|Year : 2015 | Volume
| Issue : 3 | Page : 151-156
Mass drug administration program against lymphatic filariasis: Are we on the path to success? experience from Solapur District, Maharashtra
Malangori Abdulgani Parande, Manjunath Shashikant Kamble, Vinay S Tapare
Department of Community Medicine, B. J. G. M. C, Pune, Maharashtra, India
|Date of Web Publication||30-Sep-2015|
Malangori Abdulgani Parande
462/C.2, Greenland Complex, Salisbury Park, Gultekdi, Pune - 411 037, Maharashtra
Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.
Background: Rate of coverage and consumption is the most crucial factor in the success of MDA program against lymphatic filariasis. The roles of the drug distributors and other health workers cannot be ignored in order to achieve success in MDA coverage and compliance. Materials and Methods: This was a cross-sectional study conducted in Solapur district in January 2015. A sample of 672 participants from four clusters was selected through multistage cluster sampling and interviewed using pretested and prestructured questionnaire. Additionally, MDA drug distributors were also interviewed to understand some of the operational issues encountered in MDA program. Results: The average coverage of MDA in Solapur district was 63.7%, the compliance rate was 75.5%, and effective coverage rate was 48.1%. The important reason for higher rate of noncompliance was unsupervised treatment by the drug distributor, beneficiaries were on empty stomach at the time of distribution of drugs, not received the drugs and not available at the time of drug distributor's visit and in urban area was lack of knowledge about the disease. The important reasons for noncompliance quoted by drug distributors were inadequate training of drug distributor, fear of side effects in beneficiaries, and the empty stomach at the time of drug distributor's visit. The majority of health personnel (69.7%) suggested Booth activity as an ideal method for MDA that is planned on a holiday, and more extensive training well before the planned MDA activity.
Keywords: Compliance, coverage, effective coverage rate, mass drug administration
|How to cite this article:|
Parande MA, Kamble MS, Tapare VS. Mass drug administration program against lymphatic filariasis: Are we on the path to success? experience from Solapur District, Maharashtra. MAMC J Med Sci 2015;1:151-6
|How to cite this URL:|
Parande MA, Kamble MS, Tapare VS. Mass drug administration program against lymphatic filariasis: Are we on the path to success? experience from Solapur District, Maharashtra. MAMC J Med Sci [serial online] 2015 [cited 2020 Apr 6];1:151-6. Available from: http://www.mamcjms.in/text.asp?2015/1/3/151/166306
| Introduction|| |
Lymphatic filariasis (LF) is one of the most debilitating and disfiguring scourges among all diseases. Globally, 1.3 billion people are estimated to be at risk of infection, and some 120 million people are infected in 83 countries. The South-East Asia Region accounts for about 65% of the global population at risk and 50% of the infected people. Nine of the 11 countries in the region are known to be endemic for filariasis. About 600 million people are at risk of LF in India. The National Health Policy (2002) has envisaged elimination of LF in India by 2015. The most practical and feasible method of controlling LF is to rapidly reduce the microfilaria load in the community by annual mass drug administration (MDA) of a single dose of antifilarial drugs, that is, diethylcarbamazine (DEC) with or without albendazole to all people residing in endemic areas (excluding children under 2 years, pregnant women and severely ill persons).,,,
Rate of coverage and consumption is the most crucial factor in the success of MDA program. In India, the coverage levels vary from 55% to 90%. When a proportion of the population fails to comply with MDA, a potential reservoir for the parasite is left untreated, opening the door to recrudescence of the microfilaraemia and thus reducing the probability of the program's success. It is estimated that in order to interrupt transmission, MDA compliance must exceed 65–75%, with five to six rounds of treatment; however, compliance is relatively low in the majority of the endemic areas. The major challenge is drug delivery in urban areas and the low priority given to LF.
Many studies have been performed to find out the reasons from the community perspective, but very few made attempts to understand the operational issues from the distributor's perspective. The roles of the drug distributors and other health workers cannot be ignored in order to achieve success in MDA coverage and compliance. Keeping this in mind, this cross-sectional survey was carried out in the Solapur district of Maharashtra state in India with following objectives.
- What is the coverage and compliance of MDA in Solapur district in 2014 and what are the factors affecting compliance?
- What are the operational issues involved in carrying out MDA activities from the perspective of drug distributors?
| Materials and Methods|| |
This was a cross-sectional survey, conducted in Solapur district following MDA round conducted in December 2014 for filariasis. The investigator's team comprised of two trained faculty members from the Department of Community Medicine, B. J. Government Medical College, Pune, who conducted the survey for 3 days. A multistage cluster sampling technique was used to select a sample for the survey.
