|Year : 2022 | Volume
| Issue : 4 | Page : 87-92
Coverage and compliance assessment survey following lymphatic filariasis mass drug administration in Warangal, Telangana
R Bhavani1, SM V. Kumari2, Rudrakshala Divyasri1, Punam Kumari Jha1
1 Department of Community Medicine, Kakatiya Medical College, Warangal, Telangana, India
2 Department of Community Medicine, Government Medical College, Nalgonda, Telangana, India
|Date of Submission||23-Jun-2022|
|Date of Decision||19-Aug-2022|
|Date of Acceptance||24-Aug-2022|
|Date of Web Publication||8-Nov-2022|
Department of Community Medicine, Kakatiya Medical College, Warangal, Telangana
Source of Support: None, Conflict of Interest: None
Background: Lymphatic filariasis (LF) impairs the lymphatic system causing pain and physical disability. A total of 859 million people in 50 countries require preventive chemotherapy to stop the infection. Mass drug administration (MDA) strategy was started to eliminate LF by 2020. In India, filariasis is endemic in 257 districts. Hence, this study aimed to assess the coverage and compliance following MDA toward filariasis in Warangal.
Objective: The objective was to estimate the coverage rate, compliance rate, effective coverage rate, and coverage compliance gap of MDA toward filariasis in Warangal.
Materials and Methods: The study was done in Warangal district, in which four clusters were chosen. The multistage sampling technique was adopted. Four villages were selected randomly from four PHCs. Each village included 30 households. All household members were interviewed with pretested, semi-structured questionnaire. Data were entered in Excel, and descriptive statistics were used.
Results: In total, 476 were eligible for MDA administration. The total coverage rate was 80.4%, total compliance rate was 94.2%, effective coverage rate was 75.8%, and coverage compliance gap was 5.7%. The most common reason for nonconsumption was people thought that drug was not needed. The side effect after consumption was 1.6%.
Conclusion: The overall coverage rate (80.4%) was less than the recommended level (85%) for the elimination of LF. The compliance rate was 94.2%, which says that most of the people consumed the tablet. Effective coverage (75.8%) reflects the actual coverage which has to be improved. One of the reasons for not consuming the tablet was fear of side effects, but only 1.6% had side effect.
Keywords: Compliance, coverage, lymphatic filariasis, mass drug administration, Warangal
|How to cite this article:|
Bhavani R, V. Kumari S M, Divyasri R, Jha PK. Coverage and compliance assessment survey following lymphatic filariasis mass drug administration in Warangal, Telangana. MRIMS J Health Sci 2022;10:87-92
|How to cite this URL:|
Bhavani R, V. Kumari S M, Divyasri R, Jha PK. Coverage and compliance assessment survey following lymphatic filariasis mass drug administration in Warangal, Telangana. MRIMS J Health Sci [serial online] 2022 [cited 2023 Feb 3];10:87-92. Available from: http://www.mrimsjournal.com/text.asp?2022/10/4/87/360578
| Introduction|| |
Lymphatic filariasis (LF), also known as elephantiasis, is one of the oldest neglected tropical diseases. It is caused by infection with parasites such as Wuchereria bancrofti, Brugia malayi, and Brugia timori, and it is transmitted to others through mosquitoes. These parasites block and impair the lymphatic system causing pain, physical disability, and social and financial loses leading to stigma and poverty. Globally, 863 million people in 47 countries worldwide remain threatened by LF., The WHO with its member states tried to eliminate LF as a public health problem, for which it launched the Global Program to Eliminate Lymphatic Filariasis (GPELF) in 2000. The goal was to eliminate the disease by 2020. Although impressive progress has been made, the initial target year of 2020 will not be met everywhere. The WHO recently proposed 2030 as the new target year for the elimination of LF as a public health problem.
Elimination is possible by stopping the spread of the infection by preventive chemotherapy. The WHO recommended mass drug administration (MDA) strategy of administering an annual dose of medicine to the entire at risk population. According to the GPELF progress report 2021, LF is endemic in 72 countries, in which 50% of the cases lie in the WHO South-East Asian Region. In South-East Region, India, Indonesia, Nepal, and Myanmar are the four countries endemic for LF. Of these four countries, India accounts for 91.3% of threatened population who are in need of MDA.
