Mass Drug Administration against Filariasis - A study on coverage and compliance, in a coastal district of Odisha

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1 Research Article Mass Drug Administration against Filariasis - A study on coverage and compliance, in a coastal district of Odisha Introduction Alpana Mishra *, Krishna Kar **, Durgamadhab Satapathy *** Abstract India contributes to 40% of the total global burden of filariasis. Odisha is one of the endemic states in India. Mass drug administration (MDA) of single dose of anti filarial drugs (DEC & Albendazole) for 5 years or more to the eligible is required to interrupt transmission of the disease. The objective was to estimate the coverage of MDA in the households of Cuttack districts and to assess the proportion of population who had consumed the drugs, any adverse events encountered and reasons for non-consumption of the drug. Multi stage sampling method was adopted for post MDA assessment in the district. Two rural blocks and two urban wards were surveyed. Total 300 households were surveyed. The household wise MDA distribution coverage in the district was found to be 83%. Distribution rate & consumption rate of MDA in the district was 87.1% and 64.6% respectively. Compliance among the rural & urban study population was 76.2% and 68.6% respectively. Most common reason for non consumption was fear of side effects (87.0%). Major source of information regarding MDA was ASHA (46.7%), followed by AWW (29%). Only few had encountered any adverse event. Keywords: MDA, Filariasis, Coverage, Compliance, Evaluation, Adverse event. Filariasis is one of the leading causes of disability in the world next to leprosy. 1 India contributes about 40% of the total global burden and accounts for about 50% of the people at the risk of infection. 2 Lymphatic filariasis is a disease caused by lymphatic dwelling nematodes namely Wicheria bancrofti, Brugia malayi, and Brujia timori. The most widespread LF infection is due to W. bancrofti (98%) and the remaining infection by B. malayi (2%). 3 Out of the 25 States/ Union territories in India, for which surveys have been carried out, 22 are endemic and nine states i.e. Andhra Pradesh, Bihar, Gujarat, Kerala, Maharashtra, Odisha, Tamil Nadu, Utter Pradesh and West Bengal, contributed to about 95% of the total burden. 2 National filaria control program was launched in The activity was mainly confined to urban areas however the program has been extended to rural areas since According to national health policy 2002, India has fixed the goal to eliminate lymphatic filarisis by To achieve elimination of Lymphatic Filariasis, the Government of India, during 2004, launched annual Mass Drug Administration (MDA) with annual single recommended dose of Diethyl carbamazine (DEC) tablets in addition to scaling up home based foot care and Hydrocele operation. The co-administration of DEC & Albendazole has been up scaled since Annual MDA of single dose of anti filarial drug for 5 years or more to the eligible population (except pregnant women, children below 2 years of age and seriously ill persons) is required to interrupt transmission of the disease. 7 Consumption of DEC by more than 85% of population is the most important aspect of the program. Therefore supervised drug administration by door to door visit supplemented by drug administration at booth is the recommended approach. 8 Although detailed and systematically collected data on LF in Odisha have not been reported, a compilation of national survey data and selected publications in 2000 estimated the prevalence of LF (persons with microfilaremia or clinical filarial disease) at 8%. * Senior Resident, SCB Medical College, Cuttack. ** Associate Professor, SCB Medical College, Cuttack. *** Professor and Head, SCB Medical College, Cuttack. Correspondence to:dr Alpana Mishra, Department of Community Medicine, S.C.B. Medical College, Cuttack, Odisha Id: dr.alpanamishraspm@gmail.com ADR Journals All Rights Reserved.

