The acceptability of targeted mass treatment with primaquine for local elimination of vivax malaria in a northern Myanmar township: a mixed-methods study.

BACKGROUND: Radical cure of the Plasmodium vivax latent liver stage is required to effectively manage vivax malaria. Targeted mass treatment with primaquine may be an effective mechanism for reducing reservoirs of the disease. Since community engagement and high coverage are essential for mass treatment programs, this study aimed to determine the acceptability of mass primaquine treatment in a targeted community in a northern Myanmar township. METHODS: A cross-sectional mixed-methods study was deployed among household leaders in July 2019. Face-to-face interviews using structured questionnaires and standardized qualitative guidelines were conducted to gather information. Descriptive and inferential statistics, including logistic regression models, were applied. RESULTS: Among 609 study respondents, > 90% agreed to participate in an upcoming targeted mass primaquine treatment (TPT) program. Factors contributing to higher odds of acceptability of the program were older age [adjusted odds ratios (aOR): 2.38, 95% confidence intervals (CI) 1.08-8.96], secondary education level (aOR: 3.99, 95% CI 1.12-20.01), having good knowledge of malaria (aOR: 2.12, 95% CI 1.04-4.76), experiencing malaria within the family (aOR: 1.92, 95% CI 1.14-5.13), and believing eliminating malaria from the village is possible (aOR: 2.83, 95% CI 1.07-4.07). Furthermore, 50 community respondents, 6 midwives, and 4 public health staff (grade II) participated in the qualitative component of the study. Many thought that TPT seemed feasible and stressed that high coverage of underserved groups and health education are needed before commencing the activity. CONCLUSIONS: Most respondents agreed to participate in the proposed mass treatment campaign. Older people with secondary education level and those who had experienced malaria within their families were most likely to report willingness to participate. These same individuals may be important in the community engagement process to increase community acceptance of the program.

Community acceptance of reactive focal mass drug administration and reactive focal vector control using indoor residual spraying, a mixed-methods study in Zambezi region, Namibia.

BACKGROUND: In Namibia, as in many malaria elimination settings, reactive case detection (RACD), or malaria testing and treatment around index cases, is a standard intervention. Reactive focal mass drug administration (rfMDA), or treatment without testing, and reactive focal vector control (RAVC) in the form of indoor residual spraying, are alternative or adjunctive interventions, but there are limited data regarding their community acceptability. METHODS: A parent trial aimed to compare the effectiveness of rfMDA versus RACD, RAVC versus no RAVC, and rfMDA + RAVC versus RACD only. To assess acceptability of these interventions, a mixed-methods study was conducted using key informant interviews (KIIs) and focus group discussions (FGDs) in three rounds (pre-trial and in years 1 and 2 of the trial), and an endline survey. RESULTS: In total, 17 KIIs, 49 FGDs were conducted with 449 people over three annual rounds of qualitative data collection. Pre-trial, community members more accurately predicted the level of community acceptability than key stakeholders. Throughout the trial, key participant motivators included: malaria risk perception, access to free community-based healthcare and IRS, and community education by respectful study teams. RACD or rfMDA were offered to 1372 and 8948 individuals in years 1 and 2, respectively, and refusal rates were low (< 2%). RAVC was offered to few households (n = 72) in year 1. In year 2, RAVC was offered to more households (n = 944) and refusals were < 1%. In the endline survey, 94.3% of 2147 respondents said they would participate in the same intervention again. CONCLUSIONS: Communities found both reactive focal interventions and their combination highly acceptable. Engaging communities and centering and incorporating their perspectives and experiences during design, implementation, and evaluation of this community-based intervention was critical for optimizing study engagement.

Adherence to Mass Drug Administration with Dihydroartemisinin-Piperaquine and Plasmodium falciparum Clearance in Southern Province, Zambia.

