Community engagement 'key' to effective MDA campaigns

The Indian states of Odisha and Maharashtra have both significantly reduced incidence of the disfiguring and debilitating lymphatic filariasis (LF) through mass drug administrations (MDA).

Exemplars in Global Health will soon publish new research on MDA in the large states, both which have highly endemic populations. Following their MDA campaigns, Maharashtra eliminated LF in 10 of its 17 districts with endemic populations, while Odisha achieved similar success in 10 of its 20 endemic districts.

To be declared LF-free, a district has to pass a transmission assessment survey three times over a period of four to five years. In the assessment, children are tested to see if they have been exposed to the mosquito-transmitted parasite infection. If they have not, transmission is unlikely to be occurring.

The research aims to help accelerate progress in eliminating LF by documenting the best practices of high-performing states. Overall, India bears 50 percent of the global disease burden of LF, commonly known as elephantiasis, and has ambitious plans to eliminate it by 2021 through MDA.

To mark the publication of this new research, Exemplars News spoke with Dr. Nupur Roy, the Additional Director of India’s National Vector Borne Disease Control Program about what makes an effective MDA campaign.

Dr. Roy: These are both states that perform well overall. It’s like having a student who is good in a particular subject – they tend to be good in other subjects as well. We give states policies, we give them funding, we give them technical input, but the ultimate implementers are the states themselves. Both these states followed stringent pre-MDA training, execution of pre-MDA, and had robust MDA monitoring. They tracked cases of lymphedema hydrocele [a symptom of LF in men] and updated their lists regularly. They were the first to implement, to ask for funding, to utilize those [funds], and collaborated effectively. Collaboration is very important at each level of the government, as well as with community institutions like PRI [Pancahyati Raj Institution], ICDS [Integrated Child Development Services] and other ministries and Departments of Women and Child Development. They also demonstrated strong state leadership and commitment to the program, which is also very important. They learned from other programs, like the Polio [eradication] program that was implemented throughout the entire country. For example, they were the first states to adopt the house marking system developed as part of the polio program, to trace how many people had taken the [MDA] drugs.

Dr. Roy: Whenever you launch a campaign for the elimination of LF, it’s based on twin pillars – one is mass drug administration for interruption of transmission and the other is morbidity management and disability prevention (MMDP) for patients who are already afflicted. We’ve had a number of partners such as WHO [the World Health Organization] and, for the past few years, the Bill & Melinda Gates Foundation, Clinton Health Access Initiative, and PATH. Whenever we plan an intervention like MDA, we approach them for help. They're instrumental because manpower is an issue in India, particularly when we are catering to a large population. We also work with organizations like Rotary International, Lions Clubs, Lepra, and various smaller non-governmental organizations. These organizations have some young volunteers supporting the program. Also, whenever we write a letter to the education ministry that we’ll be having a mass drug administration and we’ll need their support, they give us some volunteers to help with the implementation. We’re all working towards the same goal, so we are like a single family with these stakeholders.

Dr. Roy: That's a very good question because India is diverse. We have the other states where every two kilometers the language changes, the customs change, so it’s very important to adapt to local contexts and, if we do not do that, then it is impossible to get our desired goal of elimination. For a start, during an MDA campaign, we adapt the morbidity management and disability prevention materials into the local language so the community can understand. We conduct trainings in the local language. We also create mobile health units for hard-to-reach areas.

How do these states ensure the appropriate estimates for procurement allocation of resources at the local district and state levels?

Dr. Roy: The states ensure the appropriate estimates, procurement, and allocation of resources through effective planning at the local, district, and state level. They create district and block action plans and state performance improvement and patient safety plans. They do it very diligently and well ahead of time. Planning begins at the block level, based on funding and rough estimates from previous MDA rounds. Block action plans are then used for implementation of the state's program implementation. The State Health Society plays a pivotal role in this, with funding and resources provided by the National Vector Borne Disease Control Program. So there is complete coordination between the state and national level and detailed micro plans are made to estimate costs and the deployment of resources.

How did these states address challenges like low community awareness and engagement?

Dr. Roy: This is very important because this is the key for our success in implementing the program. We have simple and effective messaging through media and public service announcements to disseminate the maximum level of information in places like markets, railway platforms, television, and radio. We talk about MDA and how effective it is. These site-specific strategies for advocacy and social mobilization are implemented well in advance, to create momentum for community mobilization. Drug Administrators (DAs) are supposed to visit [areas] three times before the MDA. The first time, they go to the community and show them pictures of lymphedema patients and hydrocele patients to sensitize them that this is a disease. At the same time, they count how many people are in the area and then, seven days before the implementation of the MDA, they let people know that we will be coming on such and such day and that the tablets have to be ingested and not on an empty stomach. DAs are usually local, so they know each and every house. Different states prefer different [communications and media] sources and local influencers work at the district, state, and community levels. Local community members, such as members of Panchayati Raj [local self-government committees in rural villages] are invited to village coordination committee meetings to foster support. To help with personal communication, local representatives go door-to-door for counseling and dissemination of drug-related information, and all Panchayati members are involved in the distribution of information materials door-to-door during and before MDA campaigns. Local influencers are also used for awareness campaigns. In these two states, all this helps them address community fears and increase acceptance and awareness of MDA.