, and Bankura Municipality, respectively [Figure 1].
|Figure 1: Sampling framework adapted from guidelines from Government of West Bengal|
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All the people of ≥2 years of age were included in the study.
Pregnant women and seriously ill individuals were excluded from the study.
The eligible persons were interviewed using the predesigned pretested schedule after obtaining written informed consent. The schedule was customized for the study with the help of the subject experts of public health. Data were collected by the researchers after translation, back-translation, and re-translation of the prepared schedule was done with the help of language experts, followed by pretesting among a convenience sample of 30 individuals attending the OPD of Bankura Sammilani Medical College and Hospital. The pretested participants were not included in the study. Information pertaining to sociodemographic variables, receipt of DEC and Albendazole tablets as well as status of consumption (supervised/unsupervised), reasons for nonconsumption, adverse events (AEs) and seeking care after AEs were collected interviewing the responsible member (s) of the H-Hs. Scrutiny of relevant records/left out medicines, if any was also done. Interviewees were shown flash card and enquired about the presence LF case (s) in their villages, whether the flash card was shown by DAs. Interview of the drug administrators, supervisors, and filarial patients were done to obtain information on understanding the positive and negative aspects of the program.
Data were handled with strict confidentiality to maintain anonymity. Data were entered into Excel (Microsoft Inc.) and all calculations were done using the same. Data were analyzed and presented using the principles of descriptive statistics. Categorized variables were presented using statistical methods such as tables and diagrams for display and described as percentages and continuous variables in mean, median, and standard deviation.
| Results|| |
Overall 98.19% surveyed people were eligible for MDA being 23.69%, 26.61%, 25.47%, and 25.53% from the cluster Ranibandh, Raipur, Sarenga, and Bankura Municipality, respectively [Table 1].
Base line characteristics of study subjects
There was slight female predominance (51.08%) among the study participants. Overall, 5.83%, 12.02%, and 82.15% were in the age group of 2–5 years, 6–14 years, and ≥15 years, respectively, and mean and standard deviation of 31.99 ± 17.69. About one-fifth (20.30%) was illiterate or yet to schooling, 23.69% of study subjects reportedly had education up to primary level, 30.92% were educated up to secondary level, 14.92% had education up to Madhyamik or higher secondary, and 10.15% were educated up to graduation and above. The majority study participants (40.92%) were laborer/agricultural worker and 6.62% service holder/businessmen. However, 24.92% of the participants were students, 16.77% were home-maker, and 10.77% were at home/retired [Table 2].
|Table 2: Distribution of study participants as per their baseline characteristics (n=650)|
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91.87% of the respondents one each from the selected HHs were aware about LF of which 89.95% reported swelling of leg/foot/hand, 9.57% as pain, 6.22% fever, and 1.44% reported swelling of testis as symptoms of LF. 87.08% and 89.95% of them had awareness regarding transmission and correct ways of prevention. 84.41% HH was shown flash card during H-H visit by the drug administrators [Figure 2] and [Figure 3].
|Figure 3: Bar diagram showing awareness regarding the symptoms of lymphatic filariasis|
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Mass-drug-administration coverage and compliance
About one-third (34.3%) of the HHs were covered by DAs who were not routine health workers, i.e., voluntary workers. Around one-sixth (13.7%) of the participants could not be covered with MDA, either due to left out by the DAs or refusal by some HHs, especially in the urban cluster.
As a whole 86.3% of the beneficiaries were distributed both DEC, Albendazole among which 82.9% of the distribution were done correctly [Table 3].
|Table 3: Distribution of study participants as per distribution of mass drug administration medicines|
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Overall 81.1% of study participants consumed both DEC and Albendazole appropriately; among which 95.3% of all appropriate consumption of both medicines were supervised. Hence, the overall, effective coverage rate was estimated to be 95.3% [Table 4]. Furthermore, 89 participants (13.7%) were left over or refused as both medicines were not distributed to them and 12 participants have not consumed both drugs in spite of being distributed.