Mass drug administration (MDA) with artemisinin combination therapy is a potentially useful tool for malaria elimination programs, but its success depends partly on drug effectiveness and treatment coverage in the targeted population. As part of a cluster-randomized controlled trial in Southern Province, Zambia evaluating the impact of MDA and household focal MDA (fMDA) with dihydroartemisinin-piperaquine (DHAp), sub-studies were conducted investigating population drug adherence rates and effectiveness of DHAp as administered in clearing Plasmodium falciparum infections following household mass administration. Adherence information was reported for 181,534 of 336,821 DHAp (53.9%) treatments administered during four rounds of MDA/fMDA, of which 153,197 (84.4%) reported completing the full course of DHAp. The proportion of participants fully adhering to the treatment regimen differed by MDA modality (MDA versus fMDA), RDT status, and whether the first dose was observed by those administering treatments. Among a subset of participants receiving DHAp and selected for longitudinal follow-up, 58 were positive for asexual-stage P. falciparum infection by microscopy at baseline. None of the 45 participants followed up at days 3 and/or 7 were slide positive for asexual-stage parasitemia. For those with longer term follow-up, one participant was positive 47 days after treatment, and two additional participants were positive after 69 days, although these two were determined to be new infections by genotyping. High completion of a 3-day course of DHAp and parasite clearance in the context of household MDA are promising as Zambia's National Malaria Programme continues to weigh appropriate interventions for malaria elimination.

The social implications of participant choice on adherence to Isonaizid Preventive Therapy (IPT): A follow-up study to high completion rates in Eswatini.

BACKGROUND: Eswatini (formerly Swaziland) has one of the highest rates of TB and HIV co-disease in the world. Despite national efforts to improve service delivery and prevent TB and HIV transmission, rates remain high. A recent prospective, observational study of integrated, patient-selected IPT delivery showed extraordinary improvements in IPT adherence, running counter to previous assumptions. This prompted the need to understand contextual and unseen study factors that contributed to high rates of adherence. OBJECTIVE: To investigate high rates of IPT adherence rates among people living with HIV who participated in an observational study comparing modes of IPT delivery. METHODS: Community-based participatory research guided the development of in-person administration of semi-structured questionnaires. Observational and field note data were analyzed. Qualitative data were analyzed using content analysis. RESULTS: We interviewed 150 participants and analyzed responses from the 136 who remembered being given a choice of their IPT delivery method. Fifty-seven percent were female and the median age was 42. Nearly 67% of participants chose to receive facility-based IPT. High rates of self-reported IPT treatment adherence were linked to four key concepts: 1) adherence was positively impacted by community education; 2) disclosure of status served to empower participant completion; 3) mode of delivery perceptions positively impacted adherence; and 4) choice of treatment delivery seen as helpful but not essential for treatment completion. DISCUSSION: Achieving higher rates of IPT adherence in Eswatini and similar rural areas requires community-engaged education and outreach in coordination with care delivery systems.

Community perceptions of mass drug administration for soil-transmitted helminthiasis and schistosomiasis in selected schools in the Philippines.

BACKGROUND: Soil-transmitted helminthiasis (STH) and schistosomiasis are parasitic infections prevalent in tropical and subtropical countries, such as the Philippines. The prevalence of these infections remain high in certain Philippine provinces, despite established mass drug administration (MDA) programs in endemic communities. This study aimed to understand community knowledge and perceptions of these infections to determine their implications on the current control and elimination strategies, including possible barriers to MDA compliance. METHODS: The study was conducted in Northern Samar and Sorsogon, two provinces with the highest STH and schistosomiasis prevalence in the country. Focus group discussions with separate parent and children groups were utilized to gather knowledge and perceptions on STH and schistosomiasis causes, symptoms, treatment, and prevention; and on the deworming drugs and overall program implementation. Data collection in Northern Samar were done in August 2017, while the sessions in Sorsogon took place in May 2018. A cultural construction of disease framework will show how several factors affect MDA participation. RESULTS: Results showed that participants held mostly correct biomedical notions of the infections and expressed willingness to participate in MDA program. However, reservations remained due to a reported lack of information dissemination, lack of confidence in the drugs used, and widespread fear of adverse side effects. CONCLUSION: Addressing these concerns - improving the conduct of the deworming program, incorporating suggestions from the community, and managing potential adverse events - may help raise MDA participation and encourage better personal preventive practices, reducing STH and schistosomiasis prevalence. TRIAL REGISTRATION: N/A.