In India, it is still a serious public health problem. Ninety percent of the infections are due to W. bancrofti., The National Health Policy in 2002 had set the goal of eliminating LF by 2015, which got later extended to 2021. To eliminate filariasis, twin-pillar strategies of MDA (DEC + albendazole) and Morbidity Management and Disability Prevention were adopted for elimination. Each endemic district should undergo at least five rounds of MDA with an effective coverage of 65% to stop the transmission. Nationally, filariasis is endemic in 257 districts which includes Warangal district also. Furthermore, the disease is more prevalent among the urban poor and affects all the segments of the rural population. Almost 133 districts had >6 rounds of MDA, yet LF prevalence continues to be high. This may be due to the poor distribution of drugs and poor compliance to treatment. Furthermore, the transmission suppression could be achieved only through the integration of vector control with the regular evaluation surveys of MDA. Hence, this study was aimed to assess the coverage and compliance post-MDA toward filariasis in Warangal district, Telangana.
| Materials and Methods|| |
A community-based cross-sectional study was conducted in the Warangal district, which included three rural PHCs and one urban PHC. The study was conducted during September 2021 for 10 days, which is 1 month after the MDA campaign. All the eligible populations for MDA were included as the study population. Of the study population, all the eligible adults who gave consent as well as who were residing in the study area were included in the study. Pregnant women, children <2 years, and those who were critically ill were excluded according to the guidelines. Multistage sampling technique was followed.
Prior to the start of the study, Institutional Ethical Committee permission was obtained. According to the NVBDCP guidelines on the elimination of LF in India, four clusters were selected from the district. It included three rural and one urban clusters., Line listing of all the PHCs was done according to the classification of low, medium, and high drug distribution coverage in both urban and rural areas. One ward was randomly selected from the medium coverage in the urban area. Three rural PHCs from each category were selected randomly. Subsequently, one village was selected randomly after line listing of all the villages in each PHC. The respectively selected villages were Venkatapur village, Punnelu village, and Mulkanoor village in rural clusters and Sudha Nagar village from urban cluster. Through systematic sampling technique, 30 households were selected in each village according to the NVBDCP guidelines, and all the eligible populations of the household were interviewed by the investigator. The investigator used a pretested, semi-structured questionnaire for the interview. Flow chart showing the detailed methodology of selection of clusters is shown in [Figure 1]. Sample size was 476, which includes all the eligible populations of above-mentioned 30 households of four cluster villages.
The results were computed in terms of coverage rate (the proportion of eligible surveyed population who have actually received the drug), compliance rate (proportion of the eligible population who have actually consumed the drug after receiving it), effective coverage rate (the proportion of the actual target population who have actually consumed the drug among the eligible population), and coverage compliance gap (proportion of covered eligible population who have not consumed the tablets). For the statistical analysis, data collected were entered in MS Excel and analyzed using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Descriptive statistics such as frequency and percentage were used. Analytical statistics such as Chi-square test was used to calculate the difference in proportions.
| Results|| |
In the present study, four clusters were studied, which included a total population of 490 in 120 households, of which only 476 were eligible for MDA administration, which is the study population. Fourteen (2.8%) were not eligible according to the guidelines which included 12 kids <2 years and two pregnant women. Of 476 eligible population, 243 (51.1%) were male and 233 (48.9%) were female. Majority of the population were in the age group of >15 years (88.44%). [Table 1] and [Table 2] show the distribution of the study population according to the gender and age distribution in each cluster separately.
|Table 1: Distribution of the study population according to gender (n=476)|
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|Table 2: Distribution of the study population according to age categories (n=476)|
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Of the 476 eligible population, 383 (80.40%) received the tablets and 93 (19.50%) did not receive the tablets. Of 383 who received the tablets, 361 (94.2%) consumed the tablets and remaining 22 (5.7%) did not consume it. [Figure 2] and [Figure 3] explain the percentage of people who received and consumed the tablets.
|Figure 2: Pie chart showing the percentage of distribution of MDA tablets among eligible population. MDA: Mass Drug Administration|
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|Figure 3: Pie chart showing the percentage of consumption of MDA tablets among who received the MDA. MDA: Mass Drug Administration|
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The most common reason for nonconsumption of tablets was nine (40.9%) of the people thought that it was not needed as they do not have the active infection, and the next common reason was five (22.7%) forgot to take the MDA tablets [Figure 4].
|Figure 4: Bar chart showing the distribution of the study population based on the reason for nonconsumption of tablets|
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The total coverage rate was 80.4% and compliance rate was 94.2% in Warangal district. The coverage rate was high in the Mulkanoor village (90.6%) compared to other three clusters. However, the compliance rate was high in the urban cluster Pedamagatta, which is 96.9%. The second highest compliance rate was seen in Punnelu village (94.5%). Effective coverage was high in the Mulkanoor village, which is 84.7%, and coverage compliance gap was more in Venkatapur village (7.6%) as shown in [Table 3].