Four clusters per district (three from rural areas and one from urban area) were identified for the survey. Thus, a total of four clusters were studied. One taluka (cluster) was selected for each low, medium, and high prevalence. If there was no Partners for Healthy Children (PHC) falling in a particular coverage category, the PHC was selected from the next category. So, three PHCs from three different talukas (clusters) from Solapur district were selected. One sub-center from each PHC was later on randomly selected for the survey. One village from each sub-center was selected, and 30 houses from that village were selected randomly. The first house was selected randomly, and the remaining houses were selected continuously from thatfirst house. For instance, if the house was locked then the adjacent house was selected. One ward from the urban area of Solapur district was selected randomly and from that 30 houses were selected randomly. So, a total of 120 houses were selected from the district for survey.
Study design, setting, and participants
To achieve the framed objectives, two different categories of study participants were selected. For the assessment of coverage and compliance, a representative sample of individuals aged 2 years or above was selected. All children of <2 years of age, pregnant women and patients who were seriously ill were excluded and all those who were willing to participate were included in the survey. Data were collected by means of interview technique using pretested, prestructured questionnaire. Informed written consent was taken from the beneficiaries who were willing to participate in this study. In case of children <18 years, consent of the parents/guardian was taken. In addition to this, assent form was obtained from children between 12 and 18 years.
Furthermore, to have an idea about the operational issues or problems during the drug distribution, the drug distributors working in the community who were responsible for the MDA were also interviewed. Generally, the drug distributors working for MDA were all types of health workers such as auxiliary nurse midwives (ANM), accredited social health activist (ASHA), health worker male, anganwadi workers, school teachers, and sometimes the health volunteers of local community. Data were collected from these distributors with the help of pretested, prestructured questionnaire which includes both closed-and open-ended questions. As this was not the primary objective of this study, the sample size was not calculated for the drug distributors. Only those drug distributors which were present at the time of study and were willing to participate in the study were included after taking their informed written consent. Institutional ethical clearance was taken for this study.
Data collected were entered in Microsoft Excel 2010 and anlyzed using SPSS version 18.0 (SPSS Inc. Released 2009. PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc.). Descriptive statistical measures such as percentage, mean, and standard deviation were applied. An inferential statistical test such as Chi-square test was applied for assessing the association of coverage, compliance, and effective coverage rate with locality. Associations were interpreted to be statistically significant at P < 0.05.
| Results|| |
The total number of houses surveyed was 120 (30 families from each cluster chosen randomly). The total population surveyed was 702 out of which 672 (95.73%) were eligible for MDA. The rural eligible population amongst this was 511 (76.0%) and urban was 161 (24.0%). The male to female ratio among the eligible beneficiaries was 1:1.4.
The numbers of beneficiaries interviewed were 179. In this study population, 3.6% were 2–5 years of age, 17.6% were in the age 6–15 years, 72.4% were in the age 16–60 years, and 7.4% were more than 60 years of age.
Coverage and compliance of mass drug administration
Among 672 beneficiaries, MDA were distributed to 428 (63.7%) individuals. Thus, the average coverage of MDA in the Solapur district was 63.7%. The coverage of MDA was significantly higher (P < 0.0001) in the rural areas 391 (76.5%) compared to urban area 37 (23.0%).
Among the beneficiaries who had received the tablets, 323 (75.5%) consumed them (compliance rate). The compliance among those who had received the tablet was also higher in rural areas 300 (76.7%) compared to urban areas 23 (62.2%); but the difference was not statistically significant (P > 0.05).
Effective coverage rate was 323/672 (48.1%). Effective coverage rate was significantly higher (P < 0.0001) in rural areas 300 (58.7%) compared to the urban areas 23 (14.3%) [Table 1].
|Table 1: Comparison of coverage and compliance of MDA in urban and rural settings|
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Out of the 120 houses surveyed, the drug distributor had visited 115 (95.8%) houses. The total number of persons who consumed drugs in the presence of drug distributor were 172/672 (25.6%), rural being 152 (29.7%) and very low in urban that is 20 (12.4%).