|Table 4: Distribution of study participants according to the right consumption of mass drug administration medicines|
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Altogether 10.6% individual, who consumed any medicine (527), reported AEs, out of that 66.1%, 19.6%, and 14.3% complained of dizziness/headache, nausea/vomiting, and drowsiness, respectively, and 28.6% of them sought consultation with health workers [Table 5].
|Table 5: Distribution study participants as per AEs after medicine consumption and consulted agency|
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There were altogether 12 individuals who did not consume both medicines even having been distributed both of the medicines. Majority (33.3%) of them stated their “fear of AE” as a cause of nonconsumption [Table 6].
|Table 6: Distribution of study participants according to the causes of nonconsumption (n=12)|
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Knowledge of the filarial patients
Eighteen diagnosed filarial patients were interviewed with an average age of 52.4 years. There was a female predominance (72.2%) among the patients. Seventeen (94.4%) of them were aware of the disease and it symptoms. 66.7% received treatment at government facilities, 27.8% at private facilities, and 5.6% received treatment in both. 55.6% received training for self-care and 50% received self-care kits, 27.8% attended the MMDP camp, and none of them got operated for associated hydrocele. The corresponding supervisors of the filarial patients were interviewed 72.2% could mention the date of the last MMDP camp mostly around 1–2 years before. 66.7% of the supervisors have never referred any patient for hydrocele operation at higher centers.
Perception of the drug administrators
A total of 79 drug administrators were interviewed, upon whom 34 were ASHAs (Accredited Social Health Activist), 5 were AWWs (Anganwadi worker), 9 were honorary health workers, and 31 were voluntary workers. Their average age was 40.2 years. All of them were educated up to secondary and above. All of them received training and also received the medicines about 1–2 days before the MDA. All of them were aware about the adverse reactions and the AEM kits. 94.9% had appropriate knowledge on causation, transmission, and prevention of lymphatic filariasis. In the issue on reasons of nonconsumption, 36.1% feels “absence from home,” 83.7% “fear of adverse effects,” 45.2% “not suffering from filarial” was the reason. Regarding suggestions for further improvement of the program multiple responses were obtained, 100% feels increased awareness generation, 12.1% feels continuing the program each year, 15.6% feels more supervisory visits holds the key for improved program management [Figure 4].
|Figure 4: Strength, weakness, opportunity, and threats analysis of perceptions of drug administrators and supervisors regarding the program|
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Perception of the supervisors
A total of 11 ANMs, 3 health assistants, and 2 supervisors were interviewed. Their average age was 42.9 years. All of them were educated up to secondary and above. All of them received training and also received the medicines about 2–3 days before the MDA. All of them were aware about the adverse reactions and the AEM kits. Each of them had appropriate knowledge on causation, transmission, and prevention of lymphatic filariasis. 43.8% “absence from home” was the reason for nonconsumption, whereas 56.2% feels that “fear of adverse effects” was the reason. Regarding suggestions for further improvement of the program multiple responses were obtained, 75% feels increased awareness generation, 31.3% feels continuing the program each year, 43.8% feels multisectoral co-ordination holds the key for improved program management [Figure 4].
| Discussion|| |
MDA coverage increased gradually from 72.42% in 2004 to 88.96% in 2014. A study by Sinha et al. in Pashchim Medinipur district of West Bengal observed that the coverage compliance and effective coverage were 84.1%, 70.5%, and 59.3% in the year 2009 and with declining trend 78.5%, 66.9%, and 52.52% in 2010. Chattopadhyay et al. in their MDA CES in 2010 in the district of Purba Medinipur, WB reported an effective coverage rate of 73.7%.
Karmakar et al. showed coverage, compliance, and effective compliance rate of 72.87%, 70.47%, and 51.35%, respectively in the district of North 24 Parganas (NPG), WB in 2010.
