The contribution of mass drug administration to global health: past, present and future

Mass drug administration (MDA) is a means of delivering safe and inexpensive essential medicines based on the principles of preventive chemotherapy, where populations or sub-populations are offered treatment without individual diagnosis. High-coverage MDA in endemic areas aims to prevent and alleviate symptoms and morbidity on the one hand and can reduce transmission on the other, together improving global health. MDA is the recommended strategy of the World Health Organisation to control or eliminate several neglected tropical diseases (NTDs). More than 700 million people now receive these essential NTD medicines annually. The combined cost of integrated NTD MDA has been calculated to be in the order of $0.50 per person per year. Activities have recently been expanded due, in part, to the proposed attempt to eliminate certain NTDs in the coming two decades. More than 1.9 billion people need to receive MDA annually across several years if these targets are to be met. Such extensive coverage will require additional avenues of financial support, expanded monitoring and evaluation focusing on impact and drug efficacy, as well as new diagnostic tools and social science strategies to encourage adherence. MDA is a means to help reduce the burden of disease, and hence poverty, among the poorest sector of populations. It has already made significant improvements to global health and productivity and has the potential for further successes, particularly where incorporated into sanitation and education programmes. However logistical, financial and biological challenges remain.

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Modelling the ability of mass drug administration to interrupt soil-transmitted helminth transmission: Community-based deworming in Kenya as a case study

PLoS Neglected Tropical Diseases ◽

10.1371/journal.pntd.0009625 ◽

2021 ◽

Vol 15 (8) ◽

pp. e0009625

Author(s):

Nyuk Sian Chong ◽

Stacey R. Smith? ◽

Marleen Werkman ◽

Roy M. Anderson

Keyword(s):

Drug Administration ◽

Mass Drug Administration ◽

Neglected Tropical Diseases ◽

Initial Conditions ◽

Drug Efficacy ◽

World Health ◽

High Prevalence ◽

Lower Drug ◽

Health Organization ◽

The Impact

The World Health Organization has recommended the application of mass drug administration (MDA) in treating high prevalence neglected tropical diseases such as soil-transmitted helminths (STHs), schistosomiasis, lymphatic filariasis, onchocerciasis and trachoma. MDA—which is safe, effective and inexpensive—has been widely applied to eliminate or interrupt the transmission of STHs in particular and has been offered to people in endemic regions without requiring individual diagnosis. We propose two mathematical models to investigate the impact of MDA on the mean number of worms in both treated and untreated human subpopulations. By varying the efficay of drugs, initial conditions of the models, coverage and frequency of MDA (both annual and biannual), we examine the dynamic behaviour of both models and the possibility of interruption of transmission. Both models predict that the interruption of transmission is possible if the drug efficacy is sufficiently high, but STH infection remains endemic if the drug efficacy is sufficiently low. In between these two critical values, the two models produce different predictions. By applying an additional round of biannual and annual MDA, we find that interruption of transmission is likely to happen in both cases with lower drug efficacy. In order to interrupt the transmission of STH or eliminate the infection efficiently and effectively, it is crucial to identify the appropriate efficacy of drug, coverage, frequency, timing and number of rounds of MDA.

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Implementation of mass drug administration for neglected tropical diseases in Guinea during the COVID-19 pandemic

PLoS Neglected Tropical Diseases ◽

10.1371/journal.pntd.0009807 ◽

2021 ◽

Vol 15 (9) ◽

pp. e0009807

Author(s):

Fatoumata Sakho ◽

Christelly Flore Badila ◽

Benoit Dembele ◽

Aissatou Diaby ◽

Abdoul Karim Camara ◽

...

