|Year : 2017 | Volume
| Issue : 3 | Page : 137-142
Coverage of mass drug administration and status of mass drug administration program in Bankura district of West Bengal, India
Dibakar Haldar1, Sanjay Kumar Saha1, Amiya Dwari2, Daliya Biswas1, Sourav Lo1, Saswati Naskar1, Gautam Narayan Sarkar1
1 Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
2 Department of Pulmonary Medicine, NRS Medical College, Kolkata, West Bengal, India
|Date of Web Publication||9-Aug-2017|
Sanjay Kumar Saha
Sahapur Govt Housing Estate, Flat G/4, Kolkata-700038, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Government of India adopted mass drug administration (MDA) since 2004 for elimination of lymphatic filariasis (LF) by 2015 AD. MDA implementation in WB has been criticized for low coverage and Government of West Bengal (WB) emphasized directly observed therapy (DOT) (swallowing of medicines under supervision) in MDA implementation.
Objective: The objective of the study was to assess coverage of MDA and status of MDA program.
Materials and Methods: A cross-sectional survey was conducted in three subcenters of three blocks and three wards of Bankura municipality of Bankura district, WB, selected by multistage random sampling technique. Information was collected through interviewing randomly selected inhabitants; ground level workers and block level supervisors of selected clusters with verification of records/logistics used in MDA at clusters and leftover medicines at households.
Results: Around two-third of respondents knew LF among which 83.33% considered limb swelling as an important symptom and 30.34% knew about transmission. Appropriate distribution and consumption of both MDA medicines were 70.10% and 56.20% with 64.89% consumption being supervised. Information education and communication and monitoring were suboptimal including utilization of strength and opportunity of MDA program.
Conclusion: Supervised medicine consumption was found marginally increased seemingly due to DOT through repeat house visits, but effective coverage fell short of target as a result of dismal low coverage in urban cluster.
Keywords: Elimination, lymphatic filariasis, mass drug administration
|How to cite this article:|
Haldar D, Saha SK, Dwari A, Biswas D, Lo S, Naskar S, Sarkar GN. Coverage of mass drug administration and status of mass drug administration program in Bankura district of West Bengal, India. Int J Health Allied Sci 2017;6:137-42
|How to cite this URL:|
Haldar D, Saha SK, Dwari A, Biswas D, Lo S, Naskar S, Sarkar GN. Coverage of mass drug administration and status of mass drug administration program in Bankura district of West Bengal, India. Int J Health Allied Sci [serial online] 2017 [cited 2018 Jul 17];6:137-42. Available from: http://www.ijhas.in/text.asp?2017/6/3/137/212595
| Introduction|| |
In 1998, the World Health Organization had targeted elimination of lymphatic filariasis (LF) and formulated a global program on elimination of LF. India's National Health Policy (2002) goal is to eliminate LF by 2015. Mass drug administration (MDA) has been implemented since 2004 in India including West Bengal (WB) aiming at cessation of LF transmission by curbing microfilaria (Mf) load in community to <1%. In previous rounds, directly observed therapy (DOT), i.e., consumption of antifilarial medicines under supervision has not been emphasized and post-MDA coverage evaluation surveys (CESs) highlighted low coverage with high unsupervised consumption in WB. Independent appraisal carried out by vector control research center, Puducherry in July, 2014, revealed Mf rate well over 1% in LF-endemic districts such as Birbhum and Bankura of WB. Being stricken by abysmally high Mf rate and deadline of LF elimination, the Government of WB first time put emphasis on DOT through repeat house visits, paradigm shift in strategy of MDA implementation in April 2015 round. In its debut, DOT could not make impressive dent into inherent low coverage and unsupervised consumption of MDA. On the verge of LF elimination, DOT through repeat home visits was practiced once again in the last round of MDA held in December 2015 involving five districts of WB with high Mf rate, including Bankura.
Research question: what is the coverage of MDA and status of MDA program in Bankura district?
