Coverage of mass drug administration (MDA) and operational issues in elimination of lymphatic filariasis in selected districts of Jharkhand, India

ABSTRACT

Background:

Despite annual rounds of mass drug administration (MDA) being carried out every year since 2004 to break the transmission of lymphatic filariasis, India has not achieved elimination status in many areas of country. This study was conducted to determine the operational issues in the implementation of MDA for elimination of lymphatic filariasis in selected districts of Jharkhand.

Methods:

Two districts of Jharkhand state were selected for present cross-sectional study. Multi-staged cluster sampling was adopted to select study participants. Data were collected with use of prescribed questionnaire of National Vector Borne Disease Control Programme (NVBDCP) from the study participants. Data related to socio-demographic details, coverage and compliance of MDA and operational issues were collected.

Results:

Findings of independent assessment show that percentage of MDA coverage and compliance for Hazaribag district was 96.02% and 88.90%, respectively. On the other hand, percentage of MDA coverage and compliance was found to be only 67.06% and 48.44% in Chatra district. Overall drug consumption was significantly associated with age group (p-value = 0.045), educational status (p-value = <0.0001) and socio-economic status (p-value <0.0001) of eligible population. Most common reason for not swallowing the drugs was found to be absence of family members at the time of MDA rounds followed by no visit of house by drug distributors.

Conclusions:

Coverage and compliance of MDA was better in Hazaribag district as compared to Chatra district. In order to increase compliance, socio-demographic factors must also be addressed apart from other operational issues.

Introduction

Lymphatic filariasis, commonly known as elephantiasis, is a neglected vector-borne tropical disease.[1] It is the fourth most common cause of disability worldwide.[2] The infection is endemic in more than 80 countries with more than 1.3 billion people at risk and 120 million already infected globally.[3] Two-thirds of the endemic population reside in Southeast Asia, and one-thirds live in India with Andhra Pradesh, Bihar, Jharkhand and Madhya Pradesh among the worst-affected states in the country.[4]

In 1955, India launched National Filariasis Control Programme (NFCP) which was limited to urban population and was later extended to cover rural population also in 1994 and later became a part of National Vector Borne Disease Control Programme (NVBDCP) in 2003. Then in 2002 under National Health Policy, India set an ambitious goal to elimination of transmission of disease due to lymphatic filariasis by the year 2015.[5] The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched by the World Health Organization (WHO) in 2000 which aimed at eliminating LF by the year 2020 as a public health problem. In order to achieve this goal, during 2004 a ‘two-pillar’ strategy of interrupting transmission through annual mass drug administration (MDA) with diethylcarbamazine (DEC) tablets to all eligible population (which excluded pregnant women, children below 2 years and seriously ill persons) and providing care for those with the disease was adopted.[6] As a supporting tool of MDA, the IEC/BCC activities with social mobilization were adopted. MDA is a conglomeration of about 35 complex and sequential activities spreading over at least nine months each year. Broadly, MDA activities pertain to administrative, managerial, procurement, technical, logistic and supply chain management, quality control, and training, IEC/BCC operational and financial in nature with participation of community.[7]

India’s filarial control programme has scaled up MDA over the past several years with inclusion of albendazole to the treatment of the 590 million Indians living at risk of infections.[8] Successful implementation of triple drug therapy with addition of ivermectin to present regimen in selected districts of India from 2018 is likely to augment the effort for elimination of lymphatic filariasis further. Out of 24 districts of Jharkhand state of India, LF is endemic in 17, and it is suggested that compliance is relatively low in the majority of the endemic areas especially Jharkhand.[9] Hence, the objective of the present study was to determine the operational issues in the implementation of MDA for elimination of lymphatic filariasis in selected districts of Jharkhand. Study outcome will help in primary care physician to address the key issues for elimination of lymphatic filariasis as they are the first person to be contacted by community.