Keyword(s):

Drug Administration ◽

Mass Drug Administration ◽

Neglected Tropical Diseases ◽

Risk Mitigation ◽

World Health ◽

Mitigation Measures ◽

Tropical Diseases ◽

First Case ◽

Household Members ◽

Health Organization

Background Guinea reported its first case of COVID-19 on March 12, 2020. Soon thereafter, a national state of emergency was declared, all land borders were closed, schools were shut down, and public gatherings were limited. Many health activities, including field-based activities targeting neglected tropical diseases (NTDs), were paused. The World Health Organization (WHO) issued updated guidance on the resumption of NTD field-based activities on July 27, 2020. In response, the Guinea Ministry of Health (MoH) and its partners planned and resumed mass drug administration (MDA) in mid-August to September 2020 in 19 health districts. Methodology/principal findings A risk-benefit assessment was conducted to identify potential risks associated with the MDA in the COVID-19 context. Following this assessment, a risk mitigation plan with barrier measures was developed to guide MDA implementation. These measures included COVID-19 testing for all national staff leaving Conakry, mask wearing, social distancing of two meters, and hand washing/sanitizing. A checklist was developed and used to monitor compliance to risk mitigation measures. Data on adherence to risk mitigation measures were collected electronically during the MDA. A total of 120 checklists, representing 120 community drug distributor (CDD) teams (two CDDs per team) and 120 households, were completed. Results indicated that washing or disinfecting hands was practiced by 68.3% of CDD teams, compared to 45.0% among households. Face masks to cover the mouth and nose were worn by 79.2% of CDD teams, while this was low among households (23.3%). In 87.5% of households, participants did not touch the dose pole and in 88.3% of CDD teams, CDDs did not touch the hands of the participants while giving the drugs. A large majority of CDD teams (94.2%) and household members (94.2%) were willing to participate in the MDA despite the pandemic. The epidemiological coverage was ≥65% for lymphatic filariasis, onchocerciasis and soil-transmitted helminths in 10 out of 19 HDs and ≥75% for schistosomiasis for school-aged children in 7 out of 11 HDs. Conclusions/significance Guinea was one of the first countries in Africa to resume MDA activities during the COVID-19 pandemic without causing an observed increase of transmission. The development of a risk mitigation plan and a method to monitor adherence to barrier measures was critical to this unprecedented effort. The rapid incorporation of COVID-19 barrier measures and their acceptance by CDDs and household members demonstrated both the adaptability of the National NTD Program to respond to emerging issues and the commitment of the MoH to implement NTD programs.

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Population Pharmacokinetics and Pharmacodynamics of Praziquantel in Ugandan Children with Intestinal Schistosomiasis: Higher Dosages Are Required for Maximal Efficacy

mBio ◽

10.1128/mbio.00227-16 ◽

2016 ◽

Vol 7 (4) ◽

Cited By ~ 34

Author(s):

Amaya L. Bustinduy ◽

David Waterhouse ◽

Jose C. de Sousa-Figueiredo ◽

Stephen A. Roberts ◽

Aaron Atuhaire ◽

...

Keyword(s):

Young Children ◽

Schistosoma Mansoni ◽

Drug Administration ◽

Mass Drug Administration ◽

Drug Exposure ◽

World Health ◽

Preventive Chemotherapy ◽

Time Curve ◽

Dosing Regimens ◽

Health Organization

ABSTRACT Each year, millions of African children receive praziquantel (PZQ) by mass drug administration (MDA) to treat schistosomiasis at a standard single dose of 40 mg/kg of body weight, a direct extrapolation from studies of adults. A higher dose of 60 mg/kg is also acceptable for refractory cases. We conducted the first PZQ pharmacokinetic (PK) and pharmacodynamic (PD) study in young children comparing dosing. Sixty Ugandan children aged 3 to 8 years old with egg patent Schistosoma mansoni received PZQ at either 40 mg/kg or 60 mg/kg. PK parameters of PZQ racemate and enantiomers ( R and S ) were quantified. PD outcomes were assessed by standard fecal egg counts and novel schistosome-specific serum (circulating anodic antigen [CAA]) and urine (circulating cathodic antigen [CCA]) antigen assays. Population PK and PD analyses were performed to estimate drug exposure in individual children, and the relationship between drug exposure and parasitological cure was estimated using logistic regression. Monte Carlo simulations were performed to identify better, future dosing regimens. There was marked PK variability between children, but the area under the concentration-time curve (AUC) of PZQ was strongly predictive of the parasitological cure rate (CR). Although no child achieved antigenic cure, which is suggestive of an important residual adult worm burden, higher AUC was associated with greater CAA antigenic decline at 24 days. To optimize the performance of PZQ, analysis of our simulations suggest that higher doses (>60 mg/kg) are needed, particularly in smaller children. IMPORTANCE Schistosomiasis is a neglected tropical disease, typically associated with chronic morbidity, and its control is a global health priority. Praziquantel (PZQ) is the only available antiparasitic drug and is often given out, as a single oral dose (40 mg/kg), to school-aged children by mass drug administration (MDA) schemes operating within preventive chemotherapy campaigns as endorsed by the World Health Organization (WHO). This current strategy has several limitations. (i) It excludes preschool children who can be patently infected. (ii) It delivers PZQ at a dose directly extrapolated from adult pharmacological studies. To address these problems, we conducted the first pharmacokinetic and pharmacodynamic study of young children within an area of Uganda where Schistosoma mansoni is hyperendemic. Our results demonstrate that a higher dose (>60 mg/kg) is required, especially in smaller children, and draw attention to the need for further optimization of PZQ treatment based on schistosome antigenic assays, which are more sensitive to pharmacodynamic markers.

