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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 268-272

Exploring effectiveness of mass drug administration program against lymphatic filariasis in Raichur district, Karnataka


1 Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
2 Senior Regional Director, Department of Health, Family Welfare, Government of India

Date of Submission10-Jun-2019
Date of Acceptance15-Sep-2019
Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Jenee Dowerah
Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Bannimantapa, Mysuru - 570 015, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_46_19

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  Abstract 

BACKGROUND: Lymphatic filariasis is one of the oldest and most debilitating neglected tropical diseases known to humankind. In India, around 630 million people are at risk of lymphatic filariasis. Mass drug administration (MDA) program against lymphatic filariasis is a strategy adopted by the Government of India to eliminate this scourge by breaking the chain of transmission of disease.
AIMS: The objective of the study was to assess the effectiveness of MDA program.
SETTINGS AND DESIGN: This cross-sectional study was conducted across four clusters (three rural and one urban) spread over three endemic talukas of Raichur district, Karnataka, in October 2018.
MATERIALS AND METHODS: Multistage random sampling was used to select the clusters. Sixty houses in each of the selected clusters were surveyed. Information on coverage, compliance, directly observed treatment, reasons for non-consumption, source of information on MDA and adverse drug reactions were collected using pretested structured pro-forma by interview technique.
STATISTICAL ANALYSIS USED: Descriptive statistical measures such as percentages, mean, and standard deviation were applied. Inferential statistical tests such as Chi-square test and Z-test were applied.
RESULTS: Among the 240 households visited, a total of 1222 persons were identified as beneficiaries for MDA program. Among the beneficiaries, 617 (50.5%) were male and 605 (49.5%) were female. About 25.12% of the beneficiaries were under 15 years of age. Only 1147 (93.9%) of the total eligible beneficiaries had received diethylcarbamazine and albendazole tablets as part of the MDA program. The compliance rate was 87.2%. The coverage and compliance rates were significantly higher in rural areas compared to urban area.
CONCLUSIONS: Raichur district has attained a higher level of coverage and compliance for MDA, but the difference in these indicators between rural and urban areas is a disturbing phenomenon, which has to be addressed through intensive behavior change communication strategy.

Keywords: Compliance, coverage, lymphatic filariasis, mass drug administration, Raichur


How to cite this article:
Kulkarni P, Dowerah J, Thomas JJ, Naryana Murthy M R, Ravikumar K. Exploring effectiveness of mass drug administration program against lymphatic filariasis in Raichur district, Karnataka. Int J Health Allied Sci 2019;8:268-72

How to cite this URL:
Kulkarni P, Dowerah J, Thomas JJ, Naryana Murthy M R, Ravikumar K. Exploring effectiveness of mass drug administration program against lymphatic filariasis in Raichur district, Karnataka. Int J Health Allied Sci [serial online] 2019 [cited 2019 Nov 22];8:268-72. Available from: http://www.ijhas.in/text.asp?2019/8/4/268/269248




  Introduction Top


Lymphatic filariasis is one of the oldest and most debilitating neglected tropical diseases.[1] Also known as Elephantiasis, it is a painful and profoundly disfiguring disease caused by three species of parasitic nematodes – Wuchereria bancrofti, Brugia malayi, and Brugia timori. The disease, usually acquired during childhood, is transmitted by the bite of infected Culex group of mosquitoes.[2],[3] The clinical manifestations of filariasis range from chronic (lymphedema of the limbs and genital disease manifested as hydrocele, chylocele, and swelling of the scrotum and penis) to painful recurrent, acute attacks accompanied by fever. Although the majority of the infected people are asymptomatic, almost all have subclinical lymphatic damage and up to 40% of them have kidney damage.[2] Even though not fatal, filariasis is responsible for considerable suffering and deformity.[3]

