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Mass drug administration coverage evaluation for elimination of lymphatic filariasis in Chhatarpur district of Madhya Pradesh.

Abstract

Background: Mass drug administration (MDA) means administration of diethylcarbamazine (DEC) tablet to all people (excluding children <2 years, pregnant women, seriously ill persons) in endemic areas once in a year is one of the strategies to eliminate lymphatic filariasis.

Objective: To assess the coverage and compliance of MDA and factors for noncompliance.

Materials and Methods: A community-based cross-sectional house-to-house visit was carried out in endemic district Chhatarpur. Three rural and one urban clusters of Chhatarpur district, Madhya Pradesh, we selected as per National Vector Borne Diseases Control Programme guidelines. A predesigned questionnaire was used to collect information regarding consumption of DEC and other relevant information. Actual coverage, compliance, effective coverage, coverage-compliance gap (CCG), reasons for noncompliance, side effects, if any, were studied. SPSS, version 11.5, for Windows was used for statistical analysis.

Results: A total of 120 households surveyed yielded 643 eligible population. Coverage rate was 78.84%, and compliance rate, CCG, effective coverage rate was 76.52%, 23.48%, and 60.34%, respectively. It was found that 255 persons did not consume the drug. Out of 255, 53.3% did not receive drug. Fear of side effects and loose tablet distribution (low quality

of drug) were the most common reasons found for nonconsumption in rural and urban areas, respectively. Persuasion for consumption of drug by a drug distributor (DD) was found in only 35% households. Only 11.67% household had prior information regarding MDA. Information, education, and communication (audiovisual aids) activity reached to only 31.67% households. Side effects were experienced by 4.4%.

Conclusion: Both coverage and drug compliance need to be improved. Issues like fear of side effects should be addressed through effective behavior change communication strategies.

KEY WORDS: Coverage, compliance, mass drug administration, lymphatic filariasis

Introduction

Lymphatic filariasis (LF) or elephantiasis is one of the six diseases that can potentially be eradicated. The infection is endemic in more than 80 countries, with more than 1.3 billion people at risk and 120 million already infected globally. [1] It is the fourth most common cause of disability worldwide. [2] Two-thirds of the endemic population resides in South-East Asia and one-third lives in India. [3] Considering the human suffering, social stigma, and costs associated with LF morbidity, and in response to the specific resolution by the World Health Assembly, the Global Program to Eliminate Lymphatic Filariasis was launched by the World Health Organization (WHO) in 2000 with the goal of eliminating LF as a public health problem by the year 2020. [4] In 2002, India set an ambitious national health goal to eliminate LF by 2015. [5] To achieve this goal, a "two-pillar" strategy of interrupting transmission through mass drug administration (MDA) with diethylcarbamazine (DEC) and providing care for those with the disease was adopted. [6] India's filarial control program has scaled up MDA over the past several years and recently added albendazole (ABZ) to the treatment of the 590 million Indians living at risk of infection. [7] In MDA, the drug is to be consumed in the presence of a drug distributor (DD). DEC is given to almost everyone in the community, irrespective of their symptoms. This is indicated in high and hyperendemic areas. A single dose is recommended by international task force (WHO) for all except for children below 2 years, pregnant women, and very sick patients. [8] The principle behind MDA is that a single dose of DEC administered annually for 4-6 consecutive years will interrupt the transmission of filariasis. [9] However, the number of MDA rounds necessary to achieve elimination depends, to a large extent, on coverage, drug efficacy, and the endemicity level. It is estimated that to interrupt transmission, MDA compliance must exceed 65%-75%, with 5-6 rounds of treatment. [10] In India, the coverage levels vary from 55% to 90%. In India, some states viz. Andhra Pradesh, Bihar, Jharkhand, and Madhya Pradesh are among the worst affected states in the country. [11] On the basis of microfilaria surveys and the line listing of lymphoedema cases, Madhya Pradesh had identified 11 districts, and accordingly, they has been included for observing MDA since 2004. [12] The present survey was carried out to evaluate the coverage, compliance, and reasons for noncompliance (community perspective) of MDA in Chhatarpur district of Madhya Pradesh.