"We were afraid of the lion that has roared next to us"; community response to reactive focal mass drug administration for malaria in Eswatini (formerly Swaziland).

BACKGROUND: Reactive focal mass drug administration (rfMDA), or presumptive treatment without malaria testing of household members and neighbours of a passively identified malaria case, is currently being explored as a possible malaria elimination strategy in low transmission settings. One of the primary factors determining the effectiveness of rfMDA on reducing or interrupting transmission is achieving high coverage of the target population with drug administration. This study aims to explore the acceptability of rfMDA and identify facilitators and barriers to its potential implementation, as well as the community's general knowledge, attitudes and beliefs with regard to malaria elimination. METHODS: A qualitative study was performed using focus group discussions (FGDs) among villagers that received rfMDA through the National Malaria Control Programme in the low transmission setting of Eswatini as part of a 2-year clinical trial. FGDs were audio-recorded, transcribed and translated into English. All transcripts were managed in Dedoose and underwent qualitative content analysis. RESULTS: The majority of participants perceived their community to be at high risk of malaria. Witnessing others in their community suffer from malaria, proximity to Mozambique, various ecological factors, and the presence of mosquitoes contributed to this perception. The greatest motivator of participation in rfMDA was witnessing someone else suffer from malaria, since most participants had not personally experienced malaria themselves. Participants valued the education on rfMDA and on malaria in general, particularly when communicated by nurses and other health workers from the Ministry of Health. Participants were overwhelmingly motivated to participate in rfMDA in order to obtain protection from malaria. Most participants did not understand the concept of sub-clinical infection and, therefore, did not perceive the anti-malarial medication given in rfMDA to be a treatment medication. CONCLUSIONS: Perceived risk for malaria was a major driver of acceptability; therefore, future intervention campaigns could aim to better quantify risk to inform interventions and encourage uptake. There were misunderstandings about the asymptomatic reservoir of parasites in humans. Given that this phenomenon is the rationale for rfMDA, this misunderstanding could threaten the uptake of the intervention if it persists in the community. Using local authorities to deliver messaging, additional education on this concept with re-inforcement that risk of malaria is ongoing, even in the absence of frequent cases, may help to maximize and maintain acceptability.

Community and Drug Distributor Perceptions and Experiences of Mass Drug Administration for the Elimination of Lymphatic Filariasis: A Rapid Review of Qualitative Research.

STUDY OBJECTIVES: This article presents findings from a rapid review of qualitative research conducted to inform decision makers about community and drug distributor perceptions and experiences of mass drug administration campaigns for the elimination of lymphatic filariasis. We focused on questions related to acceptability of the mass drug administration campaigns within these groups and their thoughts around the feasibility of planning and carrying out the campaigns. METHODS: We carried out a systematic search in five databases to identify potential studies. We included studies that focused on community members and drug distributors and used qualitative methods for data collection and analysis. We conducted a thematic framework analysis using the Supporting the Use of Research Evidence framework. Due to time constraints, one author conducted the screening, extraction and data analysis. FINDINGS: Studies found that communities lack knowledge and information about lymphatic filariasis and the mass drug administration campaigns and that this can have an impact on how many community members choose to take medication. Health workers often had a good understanding that lymphatic filariasis was a problem in their setting, of its cause and mode of transmission and that hydrocele and elephantiasis had the same cause. However, this knowledge was not as prevalent amongst community drug distributors who often had misconceptions surrounding the topic. Furthermore, studies found that the length, timing, level of community and health system involvement, access to care for side effects, inadequate numbers of drug distributors and supervisors and motivation of drug distributors influenced participation in mass drug administration campaigns. Finally, the inadequate training of drug distributors could influence community trust in the mass drug administration program and the drug distributor themselves if there was a perception that the person was uninformed or not trained to carry out their tasks.