Materials and Methods

Study setting and duration

The present study was conducted in two districts of Jharkhand, namely Hazaribag and Chatra. Both districts are located in northern part of Jharkhand and share boundaries with Bihar. Hazaribag district is better connected with other areas of Bihar and Jharkhand compared to Chatra district. As per census 2011, overall literacy rate of Hazaribag is 70.48% and that of Chatra district is 80.18%.[10,11] These districts were selected by state NVBDCP cell, and Department of Community Medicine of Sheikh Bhikhari Medical College, Hazaribag, was assigned to do an independent assessment of MDA activities held during August–September 2020. Due to COVID-19 pandemic restrictions and other technical reasons, this independent assessment was done in February 2021.

Study design, sampling and sample size

It was a cross-sectional study, conducted in two districts of Jharkhand. In each district, three villages and one urban ward were selected for independent assessment as per NVBDCP guidelines. Multi-stage cluster sampling was done to select these areas. First of all three blocks were selected based upon highest, intermediate and lowest coverage reported by district NVBDCP cell. From all these three blocks, complete list of villages was obtained, and one village from each block was selected randomly by lottery method in both districts. One ward from urban area was also selected randomly from each district as per guidelines. Each village and ward was considered as one cluster. After selecting villages and wards in each district, data collection was started by independent assessment team. For this, one locally important place like school or any religious place of each village and ward was chosen as starting point. Thirty consecutive households were selected from each village and ward in both districts from starting point. In case of locked household, next household was selected for study purpose. Hence, a total 120 households from each district were chosen for data collection leading to total 240 households. From each household, complete list of family members was taken along with their demographic details and details related to drug consumption by them from an adult respondent. In this way, total population covered during survey was 1236. However, only 1183 of them were eligible to take drugs under MDA at the time of drug distribution. Hence, total sample size for present study was 1183.

Data collection and analysis

Questions related to operational issues were asked from all adults present in household during interview. Data were collected in prescribed tool given by state NVBDCP cell with addition of some socio-demographic parameters. Data were entered in MS Excel spreadsheet and analysed using R software.

Operational definitions

MDA coverage: Actual drug distribution during MDA in eligible population in surveyed house. It denotes number of people who really received drugs.

MDA compliance: Total number of beneficiaries/eligible population who consumed drugs in surveyed house.

Below poverty line (BPL): Those having BPL ration cards issued by govt. of Jharkhand.

Above poverty line (APL): Those not having BPL ration cards.

Ethical issues

Study was cleared by Institutional Ethics Committee of Sheikh Bhikhari Medical College, Hazaribag. Informed consent was taken from respondents prior to interview them.

Results

During independent assessment, a total of 240 households were visited in both districts. Total population covered from both districts was 1236.

Socio-demographic factors

Male-to-female ratio was nearly equal in Hazaribag district, whereas it was slightly high in Chatra district. More than half of the subjects were from age group 16–45 years, and only few were from extreme of ages. More than 70% people were literate, whereas about one-fifth of participants were illiterate. Nearly two-thirds people were from below poverty line and three-fourths of total population were from rural areas. However, proportion of illiterate and poor people were comparatively higher in Chatra district in comparison to Hazaribag district [Table 1].

Table 1.

Socio-demographic profiles of total population surveyed (n=1236)