Materials and Methods

Mass drug administration of DEC was carried out in Chhatarpur district on April 2010. A community-based cross-sectional study was conducted for the evaluation of MDA by a household survey in four selected clusters (three rural and one urban) of Chhatarpur district of Madhya Pradesh as per National Vector Borne Diseases Control Programme (NVBDCP) guidelines. The field survey was conducted after 2 months of MDA campaign (i.e., in July 2010). The study team constituted faculty members and postgraduate students of the Department of Community Medicine. The objective was to study the coverage and compliance, reasons for noncompliance, and drug-related side effects in the community. Feedback about the role of a DD in imparting health education, persuasion for consumption of drug, and knowledge about any information, education, and communication (IEC) activity undertaken before the start of the MDA round was obtained from the community. For selection of rural sites, one village was selected from a primary health center (PHC) with low coverage of DEC (i.e., below 50%), one village was selected from a PHC with medium coverage of DEC (i.e., between 50% and 80%), and one village was selected from a PHC with high coverage of DEC (i.e., above 80%). For urban area, one ward of the district was selected randomly. The selected three villages and one urban ward were designated as clusters. Selected villages and their representative PHCs were Rajapur (Bamitha), Dipoli (Ramtoria), and Angour (Angour). In urban area, ward no. 38 was selected. House-to-house survey was carried out. The house for the beginning point was selected randomly and the team moved in a particular direction. All the subjects in the house except the children less than 2 years and pregnant women were included. In each of the selected clusters 30 households were surveyed. Thus, 120 households were surveyed for evaluation of MDA. A predesigned questionnaire (provided by Director Health Services, State Health Committee, NVBDCP) was used to collect information regarding consumption of DEC and other relevant points. The data obtained were entered and analyzed using Statistical Package for the Social Sciences (SPSS), version 11.5, for Windows. All the sampled eligible population in the study area was included in the study. Exclusion criteria were pregnant and lactating mother, children below 2 years, seriously ill persons, severely debilitated patient, and elderly people.

The working definitions adopted for drug coverage and drug compliance as per NVBDCP guidelines are as follows:

Drug coverage: It is the number of eligible persons who received DEC during MDA campaign. It is calculated as the total number of persons who received drug divided by eligible population and is expressed as percentage.

Drug compliance: It is the number of persons who ingested DEC in presence of a DD during MDA campaign. It is calculated as the total number of persons who ingested drug divided by total number of persons who received the drug and is expressed as percentage.

Coverage-Compliance Gap (CCG): It refers to the people who got the drug but did not consume due to various reasons.

Effective coverage rate: It is the end product of coverage by the health system and compliance by community. The percentage for effective coverage was calculated after taking total number of people who were eligible for receiving DEC tablets as denominator (Effective coverage = No. of people who had ingested sufficient dose of DEC tablets/Total people eligible for receiving the DEC tablets x 100).

Ethics

The study was cross sectional and did not involve patient intervention methods; hence, ethical issue does not arise.

Limitation

This study was conducted after 2 months of MDA campaign, which is a limitation (recall bias).