The proportion of persons who did not receive or were not given the drugs in an urban area was relatively more than that of rural areas 124 (77.0%) and 120 (23.5%), respectively. The main reason for not taking drugs in a rural area was, beneficiaries were on empty stomach/fasting at the time of drug distributor's visit followed by beneficiaries were not at home. The important reasons for noncompliance in urban areas were a lack of knowledge and non-availability at home at the time of drug distributor's visit. Other reasons are displayed in [Table 2].
|Table 2: Reasons of noncompliance to drugs as per beneficiaries (multiple responses)|
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When the opinion of beneficiaries was assessed regarding who should an ideal drug distributor be, it was found that out of 179 beneficiaries interviewed, 63 (35.2%) told ANM will be an ideal drug distributor followed by ASHA 60 (33.5%), any health worker by 47 (26.3%). Regarding source of information about LF and MDA activity in an area, it was found that miking and davandi will be most effective source (52%) followed by newspaper (30%), ANM (14%), and others (6%).
There were 22 (6.8%) beneficiaries who experienced side effects, common side effects were giddiness followed by nausea and vomiting [Figure 1]. All beneficiaries were aware where to go if they get the side effects, but none visited PHC or subcenter for side effects and only 1 (4.5%) visited the rural hospital while 7 (31.8%) visited the private practitioner and 14 (63.7%) did not take any remedial measures.
Operational issues in mass drug administration activity perceived by drug distributor
Health personnel play a vital role in the distribution of drugs to households. Their efficiency thus determines the success of MDA program. Of the total 33 drug distributors, 19 (57.6%) were males and 14 (42.4%) were females. The mean age of drug distributors was 35.3 ± 8.8 years. Mean years of service were 12.5 ± 6.4. The majority 25 (75.8%) of them were educated up to intermediate, or high school level, and only 8 (24.2%) were educated up to graduation. Occupational distribution showed 8 (24.3%) participants to be ANM, 4 (12.2%) were ASHA workers, 2 (6.0%) were anganwadi workers (employed under Integrated Child Development Services, Government of India), 3 (9.0%) were health assistants, and 16 (48.5%) were health worker (male).
As regards the participants' experience of the MDA, majority, that is, 17 (51.5%) had > 5 years' experience, 14 (42.4%) had 3–5 years' experience, and only 2 (6.0%) had <3 years of experience before taking part in this round of the program.
All health personnel had received training of MDA, but majority, that is 22 (66.7%) received it within a week before the MDA round while 11 (33.3%) received it within 7–15 days before the round.
All drug distributors responded that they emphasized on the importance of consumption of drugs in their presence but 20 (60.6%) told that almost half (40–50%) beneficiaries consumed drugs in their presence and 13 (39.4%) said only 30–40% beneficiaries consumed drugs in their presence while remaining beneficiaries were not ready to take the drugs in their presence due to number of reasons.
All drug distributors revisited the locked houses within 3 days of MDA round but no provision was there in the program for the beneficiaries who come after 3 days of MDA round.
As per the opinion of drug distributor, who should be ideal drug distributor, 13 (39.4%) opined that ANM is an ideal drug distributor followed by health worker (male) (9,27.3%), any health worker (8,24.3%) and anganwadi worker (3,9.0%).
Regarding the source of information for LF and MDA activity, the most effective source will be miking and davandi (18,54.5%) followed by television (12,36.5%) and banners and posters (3,9.0%). The most common side effects of the MDA drug which the drug distributor came across were – nausea and vomiting 12 (36.4%), headache 7 (21.2%), dehydration 4 (12.1%), fever 3 (9.0%), rash 3 (9.0%), and giddiness 1 (3.0%).
Out of 33 respondents, 10 (30.3%) had the opinion that house to house activity was to be followed while 23 (69.7%) suggested Booth activity followed by house to house visit as an ideal method for MDA as that of pulse polio rounds.
The reasons given by drug distributor for noncompliance of MDA drug were - fear of side effects of the drugs, empty stomach at the time of drug distributor's visit, locked houses or not present at home at the time of drug distributor's visit, time constraints, multiple tablets, inadequate training and manpower, and lack of funds.
The important suggestions given by the drug distributors for improvement of MDA activity were, MDA activity to be planned on holiday as Booth approach followed by increase awareness among the beneficiaries, use of mass media like television and newspaper for advertisement and extensive training well in advance of the MDA activity [Table 3].
|Table 3: Suggestions given by the drug distributors for improving MDA program (multiple responses)|
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| Discussion|| |
LF is one of the six 321 diseases which could be targeted for elimination or eradication as a human being is the only reservoir of infection. DEC is an effective drug on the parasite and MDA annually with integrated vector control will result in the elimination of infection by interruption of transmission.