Characteristics	Hazaribag (n=625) n (%)	Chatra (n=611) n (%)	Total (n=1236) n (%)
Gender
Male	314 (50.2%)	320 (52.4%)	634 (51.3%)
Female	311 (49.8%)	291 (47.6%)	602 (48.7%)
Age group
<2	5 (0.8%)	11 (1.8%)	16 (0.97%)
2-15	168 (26.9%)	190 (31.1%)	358 (28.9%)
16-30	201 (32.2%)	207 (33.9%)	408 (33.0%)
31-45	142 (22.7%)	118 (19.3%)	260 (21.0%)
46-60	79 (12.6%)	52 (8.5%)	131 (10.6%)
>60	30 (4.8%)	33 (5.4%)	63 (4.9%)
Educational status
Illiterate	94 (15.0%)	154 (25.2%)	248 (20.1%)
Below 10	262 (41.9%)	273 (44.7%)	535 (43.3%)
10 and above	226 (36.2%)	127 (20.8%)	353 (28.5%)
Not Applicable	43 (6.9%)	57 (9.3%)	100 (8.1%)
Socio-economic status
APL	240 (38.4%)	86 (14.1%)	326 (32.0%)
BPL	385 (61.6%)	525 (85.9%)	910 (68.0%)
Residence
Urban	154 (24.6%)	155 (25.4%)	309 (25.0%)
Rural	471 (75.4%)	456 (74.6%)	927 (75.0%)

APL=Above poverty line; BPL=Below poverty line)

Coverage of MDA and consumption of drugs

Findings of independent assessment show that percentage of MDA coverage was 96.02% for Hazaribag district marginally higher than reported coverage by district officials (94.35%). However, percentage of drugs consumption was 88.90% in Hazaribag district. On the other hand, percentage of MDA coverage was found to be only 67.06% as against 91% reported by district officials in Chatra district. Similarly, percentage of drug consumption was only 48.44% in Chatra district [Table 2].

Table 2.

District-wise coverage and consumption of drugs under MDA

Variables	Hazaribag	Chatra
Total population surveyed	625	611
Total number of eligible population	604	579
Total number of eligible population who received drugs	580	389
Number of eligible population who consumed tablets	537	281
Percentage of coverage	96.02%	67.18%
Percentage of consumption	88.90%	48.53%
District reported coverage	94.35%	91%

Socio-demographic factors and consumption of drugs

Among 1236 people covered for survey, only 1183 were eligible to take drugs under MDA at the time of drug distribution. Remaining 52 were children less than two years of age and pregnant females. Chi-square test was performed to find any association between socio-demographic factors and drug swallowed by eligible population. Overall drug consumption was significantly associated with age group (p-value = 0.045), educational status (p-value = <0.0001) and socio-economic status (p-value <0.0001) of eligible population. However, drug consumption was statistically not significant with gender and place of residence of people. On the other hand, when same factors analysed district wise for actual drug consumption, educational status, age group and socio-economic status were significantly associated in Hazaribag district, whereas no factors were significantly associated with drug consumption in Chatra district [Tables 3 and 4].

Table 3.

Association between socio-demographic factors and actual consumption of drugs under MDA (n=1183)

Socio-demographic factors	Drug swallowed		P
	Yes	No
Gender
Male	423 (69.3%)	187 (30.7%)	0.91
Female	399 (69.5%)	174 (30.4%)
Age group (in years)
2-15	236 (70.2%)	100 (29.8%)	0.045
16-30	278 (70.4%)	117 (29.6%)
31-45	176 (67.7%)	84 (32.3%)
46-60	99 (75.6%)	32 (24.4%)
>60	33 (54.1%)	28 (45.9%)
Educational status
Illiterate	187 (61.3%)	118 (38.7%)	<0.0001
Literate	635 (72.3%)	243 (27.7%)
Socio-economic status
APL	247 (77.4%)	72 (22.6%)	<0.0001
BPL	575 (66.5%)	289 (33.4%)
Residence
Urban	202 (68.2%)	94 (31.8%)	0.59
Rural	620 (69.9%)	267 (30.1%)

Table 4.