Results

District Chhatarpur was selected as the study area. This district is one of the 11 endemic districts of MP. MDA round was conducted in April 2010. As per the 1991 census, the total population of the district was 1,158,076 out of which 934,552 was rural population and 223,524 is urban. Out of total population, 43,482 were scheduled tribes. Four clusters, including one from urban and three from rural areas, were studied. A total 120 households (90 rural and 30 urban) were surveyed, yielding a population of 685. Of 685 individuals, 643 were found to be eligible for drug administration (93.86%). Of 643 eligible persons, 507 received DEC by a DD. Overall coverage rate of study population was found to be 78.84% [Table 1]. It was highest in Rajapur (Bamitha; 89.24%) and lowest in Angour (65.77%). Compliance rate, CCG, and effective coverage rate are shown in Table 2. Effective coverage rate was marginally higher in urban area than rural areas, but no significant difference was found [Table 3]. The remaining (n = 255), although eligible, did not consumed the drug for various reasons [Table 4]. Of these 255 individuals, almost half of the eligible population (53.3%) did not received drug because the DD failed to deliver drug to them. This proportion was much higher in rural areas [Table 4]. Common reasons found in rural areas DD visited households when almost all family members went to the farms. The most common reason found in urban areas was they went to some other place on vacation. Of 255, 119 (46.7%) persons received the drug but did not consume due to various myths. The most common reason found was the drug was perceived hot (fear of side effects) in rural population. Loose tablet distribution (low quality of drug) was the most common reason cited by urban population for nonconsumption [Table 4]. Persuasion for consumption of drug by the DD was reported by only 35% households. Rest said that the DD handed over drugs to one family member for consumption later on. Similarly, information regarding prevention and transmission of filaria and why DEC is being given was furnished to only 35% households. Very few household had prior information regarding MDA (11.67%). In rural areas, almost all of them got this information by health staff and Integrated Child Development Services workers. Similarly IEC (audiovisual aids) activity reached to only 31.67% households [Table 5]. Side effects were experienced by 17 persons out of 388 (4.4%), which was acceptable. These were minimal, well documented, and transient.

Discussion

The present study revealed coverage rate of 78.84%, which is far behind that reported by another study conducted in Madhya Pradesh. [13] However, the success of elimination mainly depends on the actual consumption or compliance with MDA rather than the MDA coverage. This study revealed that actual MDA compliance was 76.52%. Several other studies across India revealed varied MDA compliance ranging from 42% to 89%. [14-17]

The drug distribution was during daytime when the members of the households had been to work. Most of the people were not available at home during the morning hours, so the DDs handed over the tablets to any member of the family for the whole family, thereby reducing the compliance. Thus, there is a definite need to ensure that the DD meets the person, for which he may visit the home in the evening. Similar findings were reported in another study. [11] Revisits of the houses were not undertaken in most of the places due to lack of human resources. Recruitment of more field staff is needed for door-to-door visits to have effective coverage and on-the-spot drug administration. There is an urgent need for more effective drug delivery strategies. The roles of the DDs and other health workers cannot be ignored to achieve success in MDA coverage and compliance.

Besides, the fact that DDs handed over the tablets to any one member of the family for the whole family and did not ensure that the person concerned consumes the tablets in front of them further reduced the compliance.

The concept of MDA is to approach every eligible individual in the target community and administer annual single dose of DEC. This annual dose is to be repeated every year for a period of 5 years or more with a minimum of 85% drug compliance. A highly effective coverage of (>85%) is essential to achieve the interruption of transmission and elimination of disease in India. [6] Effective coverage is one of the most valuable indicators because it reflects both coverage and compliance. It actually denotes the compliance by the community with respect to the eligible population. The effective coverage (60.34%) was far behind the recommended level ([greater than or equal to]85%) in the present study.

Coverage compliance gap is a better indicator for assessing the effectiveness of MDA program among program managers. It actually reflects the proportion of covered people not consuming the drugs and explores the possible determinants for nonconsumption. The present study revealed a CCG of 23.48%. Lesser proportion of CCG (11%) was reported in a study conducted in Gujarat. [14] Another study conducted in Madhya Pradesh reported CCG of 10.1%. [13] The difference might be due to different study setting. The CCG may be bridged up by giving enormous stress on Behavior Change Communication (BCC) strategies that aim to motivate the people for drug consumption and stress on supervised dosage.

Regarding the channels of behavioral change communication, both interpersonal and mass media communication strategy were found inadequate for awareness generation among the community, which necessitates the strengthening of BCC activities. Audiovisual aids have poor penetration, particularly in rural areas. Persons got prior information regarding MDA and DEC through health staff and previous round. This must be kept in mind when planning for IEC activities.