Factors associated with relevant knowledge of intestinal schistosomiasis and intention to participate in treatment campaigns: a cross sectional survey among school children at Ijinga Island on Lake Victoria, North-Western Tanzania.

BACKGROUND: Annual Mass Drug Administration (MDA) using praziquantel targeting primary school children is the main control strategy against schistosomiasis in Tanzania. However, there are concerns about decreasing participation in mass drug administration among primary school children for unknown reasons. Therefore, the aim of this study was to identify factors related to relevant knowledge about schistosomiasis and the intention to participate in mass drug administration among primary school children in order to give recommendations for future projects. METHODS: A cross sectional, extended knowledge, attitudes and practices (KAP) survey was conducted among 356 primary school children aged 5-17 years in February-March 2016 using a pre-tested questionnaire. This survey was part of a baseline assessment for an integrated proof of concept study aiming towards schistosomiasis elimination on Ijinga Island. Outcomes of interest in logistic regression analysis were relevant knowledge and high intention to participate in treatment campaigns. Explanatory variables were sociodemographic information sources and elements aligned to Protection Motivation Theory (PMT). RESULTS: Only 17% of the children had relevant intestinal schistosomiasis related knowledge and very few of them knew any of the S. mansoni manifestations and complications. Factors associated with relevant schistosomiasis knowledge were previous diagnosis of schistosomiasis (aOR = 2.43, 95%CI: 1.1-5.6), having heard about schistosomiasis at school (aOR = 9.94, 95%CI: 5.0-19.7) and being enrolled in 6th or 7th grade (aOR = 3.94, 95%CI: 1.3-11.8). Only 40% of the children demonstrated high intention to participate in treatment campaigns. Factors associated with high intention to participate in MDA were previous diagnosis (aOR = 2.23, 95%CI: 1.1-4.7), perceived general risk of disease transmission by lake water (aOR = 1.79, 95%CI: 1.0-3.1), perceived own vulnerability of getting infected (aOR = 5.10, 95%CI: 2.1-12.6), perceived danger of the disease (aOR = 2.47, 95%CI: 1.3-4.8) and the perceived effectiveness of medicaments to cure the disease (aOR = 2.86, 95%CI: 1.4-5.7). CONCLUSIONS: The minority of the school children had high level of theoretical knowledge about schistosomiasis and a small proportion of the children demonstrated high intention to participate in mass drug administration. In general, practical knowledge on preventive measures such as taking anti-schistosomiasis drug during MDA need to be impacted in school children to increase their participation in the control program.

Epidemic hysteria following the National School Deworming Day, Zamboanga Peninsula, Philippines, 2015.

INTRODUCTION: In July 2015, the Philippines conducted a school-based mass drug administration using albendazole for soil-transmitted helminths infection. Reports of adverse events were subsequently made through the event-based surveillance system, mostly from the Zamboanga Peninsula on the island of Mindanao. A team from the Epidemiology Bureau investigated the reports of adverse events following mass drug administration (AEFMDA). METHODS: Five schools were identified for the investigation which comprised an unmatched case-control study, key informant interviews and laboratory examinations. AEFMDA cases were students who had sudden onset of abdominal pain, vomiting, diarrhoea, loss of consciousness, headache or dizziness within 24 hours after intake of deworming tablet; controls were healthy students who did not develop signs and symptoms after deworming. RESULTS: Most (85%) of the 7313 AEFMDA cases reported nationwide were from Zamboanga Peninsula. Most reports were made after rumours of deaths following deworming and of the use of expired drug were spread through the region. Many parents sent their children to hospital, even if asymptomatic. The case-control study found that being an AEFMDA case was associated with no history of previous deworming (odds ratio = 4.08, 95% confidence interval: 1.77-9.42). DISCUSSION: The investigation concluded that epidemic hysteria was the cause of the increased number of AEFMDA cases in the Zamboanga Peninsula. The false information, aggravated by social media, caused panic and an increase in reporting. Some cases had no history of deworming, and they may not have been aware that albendazole is safe and that side-effects are expected. Risk communication before, during and after future national deworming programmes are recommended to prevent unnecessary reporting of AEFMDA.