Lymphatic filariasis is seen in the tropical and subtropical areas of the world. Globally, there are around 120 million infected people, with almost 25 million men having genital manifestations of the disease. Almost 15 million people are suffering from lymphedema.[1],[4] Apart from accounting for at least 2.8 million Disability Adjusted Life Years (DALYs), lymphatic filariasis also causes significant comorbidity of mental illness in the patients and their caregivers.[4] About 876 million (63%) people at risk for developing filariasis are from the nine endemic Member States of the WHO South-East Asia Region.[5]

In India, around 630 million people are at risk of lymphatic filariasis spread across 256 endemic districts in 16 states and 5 union territories. Filariasis cases are seen in Andhra Pradesh, Assam, Bihar, Chhattisgarh, Goa, Jharkhand, Karnataka, Gujarat, Kerala, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh, West Bengal, Pondicherry, Andaman and Nicobar Islands, Daman and Diu, Dadra and Nagar Haveli, and Lakshadweep. Five districts in Karnataka, namely Bagalkot, Bidar, Bijapur, Gulbarga and Raichur are endemic for lymphatic filariasis. Of the 13.28 million people living in the endemic districts of Karnataka, 10.14 million reside in the rural areas.[6]

Elimination of filariasis by interrupting its transmission is an important step toward poverty alleviation and economic development. The Government of India launched the National Filaria Control Programme in the year 1995 to delimit the problem, to undertake control measures in endemic areas, and to train personnel. After the World Health Assembly Resolution in 1997 for the Global Elimination of Filariasis, the Indian National Health Policy of 2002 targeted to eliminate lymphatic filariasis by the year 2015. With this aim, the Government of India launched the National Elimination of Lymphatic Filariasis Programme in the year 2004. Initially, the key strategy of preventive chemotherapy through annual mass drug administration (MDA) was undertaken with a single-drug Diethylcarbamazine (DEC). From the year 2006 to 2007, albendazole was added to DEC in the MDA program.[6],[7]

The Government of India provides logistic support in the form of training materials, drugs, and cash grants to all the endemic states on an annual basis for the implementation of the National Elimination of Lymphatic Filariasis Programme. Annual MDA of single dose of DEC and albendazole for 5 years or more to the eligible population (except pregnant women, children below 2 years of age, and seriously ill persons), home-based management of lymphedema case, and upscaling of hydrocele operations in identified Community Health Centres/district hospitals/medical colleges are the key strategies for elimination of lymphatic filariasis.[7]

Raichur, a filariasis endemic district situated in the northern part of Karnataka, observed the 15th round of MDA in the year 2018. The Department of Community Medicine, JSS Medical College, Mysore, under the instructions from the Regional Health Office, Government of India, Bengaluru, carried out an evaluation of the MDA program in Raichur district on October 30 and 31, 2018. The study was conducted with the objective to assess the effectiveness of program with respect to key indicators such as the coverage and compliance toward MDA, the rate of directly observed treatment, the source of information for MDA, and the incidence of side effects following the administration of drugs.


  Methods Top


This cross-sectional study was conducted in the month of October 2018. The timings of the survey were ensured within a month after actual administration of drugs to avoid recall bias. As per the instructions received from the Regional Office of Health, Government of India, Bengaluru, a total of four clusters of which three from rural areas and one from an urban ward were selected by a multistage random sampling technique. In Raichur district, Devadurga, Lingasugur, and Raichur talukas are endemic for filariasis. At the first stage, two primary health centers (PHCs) from Lingasugur and one PHC from Raichur talukas were selected by a lottery method. In the second stage from each of these PHCs, one subcenter was selected randomly, and in the third stage, one village was selected from these subcenters by the same lottery technique. From the list of all the wards in Mudgal town of Lingasugur taluka, one ward was selected randomly for data collection. In the above manner, the villages of Muslikaralakunti, Masarkal, and Garaladinni were selected from the PHCs of Santekallur, Masarkal, and Matmari, respectively. The urban ward of Halepete under the Mudgal PHC was enlisted as the urban cluster.