This study revealed DD imparted knowledge and awareness about LF and MDA to few community members. Hence, they have restricted knowledge about the disease and its control measures. Similar findings have been reported in other studies conducted in India. [7,18,19]

In our study, the fear of side effects was the major issue for poor compliance. Similar findings have been reported by Nirgude et al. [20] in their study. Godale and Ukarande [21] also reported fear of side effects of drugs (45.38%) as the most common reason for noncompliance followed by lack of awareness about LF. The present study reported very few side effects and they were also minor, transient (lasting few hours), and drug specific. Similar lower incidences of side effects were reported from endemic areas of Gujarat and rural West Bengal of India. [14, 22] However, they also need to be addressed as they constitute the cause of noncompliance and may adversely affect the next round. Therefore, it is imperative that people are made aware about these side effects to take proper management and not to have any misconception or fear. Training program for medical officers and health workers involved in MDA should emphasize more on how to address the fear of side effects among beneficiaries and measures to ensure "On-the-Spot Swallowing" of tablets. A common understanding is that drug is hot ("dava garam hai, garmi karegi ") prevails about allopathic medicine, particularly in rural community. Interpersonal communication may be more effective particularly when imparted by some elderly person among them. Importantly, fear is not directed specifically to DEC, which was general to any allopathic medicine. All these aspects can be taken care of by supervised "on-the-spot" DEC consumption and raising awareness of general population regarding LF (demand creation). People residing in urban areas raised the issue of distributing loose tablets. This implies that people do not have faith in the government-supplied drugs. To conclude, this study revealed that both coverage and drug compliance needs to be improved. Issues like on-the-spot swallowing, knowledge of the community regarding LF, and its common preventive and control measures including MDA and fear of side effects were not comprehensively addressed through intensive BCC strategies.

Recommendations

1. Coverage may be increased by developing a micro-plan by taking consideration the geographical location (population density/sparsity) and accordingly the number of DD and farming practices. Date and time selected for the MDA should suit for majority of the population.

2. Efforts are needed to reduce CCG gap before increasing the coverage. It needs motivating and sensitizing the community about LF through intensive health education. Community needs to be sensitized about benefits of consuming drug. Patients with filariasis residing in the community may be involved in such campaign.

3. Incidence of side effects after MDA was minimal. All side effects were mild and needed no medical intervention but need assurance. For this, medical team may be constituted at HQ and a toll-free number may be organized and widely publicized before round.

4. DD hardly insisted on supervised "on-the-spot" administration of drugs. This issue can be addressed by strict supervision and immediate feedback. This alone can bring down the CCG considerably.

5. Due emphasis must be given in training of DD on persuasion and assurance of side effect.

6. Many persons raised the issue of distributing loose tablets. This can be explained scientifically by the DD that it will reduce the cost of the medicine without affecting the quality.

7. Various modes of pre-MDA IEC can be used. For interpersonal communication, announcement in local language will be suitable for rural areas as most of them are illiterates. The announcement should be done just few days before the campaign. IEC should focus on the rationale for MDA, its benefits, side effects, risk-benefit approach, date of the MDA round, and whom to contact if they did not get drug. A toll-free number may be arranged and widely publicized regarding any information about LF, prevention, MDA, its side effect, management of side effect, and so on.

Conclusion

Both coverage and drug compliance need to be improved. Issues like fear of side effects should be addressed through effective BCC strategies.

References

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[3.] World Health Organization. Neglected Tropical Diseases, Hidden Successes, Emerging Opportunities. Geneva: World Health Organization, 2009. Available at: http://www.who.int/iris/handle/10665/44214#sthash.w9257Gz8.dpuf website (last accessed on October 24, 2014).

[4.] World Health Organization. Progress Report 2000-2009 and Strategic Plan 2010-2020 of the Global Program to Eliminate Lymphatic Filariasis: Halfway Towards Eliminating Lymphatic Filariasis. Geneva: World Health Organization, 2011. Available at: http://whqlibdoc.who.int/publications/2010/9789241500722_eng.pdf website (last accessed on October 24, 2014).