2 Mishra A et al. J. Commun. Dis. 2015; 47(4) The same study identified Orissa s eastern (coastal) districts as one of four high priority regions in India for targeted control due to their hyperendemicity (>10% combined microfilaremia and clinical filarial disease). 9 Cuttack district is one of the eastern costal districts showing high LF endemicity. As per 2011 Census, total population of the district was 26, 18, 708 of which 13,39,153 are males and 12,79,555 are females. In the year 2013, MDA activity was conducted from 7 th -9 th December in the district. This study was carried out with the objective to estimate the coverage of MDA in the households of Cuttack districts and to assess the proportion of population who had consumed the drugs, any adverse events encountered following consumption and to find out the reasons for non-consumption of the drug. Materials and Methods Post MDA assessment was conducted in the month of February. The survey team comprising of the faculty members and the post graduates were first sensitized regarding the purpose of the study and collection of data in the designed format. Multi stage sampling method was adopted for carrying out the post MDA assessment in the district. For the purpose of evaluation in rural area of the district, in the first stage, all the 14 blocks of the district were enlisted. Two blocks were randomly selected viz. Bentkar and Dampada. Subsequently in each of these two blocks, all the sub-centers were enlisted and two sub-centers were randomly chosen per block. In the third stage, in each sub-center, the lists of villages were obtained from female health worker, and five villages were visited for the study. Ten households were surveyed per village. The list of households in each village was obtained from the anganwadi worker and the households were selected by lottery method. During the survey activity, if any of the household was found to be locked, the immediate next household was included. So 50 households per sub center and a total of 100 households per block were surveyed. Thus in rural area of the district, 200 households were surveyed in two blocks. For study in urban area of the district, Cuttack municipal corporation (CMC) was purposively selected as the district has only one municipal corporation and rest are NAC areas. Total number of wards were first enlisted from which 2 wards were randomly selected i.e. ward no 2, and ward no 46. After obtaining the list of households of these wards, 50 households from each ward were surveyed. The wife of head of the family or any other responsible adult member present at the time of survey was interviewed with the help of predesigned, pretested semi-structured questionnaire. Data regarding drug distribution, receipt, consumption, occurrence of any adverse event following DEC consumption, and awareness of lymphatic filariasis, including MDA program were collected. Sources of information on MDA program was assessed among those who knew about the program. Distribution rate of MDA is defined as ratio of the population who received the drugs (DEC & Alb) to the total population. Distribution coverage is defined as ratio of the households who received the drugs (DEC & Alb) to the total households. Consumption rate is defined as ratio of the population who consumed the drugs (DEC & Alb) to total population. Compliance is defined as ratio of the population who consumed the drugs (DEC & Alb) to those who received the drugs. These terms are used in result and discussion. Results Table 1 shows the MDA (DEC & Alb) received by the studied households (distribution coverage). In block 1 of rural area, out of the 100 households, 82 households had received MDA, and similarly in block 2, out of 100 households, 96 households had received MDA. This shows that distribution coverage of was significantly higher as compared to block 1. Taking both block 1 and block 2 into consideration, out of 200 households of rural area, 178 (89%) had received MDA. In ward no 46 of urban area, out of 50 households 49 (98%) had received MDA in comparison to ward no 2 where only 23 (46%) had received MDA so, ward no 46 had a significantly higher household wise MDA distribution coverage as compared to ward no 2. Taking both ward no 46 & 2 of urban area into consideration, out of 100 households 72 (72%) had received it. This table also depicts that the MDA distribution coverage in rural area was significantly higher than the urban area. The overall household wise MDA distribution coverage in the district was found to be 83%. ISSN:

3 J. Commun. Dis. 2015; 47(4) Mishra A et al. Name of block/ ward No. of house hold surveyed No. of house hold that received MDA Block , p<0.05 Block CTC rural* (89%) Ward no , p<0.05 Ward no CTC urban* (72%) CTC total (83.3%) (X 2 = 10.87, p<0.05*) Table 1.Distribution coverage of MDA (Alb & DEC) in the rural and urban area of Cuttack district Name of block/ ward Total surveyed population Population received Population consumed DEC No (%) X 2, P value No (%) X 2, P value Rural block (85.5) 41.79, p< (64.5) 12.0, p<0.05 Rural block (96.7) 408 (74.3) CTC rural (91.4) 55.23, p< (69.6) 38.07, p<0.01 CTC urban (77.4) 242 (53.1) CTC total (87.1) 975 (64.6) Table 2.Distribution rate & consumption rate of MDA (Alb & DEC) in the surveyed population Age Group Rural N=962 received the drugs Urban N=353 received the drugs Received Consumed (%) Received Consumed (%) 2-5 yrs (63.6) (54.5) 5-14 yrs (76.4) (70.3) >14 yrs (77.3) (69.3) Total (76.2) (68.6) X 2 = 6.219, df = 2, p = X 2 = 2.163, df = 2, p = Table 3.Compliance of DEC & Alb among the rural & urban study population (age wise distribution) X 2 Table 2 describes the distribution and consumption rates among surveyed population. Population wise analysis of MDA distribution showed that in rural block 1, out of a population of 504 in 100 visited households, 431 (85.5%) received MDA but 325 (64.4%) consumed the drugs. Similarly in block 2, out of a total of 549 population, 531 (96.7%) received MDA but 408 (74.8%) consumed the tablets. This shows that distribution rate of MDA was significantly higher in block 2 than in block 1 (96.7% vs 85.5%, p<0.05). In the urban area, there were 456 people in the 100 visited households, of which 353 (77.5%) received the drugs but 242 (53.1%) consumed it. Of the total 300 studied households of the district, there were 1509 people of whom 1315 (87.1%) received the drugs and only 975 (64.6%) consumed the drugs. This table also shows that there is significant difference in distribution rate (p<0.001) and consumption rate (P<0.01) of MDA among rural and urban population of the district. Table 3 describes the age wise compliance of DEC & Alb among the rural & urban study population. Out of 962 people who had received DEC & Alb in rural area, 733 (76%) had consumed the tablets and 229 (24%) had not. Age wise break up showed that the compliance was 64% in 2-5 yrs age group, 76% in 5-14 yrs age group and 77% in >14 yrs age group. This difference in compliance among various age groups was statistically significant. From among 353 who had received DEC & Alb in urban area, 242 (69%) had consumed the tablets and 111 (31%) had not consumed them. Compliance was 55% in 2-5 yrs age group, 70% in 5-14 yrs age group and 69% in >14 yrs age group. This difference in compliance among various age groups was not statistically significant. Out of total 1315 people who received the drugs compliance, 61% were in 2-5 yrs age group, 75% in 5-14 yrs age group and 75% in >14 yrs age group. Out of 1315 persons who received the drugs, 674 were males and 641 were females. Among the males, 509 (75.5%) consumed the drugs and among the females 466 (72.7%) consumed the same. The difference in DEC & Alb consumption by males and females was not statistically significant (X 2 = 1.363, df = 1, p>0.05). 15 ISSN:

4 Mishra A et al. J. Commun. Dis. 2015; 47(4) Residence N=1315 received the drugs Consumed (%) Not consumed (%) Total Rural 733 (76.2) 229 (23.8) 962 Urban 242 (68.6) 111 (31.4) 353 Total 975 (74.1) 340 (25.9) 1315 X 2 = 7.863, df = 1, p = 0.005, OR = ( ) Table 4.Compliance of DEC & Albendazole among the study population according to residence Table 4 depicts compliance of MDA among the study population according to residence. Residence wise distribution of compliance shows that among 1315 who received DEC & Alb from both urban and rural areas, 975 (74%) consumed the drugs and 340 (26%) had not consumed them. In rural area, 962 received the drug and 733 (76%) consumed the drug whereas in urban area, 353 received the drug and 242 (69%) consumed the same. The difference in consumption by rural and urban residents was statistically significant. Odds of consumption of DEC & Alb were 1.5 times more among the rural population than their urban counterpart. Various reasons were given for non consumption of drugs by people who had received the tablets but not consumed it. The most common reason for non consumption was fear of side effect (87.0%). Other causes of non consumption were free from any disease i.e. apparently being healthy (5.3%), unwillingness to consume so many tablets (3.8%), ill health (1.7%), absence from home at the time of distribution (but family members received the drugs for them) (0.9%), thought of being old enough not to take the tablet (0.9%), and inabillity to swallow (0.3%). Only one mother complained that her children are not able to swallow the tablets. Figure 1.Reasons for non-consumption of MDA (N=340) Note: Number of people who had received the drugs but not consumed them = 340 Out of the total 300 respondents of surveyed households, the major source of information regarding MDA was ASHA for 140 (46.7%), followed by AWW for 87 (29%) households. Television was the source of information in 14 (4.7%) households and ANM in 6 (2.0%) households. 50 (16.7%) could not give any particular response regarding source of information. The adverse events as faced by the people after consumption of DEC tablets were very few. On enquiry regarding side effects following consumption of DEC & Albendazole, respondents told that only 5 (0.5%) people faced some adverse drug reaction. Among 975 people who consumed the drugs, four persons complained of reeling of head & one had vomiting. ISSN:

5 J. Commun. Dis. 2015; 47(4) Mishra A et al. Figure 2.Source of information about MDA (N=300) Discussion The household wise distribution coverage in the present study is 83.3%. In a study by Rabindra et al., household wise distribution coverage is much lower. 10 In the present study, the distribution rate is 87.1% and is higher in rural area in comparison to urban area. A similar pattern is also seen in other studies. 11,12,13 The drug distributers should be aware of the area and each allotted area to be covered on the same day, or revisit the next day. In the present study, consumption rate is 64.6% which is lower than that in the study by Ranganath et al. 11 The minimum required target of 85% coverage for elimination is not fulfilled. Among 1509 people, only 975 (64.6%) consumed the drugs. In the study, compliance is 74.1% which is higher than in other studies. 14,15,16,17 Previous studies of MDA in India reported similar lower compliance rates which were ranging from 38.8 to 52.2%. The observed 52.18% compliance in Bidar district was also below the expected target. 14 In the present study, compliance is higher in rural area as compared to urban area (76.2% vs 68.6%). Similar finding was found in other study i.e. consumption compliance was significantly better in rural area compared to urban area (62.5%, 23.5%). 14 Noncompliance in this study was 25.9%. Most common reason for non consumption was fear of side effect (87.0%) followed by attitude of apparent wellbeing (so why to take medicine - 5.3%), unwillingness to consume so many tablets (3.8%), ill health (1.7%), absence from home at the time of distribution (0.9%), and thought of being old enough not to take the tablet (0.9%). In a study by Ranganath et al., fear of side-effects (20.15%), lack of awareness of MDA program (16.88%), absence at the time of drug distribution (14.61%), and being not convinced about the benefit of MDA (12.59%) were the common causes of non-compliance. 11 Non consumption due to fear of side effect is higher in this study as compared to other studies. Conclusion The necessity for high distribution coverage, high consumption rate and high compliance for the MDA, which is essential for lymphatic filariasis elimination, should be well understood by grass root level workers and the members of the community. There is an urgent need for more effective drug delivery strategy, especially drug delivery in urban setting. Intense IEC activities are essential to clear misconception and fear regarding the occurrence of side effects following consumption of DEC & Albendazole. Parents need to be motivated to ensure consumption of the antifilarial drugs by their children. Involving school teachers can also improve the consumption among young children. Acknowledgement The researchers sincerely acknowledge the financial support provided by Directorate of Health services (NVBDCP), Dept of H&FW, Odisha, Bhubaneswar for conducting this study. Conflict of Interest: Nil References 1. Suryakanta AH. Community medicine with recent advances. Jaypee Publication, 2009: ISSN:

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