District-wise analysis of association between socio-demographic factors and actual consumption of drugs

Socio-demographic factors	Hazaribag			Chatra
	Drug swallowed		P	Drug swallowed		P
	Yes	No		Yes	No
Gender
Male	277 (89.9%)	31 (10.1%)		146 (48.3%)	156 (51.7%)
Female	262 (88.5%)	34 (11.5%)	0.57	137 (49.5%)	140 (50.5%)	0.78
Age group (in years)
2-15	148 (92.5%)	12 (7.5%)	<0.001	88 (50.0%)	88 (50.0%)	0.34
16-30	179 (92.3%)	15 (7.7%)		99 (49.3%)	102 (50.7%)
31-45	127 (89.4%)	15 (10.6%)		49 (41.5%)	69 (58.5%)
46-60	69 (87.3%)	10 (12.7%)		30 (47.7%)	22 (52.3%)
>60	16 (55.2%)	13 (44.8%)		17 (53.1%)	15 (46.9%)
Educational status
Illiterate	102 (83.6%)	20 (16.4%)		85 (46.4%)	98 (53.6%)
Literate	437 (90.7%)	45 (9.3%)	0.025	198 (50.0%)	198 (50.0%)	0.42
Socio-economic Status
APL	200 (85.1%)	35 (14.9%)		47 (56.0%)	37 (44.0%)	0.16
BPL	339 (91.9%)	30 (8.1%)	0.009	236 (47.7%)	259 (52.3%)
Residence
Urban	137 (91.9%)	12 (8.1%)	0.22	65 (44.2%)	82 (55.8%)	0.19
Rural	402 (88.4%)	53 (11.6%)		218 (50.5%)	214 (49.5%)

Operational issues in relation to MDA

Those who were available at the time of survey in their household also enquired about some operational issues regarding MDA. A total of 461 people were available at the time of interview. Most common reason for not swallowing the drugs was found to be absence of family members at the time of MDA rounds followed by no visit of house by drug distributors. Fear of drugs and absence of active lymphatic filariasis among people were also reasons for not taking drugs. Sahiya (local name of ASHA) and Anganwadi workers (AWWs) were most important source of information for people regarding MDA, whereas electronic and print media has almost negligible role. Only 105 people consumed drugs in presence of drug distributors. Sahiya and AWWs were most preferable persons for drug distribution [Table 5].

Table 5.

Operational issues in MDA coverage and compliance (n=461)

Operational issues	Response
Reasons for not swallowing drugs (More than one response possible)
Not aware of MDA	02
Fear of drugs	37
Side effects in previous rounds	15
Not suffering from LF hence no need to take drugs	42
Out of station at the time of MDA rounds	189
Drug distributers not visited house	79
Source of information (More than one response possible)
ANM	0
HW-Male	3
AWW	153
Sahiya	264
Miking	95
Handbills/Newspaper	0
TV/Radio/Social media	0
Consumed drugs in presence of drug distributors	105
Preference for drug distributors (More than one response possible)
ANM	02
AWW	163
Sahiya	277
Others	19

Discussion

Lymphatic filariasis is still endemic in nearly 250 districts of India even after launch of National Filariasis Control Programme (NFCP) way back in 1955 with use of single drug DEC and launch of MDA in 2004 with use of DEC and addition of Albendazole since 2008. India aimed to eliminate lymphatic filariasis by 2015 using estimated MDA coverage of more than 85% of targeted population for consecutive 5–7 years.[12] This estimate was based on various recommendation and studies which found at least 65% epidemiological coverage of total population for 5–6 consecutive years would interrupt transmission of LF. However, it was also recommended that lower compliance and higher baseline prevalence of LF would require more MDA rounds to interrupt the transmission as ensuring maximal compliance is vital for programmatic success.[13,14,15,16,17]

MDA coverage and compliance

In present study, MDA coverage and compliance were found to be 96.02% and 88.90%, respectively, in Hazaribag district which was similar to district reported coverage by health department of Jharkhand. There was apparent gradual improvement in those parameters for Hazaribag district as compared to findings of study by Haider et al.[18] in 2014 in Jharkhand. Raising awareness about lymphatic filariasis and involvement of village-level workers like Sahiya could be possible reasons for this improvement. However, coverage and compliance of MDA in Chatra district still is a matter of concern as it was much less than coverage reported by district officials. Thus, a wide gap was observed between district officials and our data in Chatra district. Although reasons for this gap could not be explored in present study, other reports stressed upon faulty planning and implementation of programme at grassroots level apart from lack of supervision by trained staff.[19] MDA compliance in our study was similar to recent studies conducted in neighbouring states of Uttar Pradesh and Madhya Pradesh ranging from 65% to 90%.[20,21,22]