[5.] Ministry of Health and Family Welfare, Government of India. National Health Policy. Ministry of Health and Family Welfare, Government of India, 2002. Available at: http://planningcommission.nic.in/sectors/health.php?sectors=hea website (last accessed on October 24, 2014).

[6.] Ministry of Health and Family Welfare, Government of India. Guidelines on Filariasis Control in India and its Elimination. National Vector Borne Disease Control Program; Ministry of Health and Family Welfare, Government of India, 2009. Available at: http://nvbdcp.gov.in/doc/guidelines-filariasiselimination-india.pdf website (last accessed on October 24, 2014).

[7.] Ramaiah KD. Lymphatic filariasis elimination programme in India: progress and challenges. Trends Parasitol 2009;25:7-8.

[8.] Suryakantha AH. Community Medicine with Recent Advances, 2nd edn. New Delhi: Jaypee Brothers, 2010. p. 412.

[9.] Ottesen EA, Duke BOL, Karam M. Strategies and tools for the control/elimination of lymphatic filariasis. Bull World Health Organ 1997;75:491-503.

[10.] Stolk WA, Swaminathan S, van Oortmarssen GJ, Das PK, Habbema JDF. Prospects for elimination of bancroftian filariasis by mass drug treatment in Pondicherry, India: a simulation study. J Infect Dis 2003;188:1371-81.

[11.] Lahariya C, Mishra A. Strengthening of mass drug administration implementation is required to eliminate lymphatic filariasis from India: an evaluation study. J Vector Borne Dis 2008;45:313-20.

[12.] National Vector Borne Disease Control Programme, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Filaria Endemic Districts. Available at: http://www.nvbdcp.gov.in/fil-map.html (last accessed on October 16, 2014).

[13.] Singh S, Patel M, Kushwah SS. An evaluation of mass drug administration compliance against filariasis of Tikamgarh district of Madhya Pradesh--a household-based community study. J Family Med Prim Care 2013;2(2):178-81.

[14.] Kumar P, Prajapati PB, Saxena D, Kavishwar AB, Kurian G. An evaluation of coverage and compliance of mass drug administration 2006 for elimination of lymphatic filariasis in endemic areas of Gujarat. Ind J Com Med 2008;33(1):38-42.

[15.] Nandha B, Sadanandane C, Jambulingam P, Das PK. Delivery strategy of mass annual single dose DEC administration to eliminate lymphatic filariasis in the urban areas of Pondicherry, South India: 5 years of experience. Filaria J 2007;6:7.

[16.] Babu BV, Kar SK. Coverage, compliance and some operational issues of mass drug administration during the programme to eliminate lymphatic filariasis in Orissa, India. Trop Med Int Health 2004;9(6):702-09.

[17.] Mahalakshmy T, Kalaiselvan G, Parmar J, Dongre A. Coverage and compliance to diethylcarbamazine in relation to Filaria Prevention Assistants in rural Puducherry, India. J Vector Borne Dis 2010;47:113-15.

[18.] Mukhopadhyay AK, Patnaik SK, Satya Babu P, Rao KNMB. Knowledge on lymphatic filariasis and mass drug administration programme in filarial endemic district of Andhra Pradesh, India. J Vector Borne Dis 2008;45:73-5.

[19.] Rath K, Nath N, Shaloumy M, Swain BK, Suchismita M, Babu BV. Knowledge and perceptions about lymphatic filariasis: a study during the programme to eliminate lymphatic filariasis in an urban community of Orissa, India. Trop Biomed 2006;23:156-62.

[20.] Nirgude AS, Naik PR, Kondagunta N, Sidramappav RS, Anant TA, Prasad VG. Evaluation of coverage and compliance of mass drug administration programme 2011 for elimination of lymphatic filariasis in Nalgonda district of Andhra Pradesh, India. Natl J Commun Med 2012;3(2):288-93.

[21.] Godale LB, Ukarande BV. A study on coverage evaluation, compliance and awareness of mass drug administration for elimination of lymphatic filariasis in Osmanabad district. Natl J Commun Med 2012;3(3):391-4.