The investigators visited the selected villages and identified the center point of each village with the help of local residents. From the central point, four directions were identified and numbered. One of the four directions was randomly chosen for the survey, and the number of houses in that direction was noted. Then, the investigators conducted a house-to-house survey in the street with one adult member within the age group of 18–60 years selected from each household for the survey. After explaining the purpose of the survey and obtaining verbal consent, direct interview technique, using a structured pro forma, was employed to obtain data regarding the demographic profile, awareness about lymphatic filariasis, coverage, compliance, adverse drug reactions, etc. A flashcard containing a picture of an elephantiasis case and DEC and albendazole tablets was employed to explain about the survey to participants. A total of 240 households were covered under the study with a minimum of 60 houses from each of the clusters.

Statistical analysis

The data collected were entered in MS Excel 2010 and analyzed using SPSS version 23. Descriptive statistical measures such as percentages, mean, and standard deviation were applied. Inferential statistical test such as Chi-square test was applied to find the association between locality with coverage and compliance. Z-test for difference between two proportions was applied to test the difference in coverage–compliance gap (CCG) between rural and urban areas. The difference and association were interpreted as statistically significant at P < 0.05. Results were expressed in the form of tables and graphs and figures as relevant.


  Results Top


Among the 240 households visited, a total of 1222 persons were identified as beneficiaries after excluding children <2 years, pregnant women, and elderly persons with chronic diseases. Among the beneficiaries, 617 (50.5%) were male and 605 (49.5%) were female. About 25.12% of the beneficiaries were under 15 years of age [Table 1].
Table 1: Age and sex distribution of beneficiaries

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Of the total 1222 eligible beneficiaries identified, only 1147 (93.9%) had received DEC and albendazole tablets as part of the MDA program. About 1065 persons had consumed the tablets distributed to them; thus, the compliance (effective coverage rate [ECR]) was 87.2% in Raichur district.

Among the total of 1222 beneficiaries, 300 (24.55%) were from the urban area and 922 (75.45%) hailed from the three rural areas. The coverage in the rural areas (94.6%) was significantly higher than coverage in the urban area (91.7%), with P = 0.068. The ECR of the population was also found to be higher in the rural areas (90.9%) as compared to the urban area (75.7%). This was significant with P < 0.001. The overall CCG in Raichur district was estimated to be 6.7%. The CCG was found to be higher in the urban area (16%) as compared to that in the rural areas (3.7%) [Table 2].
Table 2: The coverage, compliance, and coverage-compliance gap of mass drug administration program in the urban and rural areas

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Majority of the beneficiaries (99.52%) reported that the drug distributors including accredited social health activist (ASHA) workers and Anganwadi workers (AWWs) were the source of information regarding the MDA Program, whereas a nominal number of respondents were informed about MDA through a rally organized. Only 87.2% of the participants responded that the drug distributor had explained about the disease, reasons for MDA, and possible side effects. The remaining 12.8% were not given any information. Directly observed treatment was reported in only 83.9% of the respondents where they had consumed the tablets in the presence of the drug distributor.

Most of the respondents who did not take the tablets cited that they were out of station on the day of the visit by the drug distributor. Other major reasons for noncompliance were the fear of side effects, the presence of other comorbidities, and the lack of faith in the tablets [Figure 1].
Figure 1: Bar diagram showing the reasons for nonconsumption of the preventive chemotherapy tablets among the respondents

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In the present study, 2.7% of the beneficiaries reported adverse drug reactions following MDA. Thirty-three persons developed minor side effects with fever (93.94%) being the most common symptom noted. Other side effects cited were nausea (3.03%) and sedation (3.03%). All the events reported were self-limiting and lasted for <24 h. No medications were required to limit the side effects by any of the victims.


  Discussion Top


The present cross-sectional study was conducted in the month of October 2018 with the objectives to assess the coverage and compliance toward MDA and to assess the rates of directly observed treatment, the source of information, and the incidence of adverse drug reactions following MDA. The Raichur district coverage rate was estimated to be 93.9%, with a compliance rate of 87.2%. This ECR was above the national standard of 85% to interrupt the transmission and thereby eliminating lymphatic filariasis in a particular area.

