There is a general assumption that complex problems have complex solutions. However, sometimes complex challenges can be addressed by fairly simple solutions. Here’s a story from the state of Jharkhand to demonstrate how collaborative efforts of frontline health workers working tirelessly in eliminating lymphatic filariasis (LF), neglected tropical disease (NTD), found a simple and practical solution for a mass drug administration (MDA) campaign in times of COVID-19. MDA is a strategy for stopping transmission of LF. MDAs are carried out by ASHAs, ANMs and community volunteers by visiting every house in endemic areas and administering the drugs in their presence. Such house to house visit seemed a challenge in the context of COVID-19.
LF, also known as elephantiasis, is a disfiguring and debilitating vector-borne disease spread by Culex mosquitoes and the second leading cause of disability globally. LF is prevalent in 256 districts across 16 states and five union territories in India and affects more than 23 million people with nearly 650 million people at risk of acquiring the infection.
The National Programme for the Elimination of Lymphatic Filariasis is part of the National Vector Borne Disease Control Programme (NVBDCP) of the Ministry of Health & Family Welfare (MoHFW), Government of India.
“To sustain gains made in the past, maintaining essential health services is critical, more so, when global attention is focused on COVID-19. WHO is committed to continue its focus on combating NTDs and supporting GOI in this endeavor,” says Dr Roderico H. Ofrin, WHO Country Representative to India.
In Jharkhand, 18 out of 24 districts are endemic for LF. The implementation of strategies for prevention, treatment, control and elimination of vector-borne diseases including filaria is managed by State and District Programme Officers. The state postponed MDA twice in March and July due to the COVID-19 pandemic. However, with development of COVID safe approaches, the government managed to conduct the 10-day MDA campaign in 13 districts starting 10 August. The national deworming day was also integrated with MDA this time.
After much deliberation on the feasibility of contact-less service maintaining physical distance and ensuring effective infection prevention and control (IPC) measures to prevent COVID-19 transmission, the government and partner organizations came up with the innovative yet simple idea of using a ‘katori’ (bowl), a commonly available household utensil to dispense medicines to everyone. The effectiveness of the solution in terms of maintaining safety in rural settings was incredible and eliminated additional logistics and related costs. Here’s how it would work: on arriving at the house, the health team would call out members and calculate the drug dose as per their age; every household member would bring a small bowl from the kitchen, and place it at a safe distance; the health worker would place the medicine for each family member in their respective bowls and step back, after which each person would consume the drug in the presence of the health team.
Another challenge in MDA/IDA is measuring the height of the person to calculate appropriate dosage of Ivermectin which was normally done using a marked flex sheet. The innovation was that the drug administrator would mark the wall of the house with chalk—four lines at different levels for measuring four different doses of drug as per height. The drug administrators would then step away allowing each member of the household to stand against the wall and based on their respective height, the dosage would be determined.
The leadership for this campaign was provided by the state’s health minister Mr Banna Gupta, who launched the campaign and led by example, by taking the medicines along with his family members. At the district level, the campaign was led by senior government officials like district magistrates (DM) and civil surgeons. In addition to sharing printed information material like hand-bills, posters, pamphlets, banners and hoardings to create awareness amongst members of the community, the campaign information was additionally shared on WhatsApp and social media platforms like Facebook, Twitter etc. and well covered by the local media. To support the state government on this intensive campaign, additional WHO-NTD coordinators were called in from other states to Jharkhand. The WHO team provided technical support, facilitated field operations, organized District Coordination Committee meetings chaired by DM and trained external monitors. A direct outcome of this campaign was the increase in the coverage for this round, which was 73.5% of the total population and well above the threshold of 65%. The government was supported by WHO and other key partner organisations on ground to provide supportive supervision and monitoring. The WHO NTD team along with external monitors provided supportive supervision and hands-on training to 1341 drug administrators at 1518 booths across 13 districts during this MDA round.
The World Health Organization launched the Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000. Under GPELF, endemic countries across the world including India have adopted a twin pillar strategy—prevention through MDA and providing morbidity management and disability prevention services to those affected by the disease. Renewing India’s commitment towards elimination, the government launched the Accelerated Plan for Elimination of Lymphatic Filariasis (APELF) in 2018 and as part of intensifying efforts towards elimination later included triple drug therapy in its strategy. The MOHFW successfully piloted triple drug regimen IDA (Ivermectin, DEC and Albendazole) for MDA as per WHO’s recommendation in 2018 and this has been rolled out in many districts.
WHO is providing technical guidance, planning, surveillance, monitoring and supportive supervision of LF field activities through NTD Coordinators in eight endemic states—Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Maharashtra, Uttar Pradesh and West Bengal. The WHO NTD programme is funded by the Bill & Melinda Gates Foundation.