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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 42-49  

Is the coverage of mass-drug-administration adequate for elimination of Bancroftian filariasis? An experience from West Bengal, India


1 Department of Community Medicine, R. G. Kar Medical College, Kolkata, India
2 Department of Biochemistry, Bankura Sammilani Medical College, Bankura, India
3 Department of Anatomy, Bankura Sammilani Medical College, Bankura, India
4 Department of Community Medicine, Bankura Sammilani Medical College, Bankura, India

Date of Web Publication22-Jan-2015

Correspondence Address:
Dibakar Haldar
Anandapally, Sitko Road, Duttapara, Baruipur, Kolkata - 700 144
India
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DOI: 10.4103/2229-5070.149921

PMID: 25709952

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   Abstract 

Background: Bancroftian filariasis is the second most common mosquito-borne disease in India. Government of India adopted mass-drug-administration (MDA) since 2004 for its elimination by 2015 AD. Objective: The aim was to assess the coverage, compliance, factors-related to noncompliance to MDA. Materials and Methods: A cross-sectional survey of 1 week was conducted within 2 weeks after completion of MDA for 2012 in three villages and two municipal wards of North 24 Parganas district of West Bengal, India selected as clusters by multistage random sampling. Information was collected via interview of inhabitants of the clusters selected by systematic random sampling and drug administrators of the selected clusters along with verifying left over medicines, if any. Results: Both appropriate medicine distribution (83.4%) and 61.28% of people who received drug reported consumption and effective consumption rate (48.01%) fell short of the target. The lowest consumption (38.15%) was noted in one of the rural cluster (villages), followed by municipal wards (43.14%). Consumption was significantly higher among rural residents and Hindu community. Fear of the adverse reaction was the commonest (63.02%) cause of noncompliance. Contrary to the requirement, almost all consumptions were unsupervised by drug administrators. Only 10.71% of the respondents reportedly were paid house to house campaign of forthcoming MDA. About 64% participants had heard about filariasis out of which 71% & 47% mentioned swelling of legs as symptoms and mosquito bite as mode of spread, respectively. About one-third opined mosquito control and MDA each as means of prevention. Approximately, 60% participants had heard about MDA. Information education and communication related to MDA program was conspicuously inadequate in the last round. Conclusion: Mass mobilization as in intensive pulse polio immunization with effective monitoring and supervision is the need of the hour for universal coverage of MDA with supervised on the spot consumption of tablets.

Keywords: Compliance, filariasis elimination, mass-drug-administration, supervision


How to cite this article:
Haldar D, Ghosh D, Mandal D, Sinha A, Sarkar GN, Sarkar S. Is the coverage of mass-drug-administration adequate for elimination of Bancroftian filariasis? An experience from West Bengal, India. Trop Parasitol 2015;5:42-9

How to cite this URL:
Haldar D, Ghosh D, Mandal D, Sinha A, Sarkar GN, Sarkar S. Is the coverage of mass-drug-administration adequate for elimination of Bancroftian filariasis? An experience from West Bengal, India. Trop Parasitol [serial online] 2015 [cited 2019 Jun 24];5:42-9. Available from: http://www.tropicalparasitology.org/text.asp?2015/5/1/42/149921


   Introduction Top


Lymphatic filariasis (LF) is prevalent worldwide. As on December 2006, the total population at risk of LF was estimated to be 1254 million in 83 endemic countries, 64% of which is contributed by Southeast Asia region alone. [1] In India, it is estimated that 554.2 million populations are at risk of LF infection in 243 implementation units (districts). [2] LF has been identified as a potentially eradicable disease by the International Task Force for Disease Eradication. The National Filariasis Control Program (NFCP) was launched in 1955 for the control of Bancroftian filariasis, and now National Health Policy (2002) goal is to eliminate LF from India by the year 2015. [3]

In 1998, the WHO had targeted the elimination of this disease and formulated a Global Program on Elimination of LF (GPELF). The basic features of this program are mass-drug-administration (MDA) with appropriate antifilarial drugs and morbidity management. [4],[5] Under this program, a National Filaria Day (NFD) is being observed once a year since 2004, in the month of November, on a particular day. A single dose of antifilarial 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. [6]

The recommended DEC single dose (at 6 mg/kg of body weight) is one tablet (100 mg) to children of age 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. [7]

It aims at cessation of transmission of filariasis in the community by curbing the microfilaria load in the community. MDA in combination with other techniques has already eliminated filarisis from Japan, South Korea and 16 other countries as well as markedly reduced the transmission in China. [8] LF, the second most important mosquito borne disease [9] is prevalent in Indian states where 243 districts are identified as endemic districts with 29 million people being parasite carriers and 22 million with chronic disease, and accordingly they were included for observing MDA since June, 2004. For the year 2012, MDA activity was carried in 12 endemic districts of West Bengal on 01.03.2012-03.03.2012. The present study was conducted to evaluate the MDA program performance in North 24 Parganas district of West Bengal, India within 2 weeks after MDA activity in the district was over.