The coverage found in the present study is much higher as compared to a previous study conducted in Raichur in the year 2009 by Sanjay et al. where the coverage was 47%. Only 46 (23%) of the 200 beneficiaries in the above study had swallowed the drugs.[8] A 2014 study conducted by Waseem et al. in Bijapur observed a coverage rate of 81.63% and a compliance rate of 79.31%.[9] In a similar study conducted in Bagalkot district in 2016 by Gudegowda et al. reported that coverage and compliance rates were 88.5% and 87.5%, respectively.[10] Another study in Bijapur conducted in the year 2017 by Kulkarni et al. demonstrated a coverage rate of 80.3%, with an ECR of 72.5%.[11]

The CCG in the present study was estimated to be 6.7%. This is comparable to CCG of 7.8% observed by Kulkarni et al. in Bijapur. The overall CCG shows a reduction compared to the data from previous years.[11] The main reason for this effect is the improved Information Education Communication (IEC) activities conducted by drug distributors and the frontline health workers. Community involvement was ensured, especially in rural areas, by activities such as rallies and public meetings. The door-to-door visit by the ASHA workers before the MDA program and detailed counseling during the drug distribution improved the ECR and thereby reduced the CCG. IEC materials such as flashcards and posters were also employed by health workers to improve the awareness.

The present study reported a significantly higher coverage and compliance in the rural areas as compared to that in the urban area. This is similar to the findings by Kulkarni et al., Waseem et al., and Ranganath.[9],[11],[12] This difference can be attributed to the enhanced community mobilizing efforts of the frontline health workers, namely ASHAs and AWWs in the rural areas.

As per the recommendations of the MDA program, the administration of drugs should be under the direct observation of the drug distributor. In the present study, 83.9% of the beneficiaries reported that they had taken the tablets under the supervision of the drug distributor. This observation was higher than the findings reported in previous studies.[10],[11]

Majority of the beneficiaries cited the drug distributors (ASHAs and AWWs) as the only source of information about the MDA program. Only a few participants reported IEC activity (a rally) as the source of information. This was due to the strategy of intensively engaging the ASHA workers in sensitizing the community toward MDA.

The most common reasons cited for not consuming the tablets according to the present study were being out of station during the visit by the drug distributor, the fear of side effects, the presence of other diseases, and a lack of faith in the tablets. In a previous study conducted by Patel in Bagalkot, the major reasons for nonconsumption of the drugs were not receiving the tablet, not being present at home when the drug distributor visited, and unawareness about the tablets.[13] In a study conducted by Waseem et al., the fear of side effects was stated as the main reason for consumption of the tablets.[9] Kulkarni et al. also elicited the lack of awareness and fear of side reactions as the two major causes of noncompliance.[11]

The reported adverse drug reaction of 2.7% in the present study is lower than the findings reported by Sanjay et al. (4.3%) and Hoolageri et al. (4.1%) in a previous study.[8],[14] The incidence of side effects is comparable to the findings of Kulkarni et al. (2.4%).[11] Hyperpyrexia (93.94%) was the major side effect cited in contrast to a previous study where nausea and vomiting were reported as the major side effects following MDA.[14]


  Conclusions Top


In the present study conducted in the endemic district of Raichur in Karnataka, the coverage rate of MDA program against lymphatic filariasis was 93.9%, with an ECR of 87.2% and an estimated CCG of 6.7%. The coverage and compliance were found to be significantly higher in rural areas as compared to urban areas. The CCG was lower in rural areas. In all of the clusters evaluated, drug distributors were the major source of information. The major reasons cited for noncompliance were unavailability on the day of the visit by the drug distributor, fear of side effects, the presence of other diseases, and a lack of faith in the tablets. A 2.7% incidence of adverse drug reactions was reported following consumption of the tablets.