[22.] Haldar A, Mundle M, Haldar S, Biswas AK, Mitra SP, Mahapatra BS. Mass DEC campaign for filariasis in a hyper endemic district of West Bengal. J Com Dis 2001;33(3):192-7.

Neera Marathe (1), Charudatt Chalisgaonkar (2)

(1) Department of Community Medicine, S.S. Medical College, Rewa, Madhya Pradesh, India.

(2) Department of Ophthalmology, S.S. Medical College, Rewa, Madhya Pradesh, India.

Correspondence to: Neera Marathe, E-mail: neera13@rediffmail.com

Received March 8, 2015. Accepted March 15, 2015

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How to cite this article: Marathe N, Chalisgaonkar C. Mass drug administration coverage evaluation for elimination of lymphatic filariasis in Chhatarpur district of Madhya Pradesh. Int J Med Sci Public Health 2015;4:927-932

Source of Support: Study was funded by Govt. of Madhya Pradesh, India, Conflict of Interest: None declared.

International Journal of Medical Science and Public Health Online 2015. [c] 2015 Neera Marathe. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

Table 1: Distribution of population of surveyed districts

District               Total          Eligible          Population
Chhatarpur             population     population        covered (out
                                                        of eligible)
                                       N       %         N        %

Chhatarpur urban          139         132    94.96      115     87.12
Rajapur (Bamitha)         172         158    91.86      141     89.24
Dipoli (Bada Malhara)     217         204    94.0       153     75.0
Angour (Satai)            157         149    94.9        98     65.77
Total                     685         643    93.86      507     78.84

Table 2: Compliance rate, coverage-compliance gap, and effective
coverage rate

District       Eligible   DEC given   Consumed    Coverage-  Effective
Chhatarpur     population  by DD    (compliance  compliance  coverage
                                       rate)       gap         rate
                                     N      %       %           %

Chhatarpur       132       115      87    75.65    24.35      65.90
urban
Rajapur          158       141     108    76.59    23.41      68.35
(Bamitha)
Dipoli           204       153     112    73.20    26.80      54.90
(Bada
Malhara)
Angour           149        98      81    82.65    17.35      54.36
(Satai)
Total            643       507     388    76.52    23.48      60.34

Table 3: Drug coverage and compliance rates in urban and rural settings

Area             Coverage         Compliance     CCG (%)  Effective
                 rate (%)         rate (%)                coverage
                                                          rate (%)

Urban (N = 132)    87.12           75.65         24.35     65.90
Rural (N = 511)    76.71           76.78         23.22     58.90
Total (N = 643)    78.84           76.52         23.48     60.34
P-value             0.0084, very    0.8032, not    -        0.1717, not
                    significant     significant             significant

Table 4: Reasons for not swallowing drug

Reason                         Rural          Urban            Total
                             (n = 210),      (n = 45),       (n = 255),
                               no (%)         no (%)           no (%)

Drug not delivered           119 (56.66)     17 (37.77)     136 (53.33)
Drug is hot                   42 (20.0)      07 (15.5)       49 (19.2)
Previous experience
of side effect
(family members
and neighbors)                11 (5.2)       06 (13.3)       17 (6.67)
Out of house (drug
left to the family
members)                      09 (4.28)          -           09 (3.52)
Do not take
allopathic medicine           11 (5.2)           -           11 (4.31)
Not perceived important       18 (8.57)          -           18 (7.05)
Loose tab given by DD           -            15 (33.33)      15 (5.88)

Table 5: Drug distributor's interest and media approach to reach the
house-holders

                                   No of key persons             %
                                   in household
                                   interviewed (n = 120)

DD persuaded swallowing                 42                       35
of drug in his presence
DD explain importance and               42                       35
other details regarding
prevention and transmission
Prior information of                    14                       11.67
MDA dose, C/I , side effect
Any audio or visual                     38                       31.67
media announcement on MDA
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Title Annotation:Research Article
Author:Marathe, Neera; Chalisgaonkar, Charudatt
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Date:Jul 1, 2015
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