   Specific objectives Top


  • To find out the coverage of MDA
  • To assess the compliance of people toward DEC and albendazole tablets consumption and
  • To describe the reasons for noncompliance, if any.

   Materials and methods Top


A community-based cross-sectional survey was carried out for a period of 1 week involving the eligible population. For this purpose multistage, random sampling method was adopted. First, the district North 24 Parganas of West Bengal, India was chosen purposively. Baseline details such as number of PHCs, sub-centers and municipality; total eligible population, reported recoverage rates of last MDA done in North 24 Parganas district, etc., were collected from office of the Deputy Chief Medical Officer of Health-II, North 24 Parganas at Barasat town. Out of 22 blocks of the district 5, 7, and 10 blocks were in the arbitrary categories of low, that is, <75%; medium, that is, 80-90% and high, that is, >90% coverage rate in last MDA, respectively. Similarly, out of 28 municipalities 10, 5, and 13 reportedly were of low, medium, and high coverage, respectively. Three blocks, one each from low, medium, and high coverage and one municipality were selected by simple random sampling for post -MDA survey. Thus, the block Barackpore-I (low coverage), Amdanga (medium coverage), and Barasat-II (High coverage) along with the municipality Halisahar (high coverage) were selected for the coverage evaluation survey.

In the next stage, out of the 32, 25 and 34 sub-centers of Barasat-II, Amdanga, and Barackpore-I blocks one sub-center from each was selected by simple random sampling. Then from each selected sub-center, one village was chosen by simple random sampling. Likewise, two wards (ward 8 and 15) of Halisahar municipality were selected [Figure 1].
Figure 1: Map of the study area

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At least 30 households with a minimum total of 150 individuals from each sub-center area were to be included in the study.

A household list of the selected villages was prepared and subsequently required numbers of households were included following a systematic random sampling technique. Thus, altogether 140 households were selected, and from the selected houses, a total of 697 individuals were surveyed.


   Inclusion criteria Top


All the people ≥2 years.


   Exclusion criteria Top


Pregnant women, lactating mothers, seriously ill-patients.

Information pertaining to age, gender, religion, physiological status of women, ill-health, category of drug administrator (DA) and house-to-house (H-H) visits, information education and communication (IEC), receipt of DEC and albendazole tablets as well as status of consumption, reasons for nonconsumption, adverse events (AEs) and seeking care after AEs, awareness about LF and MDA, etc., were collected via interview of the responsible member(s) of the households and scrutiny of relevant records/left out medicines if any; using a predesigned structured questionnaire. Interview of the DAs including auxiliary nurse mid-wives (ANMs), block medial officer of health (BMOH)/medical officer-in charge (MOIC) of selected block/municipality was conducted. Informed consent from all concerned was obtained and the Ethical clearance for the study as well.

The data were analyzed by calculating various parameters like proportion, mean, standard deviation (SD), median; using statistical methods like tables and diagrams as well as adopting statistical tests like χ2 test, odds ratio (OR) with 95% confidence interval (CI) for drawing statistical inferences. For the purpose of analysis Microsoft Excel, SPSS-16 and Epi info 3.4.3 version were utilized.


   Results Top


The population involved in the survey was 163, 176, 196, and 162 from 40, 33, 31, and 36 H-H of villages Bora, Dariapur, North Jojra and the ward no. 8 and 15 of Halisahar municipality, respectively. Out of 697 people surveyed, 656 (94.12%) were found eligible for MDA. The average age of the participants was 31.54 ΁ 18.63 (mean ΁ SD) with a median of 29 and a range of 2-93 years. Male: female ratio was 1.04:1. Majority (73%) of the study subjects belonged to the age group of 15-60 years. However, 7% were in 2-5 and >60 years of age groups each.

Out of the 656 eligible subjects, 550 (83.84%) received the medicines. The proportions in different clusters were 96.79%, 95.06% and 94.05% in Bora, Dariapur, North Jojra villages, respectively with a gloomy 46.41% in Halisahar municipality.