Ray et al. documented an effective coverage of 41.18% in the district of Bardhaman, WB in 2010. Ghosh et al. estimated an effective coverage of 93.7% in the district of Bankura, WB in 2012. Haldar et al. revealed coverage, compliance, and effective coverage rates of 83.4%, 61.28%, and 48.01%, respectively, in district NPG, WB in 2012. All these reports are government sponsored post-MDA CESs and most of them have been published. The difference in their results for evaluating same program conducted in same state of India following same standard methodological guidelines might be due partly to the variation in the efficiency of program implementing strategy in different districts as well as perception and motivation of local people. It is noteworthy that most of the studies reported coverage rates of below the desired cutoff, i.e., 85% or more. The trend noted in the present study with an effective coverage rate of 95.3% were much above the minimum of at least 65% for LF elimination and also exceeds the desired cutoff of 85% or more.
Universal unsupervised consumption in both 2009 and 2010 in the district of Purba Medinipur and in 2010 in NPG, West Bengal was reported by Sinha et al. and Karmakar et al., Ghosh et al. and Haldar et al. also found that 66.9% and 97.52% unsupervised drug consumption in 2012 in NPG and Bankura district, West Bengal., Unsupervised medicine consumption was alleged for suboptimal coverage in previous rounds and DOT was emphasized since April, 2015 including this round. The DOT was found to be improved in this round leaving only two-third (22.8%) of drug consumption unsupervised. Shifting priority on DOT seemed to work making provisions for reinforcement in the program implementing system. However, other outcomes of the program such as awareness about LF, its transmission, and ways of prevention are on increase.
Clients' attributes for noncompliance to distributed medicines was revealed to be not much altered in respect with previous rounds. As per the current study, majority (33.3%) of them stated their “fear of AE” as a cause of nonconsumption, 21.2% stated “illness” as the reason of their noncompliance in concurrence to the findings of Haldar et al. who found “fear of side effects” as the most common (63.02%) cause of noncompliance followed by “not aware/counseled” (24.48%), “no drug required for a healthy person” (13.54%) in NPG in 2012. Chattopadhyay et al. also revealed “fear of side effects” as the most common cause (41.5%) of noncompliance in Purba Medinipur district, WB in 2010.
“Fear of side effects” was found to be one of the important common causes but ironically AEs were reported only by 8.6% and that too minor in nature 28.6% of them sought care as also observed by Haldar et al. only in 5.08% clients in NPG. Chattopadhyay et al. had found only 2.0% complaining of minor AEs. Lack of awareness of beneficiaries regarding LF may be one of the important reasons for their demotivation for consuming MDA drugs.
The current study revealed 91.87% of the respondents were aware about LF of which 89.95% reported swelling of leg/foot/hand, 9.57% as pain, 6.22% fever, and 1.44% reported swelling of testis as symptoms of LF. 87.08% and 89.95% of them had awareness regarding transmission and correct ways of prevention. Haldar et al. observed that almost two-third respondents had awareness about LF about 47.0% had correct knowledge about transmission of LF, 60% heard about MDA predominantly (47.68%) from HWs. PreMDA visit for this round was paid by HW only in one-tenth of H-Hs. Chattopadhyay et al. explored that 85.1% respondents were aware of filariasis and 38% knew its mode of transmission. Low awareness level also reported by Ghosh et al.(about 60%), Karmakar et al.(55.42%), Roy et al.(41.4%) and Sinha et al.(55.42%).,,, Effective IEC might be responsible for this knowledge gain in awareness over years as found in our study.
| Conclusion|| |
Rethinking on program implementation utilizing mass mobilization and involvement of Panchayat for drug administration and mop-up may be tried in the next round to motivate this uncovered section by universal DOT. The pincer strategy of DOT by repeat house visit would turn the wheel in the reverse direction. It further requires intensive social mobilization through powerful advocacy, behavior change communication for motivating the systematically noncomplaints for participating in MDA, supportive supervision of all levels of workers are highly required for the success.
Limitation of the study
Recall bias was an issue in the study. We tried to verify the interview findings with the showing of empty medicine strips, but many individuals failed to do so and we had to rely only on the interview, thereby Hawthorne effect could not be ruled out.
The study was conducted with permission from Bankura Sammilani Medical College, local health administration and informed consent from each of the participants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]