Socio-demographic factors and MDA coverage and compliance

It is always stressed that policy-makers should consider the likely effect of socio-demographic and cultural factors prevailing in that area before launching a health programme or any intervention to promote and maintain the health of people. Acceptability of health services largely depends upon these factors which in turn determine success or failure of such programs. Drug compliance in our study found to be significantly related with some socio-demographic factors like educational status, age and socio-economic status of beneficiaries. Although no difference was found to be at gender level for drug compliance in our study, such differences have been observed in other studies.[20,23] Effect of educational status on compliance for MDA has been also reported by some studies conducted in India.[23,24] On further analysis of district wise compliance, it was observed that socio-demographic factors were significantly associated for Hazaribag district and not for Chatra district. Overall, low coverage, low level of literacy and relative backwardness of Chatra district could be the possible reasons for no relation of socio-demographic factors and MDA compliance. To improve the scenario, policy-makers should take these factors in account and all measures should be taken to improve MDA coverage and compliance.

Other operational issues

Non-consumption of drugs is one among many operational issues related to MDA activities. Most common reason for non-consumption in our study was absence of beneficiaries during drug distribution. They are possibly working population who went out for their work at the time of drug distribution. A similar observation has been made by Marathe N and Chalisgaonkar[20] in their studies. Since operationally it is difficult to make drugs available to everyone’s convenient timing, raising awareness must be stressed upon to understand the importance of MDA. Another important reason for non-consumption of drugs in our study was found to be no home visits by drug distributors and drugs were distributed mainly at fixed booth. Similar reason was observed in a study by Hussain et al.[23] in Odisha. Fear of side effects of drugs was not an important reason for non-consumption of drugs in present study; however, few studies have found this factor as one of the important reasons for not consuming drugs.[20,25,26] Sahiya and Anganwadi workers were most important source of information for study participants and was very surprising to find almost negligible role of mass media in awareness generation about filariasis and importance of MDA. Undoubtedly, these workers are vital link between people and health system; their efforts in raising awareness must be supplemented by effective use of mass media. Role of mass media in raising awareness must be realized and utilized in best possible manner to increase coverage and compliance of MDA. Apart from this, acceptability of ASHA and AWWs may not be uniform among all communities owing to complex caste system and religious diversity in India. This may lead to differences in preference for drug distributors in community and ultimately leading to low coverage and compliance. Present study has also found differences in preferences for drug distributor.

We could not observe the other side of operational issues, viz. fund supply, logistic issues, difficult faced by drug distributors, etc., as we did not include them in present study. This is one of the important limitations of our study. Gap between MDA round and independent assessment was about five months and recall problem of respondents cannot be denied. This was another limitation of our studies.

Recommendations

Activities to raise awareness must be planned well in advance of MDA rounds with use of mass media, members of Panchayati Raj institutions and other influential people in community. Training of drug distributors with supervisory visit during MDA rounds shall be done effectively. Independent assessment of MDA coverage must be done as soon as possible after MDA rounds in order to avoid recall bias.

Conclusions

Both MDA coverage and compliance was found to be much below the national target for Chatra district. Education and socio-economic status appear to be key determinants for low MDA coverage and compliance. Remote and hard-to-reach areas along with poor awareness about lymphatic filariasis among people are other possible factors for low coverage.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

NVBDCP Cell, Health Directorate, Govt. of Jharkhand.

Conflicts of interest

There are no conflicts of interest.