Mass anti-malarial administration in western Cambodia: a qualitative study of factors affecting coverage.

BACKGROUND: Mass anti-malarial administration has been proposed as a key component of the Plasmodium falciparum malaria elimination strategy in the Greater Mekong sub-Region. Its effectiveness depends on high levels of coverage in the target population. This article explores the factors that influenced mass anti-malarial administration coverage within a clinical trial in Battambang Province, western Cambodia. METHODS: Qualitative data were collected through semi-structured interviews and focus group discussions with villagers, in-depth interviews with study staff, trial drop-outs and refusers, and observations in the communities. Interviews were audio-recorded, transcribed and translated from Khmer to English for qualitative content analysis using QSR NVivo. RESULTS: Malaria was an important health concern and villagers reported a demand for malaria treatment. This was in spite of a fall in incidence over the previous decade and a lack of familiarity with asymptomatic malaria. Participants generally understood the overall study aim and were familiar with study activities. Comprehension of the study rationale was however limited. After the first mass anti-malarial administration, seasonal health complaints that participants attributed to the anti-malarial as "side effects" contributed to a decrease of coverage in round two. Staff therefore adapted the community engagement approach, bringing to prominence local leaders in village meetings. This contributed to a subsequent increase in coverage. CONCLUSION: Future mass anti-malarial administration must consider seasonal disease patterns and the importance of local leaders taking prominent roles in community engagement. Further research is needed to investigate coverage in scenarios that more closely resemble implementation i.e. without participation incentives, blood sampling and free healthcare.

Community-directed mass drug administration is undermined by status seeking in friendship networks and inadequate trust in health advice networks.

Over 1.9 billion individuals require preventive chemotherapy through mass drug administration (MDA). Community-directed MDA relies on volunteer community medicine distributors (CMDs) and their achievement of high coverage and compliance. Yet, it is unknown if village social networks influence effective MDA implementation by CMDs. In Mayuge District, Uganda, census-style surveys were conducted for 16,357 individuals from 3,491 households in 17 villages. Praziquantel, albendazole, and ivermectin were administered for one month in community-directed MDA to treat Schistosoma mansoni, hookworm, and lymphatic filariasis. Self-reported treatment outcomes, socioeconomic characteristics, friendship networks, and health advice networks were collected. We investigated systematically missed coverage and noncompliance. Coverage was defined as an eligible person being offered at least one drug by CMDs; compliance included ingesting at least one of the offered drugs. These outcomes were analyzed as a two-stage process using a Heckman selection model. To further assess if MDA through CMDs was working as intended, we examined the probability of accurate drug administration of 1) praziquantel, 2) both albendazole and ivermectin, and 3) all drugs. This analysis was conducted using bivariate Probit regression. Four indicators from each social network were examined: degree, betweenness centrality, closeness centrality, and the presence of a direct connection to CMDs. All models accounted for nested household and village standard errors. CMDs were more likely to offer medicines, and to accurately administer the drugs as trained by the national control programme, to individuals with high friendship degree (many connections) and high friendship closeness centrality (households that were only a short number of steps away from all other households in the network). Though high (88.59%), additional compliance was associated with directly trusting CMDs for health advice. Effective treatment provision requires addressing CMD biases towards influential, well-embedded individuals in friendship networks and utilizing health advice networks to increase village trust in CMDs.