- To assess the coverage of MDA in December 2015 round
- To find out correlates of noncompliance, if any
- To describe strength, weakness, threats, and opportunity (SWOT) of MDA program.
| Materials and Methods|| |
A cross-sectional survey carried out within 2 weeks after implementation of the last round of MDA (house-to-house visit on initial 6 days for drug administration through DOT by drug administrator [DA] and check survey by MDA supervisors on last 2 days) in Bankura district. Of 22 community development blocks of district, 7, 9, and 9 were in arbitrary categories of low, medium, and high performing with <70%, 70%–85%, and >85% MDA coverage rate in the last round. Of three municipalities, Bankura and Bishnupur municipalities had low coverage rate, i.e., <70% and Sonamukhi municipality reported medium coverage of 70%–85%. As the first step of multistage random sampling, one block primary health center (BPHC) from each of category of block and one municipality of any coverage were selected by simple random sampling (SRS) for post-MDA CES. Thus, Hirbandh (low coverage of 62.03%), Indpur (medium coverage of 78.53%), and Onda (high coverage of 90.95%) BPHCs along with Bankura municipality (coverage of 66.0%) were selected as clusters. Next, one subcenter (SC) was selected by SRS out of the 18, 27, and 34 SCs of Hirbandh (Bhuakana SC), Indpur (Chakoltore SC), and Onda (Majhdia SC) BPHCs, respectively. Subsequently, three villages/municipal wards were chosen by SRS from each cluster. Then, households (HHs) were selected following systematic random sampling technique in a manner that criteria of both minimum 30 HHs and 150 individuals from each cluster were fulfilled. Thus, a total of 692 individuals were surveyed from 132 selected HHs with breakup of 168, 178, 171, and 175 individuals from 30, 30, 36, and 36 HHs from SC Bhuakana, Chakoltore, and Majhdia and ward no. 1, 6, and 20 of Bankura Municipality, respectively.
Inclusion criteria were people aged ≥2 years.
Exclusion criteria were pregnant women, lactating mothers, and seriously ill individuals.
Information was collected interviewing responsible member(s) of HHs and ground level health workers (HWs) as well as their block level supervisors using predesigned questionnaire, scrutinizing relevant records/left out medicines. Socioeconomic status (SES) of respondents was determined by modified B. G. Prasad's scale updated by 2014.
Data were analyzed by SPSS Statistics 22 version (IBM Armonk, New York, USA) for estimation of mean, standard deviation (SD), proportion, and using tables and diagrams for display. Chi-square test and odds ratio with 95% confidence interval were used for drawing statistical inferences. Multiple logistic regressions were done for establishing a relationship between variables.
Limitation of study
Information regarding medicines distributed/consumed could not be verified as survey was conducted after 2 weeks since MDA implementation and respondents failed to show empty strips of MDA medicines which were disposed by that time. All beneficiaries in sampled HHs could not be interviewed, and recall bias with socially favorable responses by noncompliants were likely.
| Results|| |
Among 692 individuals surveyed, 669 (96.68%) were eligible for MDA, of which 23.77%, 25.71%, 25.26% and 25.26% contributed by cluster Bhuakana, Majhdia, Chakoltore, and Municipality, respectively.
Sociodemographics of participants
Participants were Hindu predominantly from joint family (60.69%), backward class (74.0%), adult (77.0%) with slight male dominance (50.67%), and 6.0%, 17.0%, and 77.0% belonged to age group of 2–5, 6–14, and ≥15 years, respectively. Average age was 31.47 ± 19.34 (mean ± SD) with range 2.5–95 years.
Overall, around 41% participants were illiterate/just-literate or yet to schooling, and it was found true at cluster level also except municipality where the figure was slightly more than one-fifth. Overall proportion of people having education up to Madhyamik Pariksha and above was about one-tenth, but it is due to higher proportion in municipality where it was almost 30%.
Overall, one-fourth of participants were student and homemaker each. A higher proportion of service holders/businessmen were from municipality. More than three-fourth (86.1%) of participants belonged to lower SES (Class IV and V) with lowest proportion in urban cluster (63.9%).
Awareness about lymphatic filariasis
Around two-third (65.15%) of respondents had awareness about LF, of which 83.33%, 30.34%, and 37.08% reported limb swelling as important symptom, knew mode of transmission, and prevention of LF, respectively. After being shown flash card, 23.48% participants reported the presence of LF case in community.
Information education and communication in last mass drug administration round
Overall, 32.58% participants heard about MDA and 79.07% stated HWs as a source of information. Other modes of information education and communication (IEC) were poor as 20.93% respondents received message from miking/TV/relatives. One-fourth (25.0%) of 132 respondents knew avoidance of LF as the purpose of MDA. Flash card was shown by DAs to 21.97% participants.