The task of anti-filarial medicines distribution was carried out mostly by the acredited social health activist (ASHA) (25%) and locally arranged individuals called "community volunteer" (CV) (23%). However, trained Dai (TD) (14%) and angan wadi workers (AWW) (11%) also shared the responsibility. Disbursement of wrong dosage was found to be significantly higher among the new category of DAs, that is, CV deployed in Dariapur village and Halisahar municipality [Table 1].
Table 1: Distribution of drug administrators as per appropriateness of medicine distribution


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Distribution of appropriate dosage was estimated to be about 93.45%, on the whole, being lowest in the Halisahar municipality (71.83%). Out of those received correct dose, as a whole 61.28% consumed the medicines properly, and it was highest in Bora and lowest in North Jojra clusters (97.2% vs. 38.15%). Overall noncompliance rate was 38.72%. Worth mentioning is that 97.52% of the consumption was unsupervised and in this regard no difference could be observed across the clusters. The consumption was significantly higher in rural area (χ2 = 256.11, df = 1, 0.0000; OR 25.19 {95% CI 15.47-41.19}). Coverage was found to be significantly highest in North Jojra and lowest in Halisahar municipality (χ2 for trend = 14.374 and OR 67.84 with reference to that of the Halisahar municipality). However, consumption was revealed to be highest in Bora village and lowest in North Jojra (χ2 for trend = 109.44 and OR 56.34 with reference to that of the North Jojra). Consumption among the Muslim was found to be lower (84.68 versus 41.58%) and the difference was statistically robust (χ2 = 99.89 at df = 1, P = 0.0000000; OR = 7.77 with 95% CI of 4.96-12.20). There was, of course no statistical difference across the gender as well as the age groups in regard to the consumption of medicines (χ2 = 3.57 at df = 1, P = 0.0587743; OR = 1.41 with 95% CI of 0.97-2.05) and χ2 = 1.12 and P = 0.572 at df = 2 [Table 2].
Table 2: Distribution of study subjects as per consumption status of anti-filarial medicines


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The most common cause of noncompliance was found to be "fear of side effects" (63.02%) followed by other reasons like "not aware or counseled" (24.48%), "belief that no drug is required for a healthy individuals" (13.54%), and "not at home" (7.81%) [Table 3].
Table 3: Distribution of respondents as per the reported causes of nonconsumption/wrong consumption (n=199)


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Out of the 140 respondents, 89, that is, almost 64% had heard about LF and out of them majority (70.79%) reported swelling of legs as symptoms of LF. Fever and swelling of hands/body were reported as symptoms by 7.87% and 6.74%, respectively [Table 4]. One or more AE (s) such as headache, body ache, dizziness, vomiting, and drowsiness was/were reported by 5.08% of subjects out of that drowsiness being the most common, that is, 81.25%. No care seeking by the affected individuals reflected the trivial nature of AEs. It was noted that the majority that is, 50.0% of AEs developed within 1 h, 31.25% within 1-24 h and 18.75% developed after 24 h of consumption of medicines.
Table 4: Distribution of study subjects as per their knowledge about the symptoms of lymphatic filariasis (n=89) (multiple responses)


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Out of the respondents who had heard about LF 47.19% reported the exact mode of spread of filariasis. However, more than half (51.69%) were found to have no idea on this issue. Again, one third of them opined for mosquito control and another one third were in favor of MDA for prevention of LF. However, two-fifth (42.69%) revealed to be unaware about prevention of the disease.

Out of 140 respondents, majority, that is, 86 (61.43%) reportedly had heard about MDA and amongst them 47.68%, 22.09%, 5.81% and 20.93% got the message from routine health workers (ANM, ASHA, AWW, TD, community health guide), CV, relatives and television, respectively.

Analysis of multiple responses revealed that only 17.14% respondents reportedly received message about the last round of MDA through the usual modes of mass communication. Only 10.45%, 8.14%, 5.81%, and 5.81% stated TV, banner/poster, radio and local miking, respectively, as the source of message.

Conduction of H-H visit by health workers before the last round of MDA program was reported by only 10.71% respondents and out of them only 46.67% were explained about the program.

Interview of the DAs, ANMs, and BMOHs/MOIC revealed conflicting responses regarding the training/reorientation of the DAs and other staffs of the block in the last round of MDA. What was felt was that the training was not held formally, only the information regarding the date of MDA commencement was disseminated. It was further substantiated by the confusion among the DAs about the lower and upper cut off for age of the beneficiaries. Quite a few occasions, members of the youngest group (just 2 years and slightly more) and old/very old were not supplied with the medicines. It might be due to lack of training or to avoid unwanted public repercussion arising out of anticipated AEs in extremes of ages. It was revealed that the monitoring part of the program, both during and after implementation phase was conspicuous by its absence. Involvement of the Panchayat Raj Institution personnel was not evident in most of the places and in few places it was only indirect and rudimentary in nature. Initiative for community involvement was also noted to be feeble. However, co-ordination between the primary level health workers and the AWWs was vivid. IEC component of the program was ignored understandably. Not much interest among the community members about the program was noticed. Microplan with the site map, deployment of DAs, supervisors, etc., was not found both in the field level and at the headquarters. Moreover, the coverage rate documented at district level was based on the reported coverage by the DAs and consumption were not supervised in most of the cases thereby having a question mark on its reliability.