In this study, the average coverage of MDA of Solapur district was 63.7%, the coverage was significantly higher in a rural area (76.5%) as compared to an urban area (23.0%). The minimum required target of 85% for elimination is not fulfilled. Other researchers , from Karnataka and West Bengal also reported the coverage below the required level. However, the coverage rate reported in other studies was comparatively higher than the present study., The reason for inadequate coverage can be attributed to the MDA drugs distributed in the day time when majority of the beneficiaries had left for work hence not available to collect the drugs.
The compliance of MDA is a more sensitive indicator than the coverage as it indicates the actual consumption of tablets by the beneficiaries. Among the beneficiaries who had received the tablets, 323 (75.5%) consumed them (compliance rate); the compliance was also higher in rural areas compared to urban areas, only 172 (25.65%) swallowed the drug in presence of drug distributor, and in urban area it was very low (12.4%). Similar observations were made by other studies ,, but in a study  in Burdwan district of West Bengal, higher compliance rate (85.4%) was noted. The important reason for a higher rate of noncompliance was unsupervised treatment by the drug distributor, mixing of tablets for all members of the family; beneficiaries were on an empty stomach at the time of distribution of drugs.
The effective coverage rate which tests the actual drug intake against the total number of beneficiaries was 323 (48.1%) and was significantly higher in rural areas, than urban areas. In a study  conducted in Karnataka, similar findings were there while in another study  effective coverage rate was low (34.2%). There is no seriousness about the disease as well as the strategy among the beneficiaries. It is evident from the fact that majority of the beneficiaries who did not consume the tablets quoted that the important reasons for nonconsumption were that they did not receive the drugs and that they were not available at the time of drug distributor's visit. In an urban area, the important reason for noncompliance was a lack of knowledge about the disease. In a rural area, the PHC staff is involved in the MDA program while such type of mechanism is absent in urban areas, so urban-specific strategies are needed to increase coverage and compliance of MDA.
One of the reasons for noncompliance quoted was fear of side effects, but ironically side effects were reported only by 6.8%, were minor in nature and the majority either had not taken any remedies, or they visited private practitioner for that. Similarly, Dibakar Haldar et al. reported that only 5.08% of the beneficiaries who had ingested the tablets reported minor side effects.
According to the opinion of the beneficiaries, an ideal drug distributor for this program will be an ANM followed by ASHA. The most effective source of information regarding the MDA activity for these beneficiaries who work best will be miking and davandi.
Regarding the operational issues of this program, in this study we interacted with 33 health personnel who worked as a drug distributor. Even though all health personnel received training of MDA but majority received it within a week prior to the MDA round due to which they would not get enough time to prepare for the activity. The important reasons for noncompliance quoted by drug distributors were fear of side effects, empty stomach at the time of drug distributor's visit, locked houses, or not present at home at the time of drug distributor's visit, multiple tablets, inadequate manpower, and lack of funds.
Majority of health personnel (69.7%) suggested Booth activity as an ideal method for MDA and should be planned on a holiday like pulse polio in addition to increasing awareness among public with the help of effective mass media involvement such as miking and davandi, more extensive training well before the planned MDA activity and fixed dose combination of drugs and increase manpower and funds.
| Conclusions and Recommendations|| |
- The present study of evaluation of MDA reaffirmed the fact of "short of target MDA coverage, compliance and effective coverage rate and huge unsupervised consumption" especially in urban settings. Better compliance in the rural area itself gives us a clue regarding the PHC staff and community involvement, this can be further strengthened and the same model applied in urban areas as well. The drug distributor should insist for "on the spot" consumption of tablets.
- Undercoverage and noncompliance in turn might have resulted from day time distribution of the drugs; beneficiaries were on empty stomach at the time of drug distributor's visit and especially in urban areas the reasons were lack of knowledge and not at home at the time of drug distributor's visit. Low compliance can be addressed by effective behavior change communication and interpersonal communication.
- Side effects of MDA reported were very less and mild in nature. However, no mechanism for reporting and management of side effects and follow-up were seen. Even if side effects are minor and transient, they need to be addressed as they constitute the cause of noncompliance.
- As per health personnel perspective, Booth activity planned on holiday will be an ideal method for MDA along with the mass media involvement such as davandi and miking for increasing the awareness among the public. Fixed dose combination of drugs to be tried for MDA.
The authors are thankful to the Dean, B. J. Government Medical College, Pune and Professor and Head, Department of Community Medicine, BJGMC, Pune for granting permission to conduct this evaluation. The study had financial and material support by the District Malaria Officer, Pandharpur.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]