Acknowledgment

We would like to thank district vector-borne disease control officer, Raichur, medical officers, health workers, ASHA workers, district consultants for vector-borne diseases, and entomologists.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Progress Report 2000-2009 and Strategic Plan 2010-2020 of the Global Programme to Eliminate Lymphatic Filariasis. Geneva: World Health Organization; 2010.  Back to cited text no. 1
    
2.
World Health Organization. What is Lymphatic Filariasis. World Health Organization. Available from: http://www.who.int/lymphatic_filariasis/disease/en/. [Last accessed on 2019 Mar 01].  Back to cited text no. 2
    
3.
Park K. Epidemiology of communicable diseases. Park's Textbook of Preventive and Social Medicine. 25th ed., Ch. 5. Jabalpur: M/s Banarsidas Bhanot; 2019. p. 295-300.  Back to cited text no. 3
    
4.
World Health Organization. Epidemiology. World Health Organization. Available from: http://www.who.int/lymphatic_filariasis/epidemiology/en/. [Last accessed on 2019 Mar 01].  Back to cited text no. 4
    
5.
World Health Organization. Asia RO for S-E. Elimination of Lymphatic Filariasis in the South-East Asia Region: Report of the Ninth Meeting of the Regional Programme Review Group (RPRG) Yangon. Myanmar: World Health Organization; 2012. Available from: https://apps.who.int/iris/handle/10665/204988. [Last accessed on 2019 Mar 01].  Back to cited text no. 5
    
6.
Filaria: National Vector Borne Disease Control Programme. Available from: https://www.nvbdcp.gov.in/index1.php?lang=1&level=1&sublinkid=5777&lid=3691. [Last accessed on 2019 Mar 03].  Back to cited text no. 6
    
7.
Ministry of Health and Family Welfare, National Vector Borne Disease Control Programme, Government of India. Elimination of Lymphatic Filariasis, Training Manual on Mass Drug Administration and Morbidity Management. New Delhi: Ministry of Health and Family Welfare, National Vector Borne Disease Control Programme, Government of India; 2004.  Back to cited text no. 7
    
8.
Sanjay TV, Kishore SG, Gowda G, Ravi KK. An evaluation of mass drug administration (MDA) for the elimination of lymphatic filariasis in Raichur District, Karnataka. Indian J Prev Soc Med 2012;43:197-201.  Back to cited text no. 8
    
9.
Waseem A, Dorle AS, Mannapur BS, Vetri S. Coverage and compliance of mass drug administration for elimination of lymphatic filariasis in Bijapur District, Karnataka. Ann Community Health 2015;2:6-10.  Back to cited text no. 9
    
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Gudegowda KS, Duraisamy S, Narayanappa RR, Sobagiah RT. Evaluation Of mass drug administration for lymphatic filariasis in Bagalkot District, Karnataka, cross sectional study. Nat J Res Comm Med 2017;6:71-6.  Back to cited text no. 10
    
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Kulkarni P, Krishnaveni YS, Murthy MN, Kumar KR. Coverage and compliance towards mass drug administration programme against lymphatic filariasis in Vijayapura (Bijapur) district, Karnataka, India. Int J Community Med Public Health 2018;5:4311-5.  Back to cited text no. 11
    
12.
Ranganath BG. Coverage survey for assessing mass drug administration against lymphatic filariasis in Gulbarga District, Karnataka, India. J Vector Borne Dis 2010;47:61-4.  Back to cited text no. 12
    
13.
Patel PK. Mass drug administration coverage evaluation survey for lymphatic filariasis in bagalkot and Gulbarga districts. Indian J Community Med 2012;37:101-6.  Back to cited text no. 13
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14.
Hoolageri MS, Kamath R, Ravikumar K, Jagadish G, Kamath S. Evaluation of mass drug administration programme for elimination of lymphatic filariasis in Bidar district, Karnataka. Intl J Community Med Public Health 2018;5:1020-3.  Back to cited text no. 14
    


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