Out of 545 individuals received/administered medicines, 526, i.e., 96.51% reported familiarity with DAs and 21.38% of got medicines from community volunteer (mentioned as “other”) who were not routine ground level HWs. One-fifth (21.21%) respondents reported pre-MDA campaign by HWs before last MDA round.
Coverage and correlates
Overall, 70.7%, 80.20%, and 70.10% of beneficiaries were distributed DEC, albendazole, and both correctly, lowest in urban cluster [Table 1].
|Table 1: Distribution of study subjects as per mass drug administration medicines distribution|
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Among 669 individuals, 18.54% was not delivered medicines and 10.76% was given wrong dosage with effective distribution rate of 70.10%.
Most common cause of nonrecipients of medicines was “left out by DAs,” especially in municipality where 12.1% of people refused to receive medicines as well. Major cause (23.39%) in rural areas was found to be “long absence” resulting from mobility of laborer in search of job during harvesting time. Multiple logistic regressions between non/distribution of medicines and factors such as residence, caste, SES, age category, occupation, category of Das, and their familiarity which were found significantly associated with appropriate medicines distribution in bivariate analysis revealed that “lower age” and “unknown DA” had significant negative impact on right distribution of both medicines.
Among recipients of correct medicines, 56.20% consumed both correctly, i.e., effective coverage rate was 56.20%. Rural clusters except Majhdia achieved minimum cutoff criteria of 65% effective coverage, but urban cluster was revealed as a concern [Table 2]. Around 65% of consumption was supervised.
|Table 2: Distribution of study subjects as per consumption of mass drug administration medicines|
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Bivariate analysis revealed a positive association between factors such as rural residence, backward class, joint family, lower SES, low education, consumption in previous MDA round, ground level HWs (ASHA/ANM) worked as DA, familiarity with DA, and right consumption of both medicines. Binary logistic regression involving these predictors showed that appropriate consumption was positively influenced by experience of consumption in the previous round and familiarity with DA and it had a negative association with upper SES.
Out of 435 consumed any medicine, 6.44% reported adverse events (AEs) of which 60.71%, 53.57%, and 35.71% complained of dizziness, vertigo, and nausea, respectively, within a median time of 1.5 h after consumption. However, only 3.57% sought consultation from concerned DAs.
Having had right distribution, around one-fifth individuals did not consume medicines due to “fear of side effects” (46.24%) and “not told specifically why to consume” (27.96%) [Table 3].
|Table 3: Distribution of participants as per cause of nonconsumption (n=93)|
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- IEC was poor like few leaflets, 2–3 posters, and 1 round campaign by loudspeaker (miking)
- Reporting by 4.54% respondents about visit of any person other than DA for cross-checking of medicine consumption indicated dismally low monitoring. The fact was cross-checked by interviewing block/ward level supervisors (BPHN/PHN/individuals worked as supervisor at municipality)
- Reluctant DAs in urban cluster mostly had not informed people about the purpose of MDA before/during tablet distribution.
SWOT analysis of MDA program revealed underutilization of positive aspects (strength and opportunity) with increased potential of negative dimensions (weakness and threat) [Box 1] [Additional file 1].
| Discussion|| |
MDA implementation in WB has been criticized for mere distribution of medicines for unsupervised consumption leading to suboptimal coverage. In CES in Paschim Medinipur district of WB, Sinha et al. observed 59.3% effective coverage in 2009 and with declining trend 52.52% in 2010. Chattopadhyay et al. reported effective coverage of 73.7% in Purba Medinipur district of WB in 2010. Karmakar et al. showed effective coverage 51.35% in North 24 Parganas (NPG) district of WB in 2010. Roy et al. documented effective coverage of 41.18% in Bardhaman district of WB in 2010. Ghosh et al. estimated an effective coverage of 93.7% in Bankura district, WB in 2012. Haldar et al. revealed effective coverage rate of 48.01% in NPG district, WB In 2012. Unpublished data of CES conducted in Bankura district by Ghosh et al. and Gupta et al. reported effective coverage rates of 84.7% and 76.55% in 2013 and 2014, respectively., Unpublished CES report for NPG district, WB carried out by Basu et al. showed estimated coverage of 81.2% in 2014. Variation in result of these government-sponsored post-MDA CESs in the same state conducted under same methodological guidelines might be due partly to variation in efficiency of program implementation in different districts, validity of collected information as well as perception and motivation of local people toward MDA. It is noteworthy that most of the studies reported coverage rate below desired cutoff of ≥85% including the present one.