|Table 3: Coverage rate, compliance rate, effective coverage rate, and coverage compliance gap of the study population (n=476)|
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Of the people who consumed the drugs, only six (1.6%) had side effects. People developed fever, diarrhea, dizziness, and skin rashes as side effects. Urban cluster had no side effect as shown in [Table 4].
|Table 4: Distribution of the study population according to the side effects among received people|
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Although coverage was higher in rural, 286 (81.25%), compared to urban with 97 (78.22%), compliance was better among urban people with 94 (96.9%) compared to rural people, 267 (93.35%). However, there was no significant association between coverage and area of residence (X2=0.53 and P = 0.46) as well as compliance and area of residence (χ2 = 1.68 and P = 0.19) [Table 5] and [Table 6].
| Discussion|| |
LF is a disease which causes significant morbidity in the people affected by the disease. The WHO-proposed MDA strategy helps eliminate the disease in a cost-effective manner. The principle behind MDA is to approach every eligible individual in the target community and administer annual single dose of DEC and albendazole, which is to be repeated every year for 5 years or more aiming at attaining coverage more than 85% and drug compliance at least 85%.,
The coverage rate of the current study was 80.4%, which is below the expected range of interruption of transmission and elimination of the disease. In a study done by Bhue et al. in Western Odisha in 2021 and Panika and Rupesh in Madhya Pradesh in 2019, the coverage rates were 87.2% and 86.54%, which is above the recommended coverage level., However, in the study done by Gururaj et al. in Karnataka, the coverage rate was 73.1%, which is also less compared to the recommended level. The low coverage rate in our study indicates the lack of motivation among drug distributors to cover the eligible population. The coverage rate is very essential for the elimination of the disease. Hence, this should be emphasized more among drug distributors during the training session.
The compliance rate was 94.2% in the current study, which is above the recommended level. Similarly, high rate was seen in the study by Bhue et al. too, where it is said that higher compliance rate was because the people were compelled to take drugs in front of the drug distributors. Low compliance rates were seen in Karnataka in the studies done by Gururaj et al. and Koradhanyamath et al., which were 73.1% and 62.3%, respectively., Compliance rate is a more sensitive indicator than the coverage rate, because this indicates the actual consumption of tablets by the beneficiaries. Very high or even universal coverage will be of no use if the compliance is poor.
Furthermore, in our study, the coverage among the rural population was high compared to the urban population. Similarly, in the study by Mehta et al. in Surat, rural coverage was good, but urban compliance was good. This may be due to the fact that drug distributors must be familiar with people in rural area compared to the urban area. However, the literacy in the urban people made them more compliant toward the tablet than rural. However, this finding is in contrast to the study by Koradhanyamath, where both coverage and compliance were higher in the rural area. This may be because the drug distributors could have motivated the people during distribution to take the tablets correctly.
The effective coverage rate was 75.8% in our study, which is also similar to other studies.,, The effective coverage rate reflects the motivation among both drug distributors and community. Low rate reflects the lack of motivation in our study. The coverage compliance gap ideally should be zero, and the aim of the program is to work in that direction. However, in our study, it was 5.7%, which is actually less compared to other studies done in Surat and Karnataka.,,
The major reason mentioned in our study for not taking the drug was people thought that the drug was not needed as they do not have an active infection. Other common reasons were people forgot to take and fear of side effects. This is similar with almost all the other studies.,, All these reasons reflect the lack of health education regarding the disease among the people.
Among people consumed, only six (1.6%) had side effects in our study. Even in other studies, side effects were very less around 2.2% and 1.6%., One of the reasons for not consuming the tablet was fear of side effects, but the actual occurrence of side effect was only 1.6%. This clearly shows the lack of health education among the community.
| Conclusion|| |
The overall coverage rate was 80.4%, which is lower than 85%, which is the recommended level for the elimination of LF. However, the compliance rate was 94.2%, which implies that almost most of the people consumed the tablet. Although coverage rate was higher in rural areas with 81.25%, compliance rate was higher in urban area. The importance of literacy in the urban area is highlighted here. The effective coverage rate reflects the actual coverage, which was 75.8%. The coverage compliance gap was 5.7%. One of the reasons for not taking the tablet was people said they were worried about side effects, but only 1.6% of people who consumed the tablet had side effects. This reflects the lack of health education in the people.
Mop-up system in covering the houses for drug distribution should be strengthened among the health-care workers to increase the coverage. The coverage compliance gap can be reduced by making the people to take the drug in front of the drug distributors. Fear of side effects and wrong perception about MDA can be reduced by a proper health education. This reduces the misconceptions among beneficiaries toward MDA, and it results in the better implementation of the program.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]