   Discussion Top


As per WHO DEC coverage in India was recorded as 54.5% during MDA program in 2006. [1] In the present study, the effective coverage was revealed to be 48.01% (93.45 × 61.28) which was far below the desirable coverage of 80% or more and minimum of at least 65% for LF elimination. [10] In their study in Andhra Pradesh Mukhopadhyay et al. reported 64.64% compliance. [2] Babu and Satyanarayana also noted that in East Godavari district of Andhra Pradesh 77% population received DEC in MDA program of which 64% consumed the medicine. [5] The present study revealed that the consumption was significantly higher in a rural area and among the Hindu community with no statistically robust difference across the gender and age groups. In their study in the district of Bankura, West Bengal Ghosh et al. reported significantly higher drug consumption in a rural cluster. [11] Karmakar et al. also observed that consumption rate was higher in rural area and was not different across the gender and age groups. [12] In a study in Thiruvananthapuram district of Kerala, India, Nujum observed that there was no such association between compliance and sociodemographics, however, the study reported association between compliance and type of DAs and recommended for alternate drug delivery system to improve the coverage and compliance. [13] On the contrary, the present study observed improper drug distribution was more among the DAs other than a routine health workers, and it was corroborated with the observations made by Mahalakshmy et al. [14] who along with Babu and Kar [3] also reported lower compliance rate among the subjects who were distributed medicines by volunteers. Rigorous training/retraining and strict supervision cannot be overemphasized in case of deployment of DAs other than a routine health workers as it was rightly suggested by some investigators for the sake of better program performance. A Kenyan study done by Njomo et al. reported that religion was significantly associated with compliance; P < 0.001 (χ2 = 24.021; df 3). Although about one half (49.1%) from the high compared to 34.3% from the low compliance villages were Christians, 40.6% from the low compared to 29% from the high compliance villages were Muslims. [15] However, another study conducted in Philippines by Amarillo et al. observed 60% overall compliance but no influence of religion. [16] Religious difference as revealed in present study might happen exactly in same way what was found in intensified pulse polio-immunization (IPPI), that is, feeling of untrustworthiness/unfaithfulness of beneficiary on the upstart, nonmedical DAs belonging to other religion. There might be some other misconception or religious belief which could not be explored from this study with cross-sectional quantitative approach.

As per present study findings, 97.52% drug consumption remained unsupervised with a high noncompliance rate of 38.72% and "fear of side effects" was reported as the commonest (63.02%) cause of noncompliance followed by "not aware/counselled" (24.48%), "no drug required for a healthy person" (13.54%). High level of noncompliance was observed by Lahariya and Mishra. [17] Kumar et al. also informed "fear of side-effects" as the main cause (80.6%) of nonconsumption while 6.7% did not consume for the reason of failure to deliver the drugs. [18] In their study from Purba Medinipur, West Bengal, India Chattopadhyay, et al. revealed "fear of side-effects" as the most common cause (41.5%) of noncompliance. [19]

This high rate of noncompliance might be multifactorial, for example, forgetfulness, not at home, mixing of tablets for all members of the family, etc., but no doubt the awareness of the beneficiaries regarding LF was one of the important reasons.

The present study revealed that just short of two-third of the respondents heard about LF out of which 70.79% knew swelling of legs as the symptoms, about 47.0% had the correct knowledge about transmission of LF, 60% heard about MDA and routine health workers were stated as the source of message for majority (47.68%) of them whereas 17.14% got information from mass media and only 8.14% from poster and banner. Pre-MDA visit for this round was paid by the HW only in one-tenth of H-Hs. Mukhopadhyay et al. reported that 95% had heard about LF and 64.67% respondents knew that filariasis is a disease. Almost two-third (65.06%) told that it was transmitted by mosquito; 69.96% received DEC and 53.66% (77.85% from Health workers, 20.87% from media) had heard about MDA. [2] Chattopadhyay et al. also explored that 85.1% respondents were aware of filariasis, 38% knew its mode of transmission and 28.9% respondents recommended antimosquito measures for prevention of filariasis. [19] Lower awareness level also reported by Patel (24.3-33.8%), [20] Ravish et al. (41.4%), [9] Ghosh et al. (about 60%), [11] Karmakar et al. (55.42%), [12] Roy et al. (41.4%),[21] and Sinha et al. (55.42%). [22]