Universal unsupervised consumption in both 2009 and 2010 in Purba Medinipur and in 2010 in NPG districts, WB reported by Sinha et al. and Karmakrar et al., Ghosh et al. and Haldar et al. found that 66.9% and 97.52% unsupervised drug consumption in Bankura and NPG districts, WB in 2012., Ghosh et al. reported 22.8% supervised consumption. Gupta et al. stated most of consumption to be unsupervised in Bankura district, WB in 2014.
Mere distribution of antifilarial medicines for unsupervised consumption was alleged for suboptimal and suspicious coverage in previous rounds, and DOT was emphasized in the last two rounds including this one. The DOT was found to be neglected in previous round (April 2015) seemingly due to legacy of habit of mere tablet distribution for unsupervised consumption leaving third-fourth (75.31%) of drug consumption unsupervised in Bankura district. In this round, hopefully supervised consumption increased to 65.0%. Shifting priority to DOT seemed successful in making a dent in problem of MDA program implementation.
Clients' attribute for noncompliance was unaltered with respect to previous rounds. As per current study, “Fear of side effects” was the most common (46.24%) cause of noncompliance followed by “not told why to consume” (27.96%) concurrent to Haldar et al. who found “fear of side effects” as the most common (63.02%) cause of noncompliance in NPG district 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.
Ironically, AEs were reported in the present study only by 6.44% of respondents consumed medicines and that too minor in nature developed within 24 h and care was sought only by 3.57% of victims as also observed by Haldar et al. only in 5.08% clients in NPG district. Aswathy et al. observed mild AEs (fever, drowsiness, swelling/edema, and/or vomiting) occurring within 24 h of consumption among 2.7% of interviewee. Chattopadhyay et al. found 2.0% complaining of minor AEs.
No doubt lack of awareness regarding LF was one of the important reasons for disinterest in consuming MDA medicines.
The current study revealed around two-third of respondents to be aware of LF among whom 83.33% knew at least one symptom (limb swelling), 30.34% had knowledge about transmission of LF. Around 32.58% heard about MDA, pre-MDA house visit for this round was paid by HWs only in 21.21% of HHs. Haldar et al. observed almost two-third of respondents had awareness about LF, of which 47.0% had correct knowledge about LF transmission and 60% heard about MDA predominantly (47.68%) from HWs. Pre-MDA campaign was made by HWs only in one-tenth of HHs. Chattopadhyay et al. explored that 85.1% respondents were aware of LF and 38% knew mode of transmission. Low awareness reported by Ghosh et al. (about 60%), Karmakar et al. (55.42%), Roy et al. (41.4%), and Sinha et al. (55.42%). Suboptimal ineffective IEC might be responsible for poor awareness.
The present study observed improper distribution/nondistribution of medicines and noncompliance was more among the subjects received medicines from DAs other than routine HWs corroborating to the observation made by Haldar et al. from NPG district. Mahalakshmy et al. also reported lower compliance rate among subjects who were distributed medicines by volunteers.
Careful selection, rigorous training, and supervision cannot be overemphasized in case of deployment of DAs other than HWs as rightly suggested by investigators for the sake of better program performance.
With due apprehension about consequence of dismal under coverage and noncompliance, Joseph et al. concluded from their study in Samoa that persistent transmission in residual areas, despite many years of MDA might be partly due to systematic noncompliance of infected individuals who maintained chain of transmission serving as reservoirs, thus impeding successful elimination of LF.
| Conclusion|| |
Even after two rounds, only DOT by repeat house visit seemed to require more integrated endeavor to turn the wheel in reverse direction. Strength and opportunity of MDA program such as intensive social mobilization through advocacy, behavior change communication for motivating noncompliants, effective participatory microplanning, supportive supervision, and coupling of MDA program with other public health program are to be utilized for success.
The authors would like to thank Deputy Director of Health Services (PH and CD), Government of WB, India for financial aid (INR 15,000/- only) and technical guide.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]