Assessing Coverage and Compliance of Mass Drug Administration under Elimination of Lymphatic Filariasis Program in Malda District, West Bengal

Introduction:

Lymphatic filariasis, commonly known as elephantiasis, is a neglected tropical disease. The painful and disfiguring visible manifestations of the disease, lymphoedema, elephantiasis and scrotal swelling occur later in life and lead to permanent disability. These patients are not only physically disabled, but suffer mental, social and financial losses contributing to stigma and poverty. Currently, 1.23 billion people in 58 countries are living in areas where lymphatic filariasis is transmitted and are at risk of being infected. Approximately 80% of these people are living in 10 countries including India^[1].

The World Health assembly took the resolution in 1997 for Global elimination of Lymphatic filariasis. AS signatory to this resolution the Government of India took steps towards elimination of the disease in India by 2015. In pursuit of the goals, the Government of India launched in 2004 nationwide Annual Mass Drug Administration (MDA) of single dose of DEC (Diethylcarbamazine citrate) and Albendazole for 5 years or more to the eligible population (except pregnant women, children below 2 years of age and seriously ill persons) to interrupt transmission of the disease as well as home based morbidity management, scaling up hydrocelectomies in hospitals and CHCs. The population coverage during MDA has improved from 73% in 2004 to 83% in 2013 (Prov.) which has resulted in the overall reduction of microfilaria rate from 1.24% in 2004 to 0.29% in 2013 (Prov.). Intensive social mobilization during MDA, have been carried out by various states/ UTs involving political/ opinion leaders, decision makers, local leaders and community. All the districts have completed more than 5 rounds of MDA by the end of 2013^[2].

In May-June 2015, few weeks after one such MDA, a household survey was conducted in the Malda district of West Bengal to evaluate coverage and compliance.

Objectives:

Objectives of the survey were as follows:

1. To calculate the coverage of the MDA for Filaria in the area under survey.

2. To identify the adverse effect following drug consumption

3. To identify the reasons for non-consumption of MDA drugs.

4. To find out any loopholes of the programme.

Materials & Methods:

Results:

A total of 564 constituted the study population of 120 families residing in four selected areas, of them, 285(50.53%) were males & 279 ((49.47%) were females. 86 (15.25%), 127(22.52%) & 351 (62.23%) were belonging to 2-5 yrs, 6-14 yrs & >15 yrs age group respectively. [Table-1]

97.5% families received drugs, 85.8% consumed, but only 43.3% family members consumed drugs immediately. One family in Ratua II & 2 families in Kaliachak-I did not receive any drugs. Consumption was maximum in Manikchak (96.67%) & minimum in English Bazar Municipality (73.33%), where no one was found to consume it immediately. [Table- 2]

The coverage rate for DEC plus albendazole was 95% & the compliance rate was 71.63%. Compliance refers to actual consumption of the drug by the community.

Only 25% got these under supervision. Out of 142 eligible persons in EBM, 100% received both of the drugs, but 71% consumed them, which were supervised only in 17.6% cases. In Kaliachak, out of 131 eligibles, 83.9% received both of the drugs, but only 33.6% consumed them, while supervision was much less (only 22%). Supervised drug consumption was not reported in Ratua-II block. [Table-3]

The reasons quoted by the individuals for non-consumption of drugs, maximum responses were ‘not necessary’, ‘no knowledge why tablets were given’ & ‘fear of side effects’. [Table-4]

11.7% of surveyed families mentioned some side effects. Out of 103 families (members of these families actually consumed drugs) 14(13.59%) showed some side effects following consumption of drugs, which included dizziness, nausea, vomiting & pain abdomen. Most of the cases either no treatment was required, or village quacks were consulted. [Table-5 & 6]

Discussion:

Lymphatic filariasis is one of the diseases which creates a major public health concern and elimination of it becomes a priority even at the international level. Lot of time and money has been spent over years to reduce the burden of filariasis. The key strategy to eliminate filariasis is to achieve a coverage rate of 85% for at least 5 years along with good compliance and active community participation. In our study the coverage rate for DEC plus albendazole was 95%. In studies conducted by Pattanshetty S et al and Ranganath BG the coverage rates were 83% and 85% respectively^[3,4,5]. The motivated health officials and field workers might be the reason for good coverage obtained in our study.

The compliance rate reported in our study was 71.63%. Compliance rates of 74% and 69% were reported by Mukhyopadhay and Karmakar in their studies^[6,7]. As the awareness about the MDA program was poor, earning persons in the households were not available at home during the distribution of drugs. Alternatively, other member at home or their neighbours had collected the drugs on their behalf and had forgotten to inform the same to the absentees. Drug consumption in front of the drug distributors was not ensured for those who received the drugs directly from the drug distributors, as the members of the households quoted reasons like lack of proper food intake, fear of taking all the drugs at once and consuming drugs in divided doses over few days. All these hindered direct observed treatment which is essential for ensuring a good compliance. The report of side effects after consumption of DEC in the past had created a fear among people regarding the consumption of drugs. A good Information, Education and Communication (IEC) and community awareness about the drugs would have improved the compliance rate. The failure of community awareness and lack of rapid response team to tackle the side-effects resulted the main reason for non compliance in this study and similar findings have been noted in studies by Karmakar PR et al, Kumar A et al and Kumar P et al^[7,8,10].

The success of any national health programme directly depends on active community participation. The path to achieve it is through community awareness about the disease and its complications. 68.33% head of the families had some idea about the disease for which drugs were distributed through interpersonal communication, which is higher to similar study conducted by Lahariya & Mishra and also of Karmakar et al where the awareness was only 21.08%^[7,9].

Conclusion:

The major challenge of MDA programme is to sustain a high level of coverage (>85%) for a period of at least five years. Our study reported coverage rate of 95% and compliance of 71.63% depicting the limitation of the program to be poor compliance and lack of proper supervision, appropriate counselling and community awareness. Even though very few and minor side effects were reported in our study, they need to be addressed as they may constitute cause for future non-compliance. This shows that there is a need to strengthen the programme in terms of creating awareness through appropriate media in the community with efficient microplan, supply of blister package MDA drugs, improved supervision, intersectoral co- ordination, teaching and training of health workforce to make filariasis to enter the oblivion like many other diseases in the past.