The most common cause of noncompliance was found to be "fear of side-effects" but ironically AEs were reported only by 5.08% and all were minor in nature developed within 24 h and no care was sought by the victims. Similarly, Aswathy et al. also reported that only 2.7% of the interviewees who had ingested the distributed tablets reported AEs and these were mild (fever, drowsiness, swelling/edema and/or vomiting) and only occurred within 24 h of tablet ingestion. [23] Chattopadhyay et al. had found that only 2.0% complained of minor side effects. [19]

Studies have shown that the main limitation in this programme is comparatively poor coverage and "on the spot consumption" supervised by DAs. District authorities report higher coverage rate considering the tablet distribution as reported by the DAs but not the supervised "on the spot consumption" which is the essence of the program. [24]

Many independent evaluations from West Bengal, as well as other states of India, portrayed gloomy pictures with effective coverage/compliance rate below the recommended cutoff. [1],[2],[3],[8],[9],[12],[17],[18],[19],[20],[21],[21],[22],[25],[26],[27] This is a matter of concern as the rate of coverage and compliance is the most crucial factor in the success of MDA program and this is to a large extent dependent on the type of personnel involved in as well as mode of drug distribution, that is, whether the consumption by informed motivated individuals is supervised or not.

Ownership of the program seemed to be diluted amongst the stakeholders. Absence of reorientation before the last round of the program and field level monitoring during program implementation might lead to inadequate microplaning with deployment of DAs who in turn finished their task merely by distribution of tablets allowing almost 98% clients left for self-consumption. Very feeble community mobilization/interest might be indicative that the program has lost its momentum/gravity to the beneficiaries as well.

Sub-optimal awareness as well as interest of the beneficiaries about LF and or the program arising out of the under-functioning of various components of the program, specially the IEC was found very evident.

Poor coverage and compliance in urban areas was revealed to be a concern as observed by Weerasooriya et al. that information of MDA reached more people in the periphery than in Colombo city, 35.2% from Colombo municipality were unaware of MDA, 35.6% in Colombo district and 53.4% from Colombo municipality did not receive drugs and drugs were consumed by 71.4% of those who received. The study revealed significant positive correlation between consumption and awareness of MDA and concluded that poor awareness and compliance in Colombo and urban areas could be rectified with separate strategy for urban areas, more time for MDA and trained adequate manpower would ensure coverage to achieve elimination. [28]

With due apprehension about the consequence of dismal under coverage and noncompliance, Joseph et al. concluded from their study that in Samoa, persistent transmission in residual areas, despite many years of MDA might be in part due to systematic noncompliance of infected individuals who maintained the chain of transmission serving as reservoirs, thus impeding successful elimination of LF in Samoa. The study established that among the infected individuals, 33% admitted to being systematically noncompliant with a significant association between MDA compliance and knowledge of LF. This exploratory study also highlighted the need for restructuring current educational campaign and their deliverance to systematically noncompliant individuals. [29]


   Take home message Top


  • Present study reaffirmed the fact of "short of target MDA coverage/compliance and huge unsuprevised consumption," especially in the urban settings - the observations made by many investigators
  • Undercoverage/noncompliance in turn might have resulted from less awareness and interest of people about LF as well as the MDA due to suboptimal implementation of IEC components of the program
  • Casual mindset of providers and clients might be due partly to the fatigue of prolong program implementation as well as to the apparent benign nature of LF, for example, lack of epidemic potentiality, long incubation period and gradual onset and progression to serious stage, etc., which are enough to confuse the lay people to co-relate the disease with mosquito-bite as mode of transmission.

   Conclusion Top


Unsupervised reported short of target consumption is to be considered seriously to prevent resistance to the best weapon, that is, MDA for fighting against LF. Rethinking on the part of stakeholders is the need of the hour for strengthening of MDA program by every possible way keeping in view the fact that strict directly observed MDA, that is, supervised antifilarial medications along with universal coverage should be the mainstay of the GPELF. It can be another historical initiative incorporating the mixed strategies/approaches of DOTS in RNTCP and IPPI programs which successfully made the wheel turn in reverse direction with supervised short course chemotherapy and universal OPV coverage through intensive social mobilization via powerful advocacy, H-H visit for covering the left out beneficiaries, behavior change communication for motivating the systematically noncompliants people participating in MDA, supportive supervision, etc.


   Acknowledgment Top


The authors sincerely thank the Deputy Director of Health Services (PH and CD), Government of West Bengal, India for giving permission.

 
   References Top

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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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