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Factors influencing mass drug administration adherence and community drug distributor opportunity costs in Liberia: a mixed-methods approach

Parasites & Vectors ◽

10.1186/s13071-021-05058-w ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

Efundem Agboraw ◽

Fred Sosu ◽

Laura Dean ◽

Alice Siakeh ◽

Rachael Thomson ◽

...

Keyword(s):

Health System ◽

Drug Administration ◽

Mass Drug Administration ◽

Opportunity Cost ◽

Health Workers ◽

Neglected Tropical Diseases ◽

Opportunity Costs ◽

Supply Side ◽

Preventive Chemotherapy ◽

The Mean

Abstract Background Preventive chemotherapy delivered via mass drug administration (MDA) is essential for the control of neglected tropical diseases (NTDs), including lymphatic filariasis (LF), schistosomiasis and onchocerciasis. Successful MDA relies heavily on community drug distributor (CDD) volunteers as the interface between households and the health system. This study sought to document and analyse demand-side (households) and supply-side (health system) factors that affect MDA delivery in Liberia. Methods Working in two purposively selected counties, we conducted a household MDA access and adherence survey; a CDD survey to obtain information on direct and opportunity costs associated with MDA work; an observational survey of CDDs; and key informant surveys (KIS) with community-level health workers. Data from the CDD survey and Liberian minimum wage rates were used to calculate the opportunity cost of CDD participation per MDA round. The observational data were used to calculate the time spent on individual household-level tasks and CDD time costs per house visited. KIS data on the organisation and management of the MDA in the communities, and researcher reflections of open-ended survey responses were thematically analysed to identify key demand- and supply-side challenges. Results More respondents were aware of MDA than NTD in both counties. In Bong, 39% (103/261) of respondents reported taking the MDA tablet in the last round, with “not being informed” as the most important reason for non-adherence. In Maryland, 56% (147/263) reported taking MDA with “being absent” at the time of distribution being important for non-adherence. The mean cost per CDD of participating in the MDA round was −$11.90 (median $5.04, range −$169.62 to $30.00), and the mean time per household visited was 17.14 min which equates to a mean opportunity cost of $0.03 to $0.05 per household visited. Thematic analysis identified challenges, including shortages of and delays in medicine availability; CDD frustration over costs; reporting challenges; and household concerns about drug side effects. Conclusions Improved adherence to MDA and subsequent elimination of NTDs in Liberia would be supported by an improved medicine supply chain, financial compensation for CDDs, improved training, healthcare workforce strengthening, greater community involvement, capacity building, and community awareness. Graphical Abstract

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Longitudinal changes in the prevalence and intensity of soil-transmitted helminth infection following expanded community-wide mass drug administration in the delta region of Myanmar

10.1101/341677 ◽

2018 ◽

Author(s):

Julia C Dunn ◽

Alison A Bettis ◽

Nay Yee Wyine ◽

Aye Moe Moe Lwin ◽

Aung Tun ◽

...

Keyword(s):

Drug Administration ◽

Mass Drug Administration ◽

Neglected Tropical Diseases ◽

Age Groups ◽

World Health ◽

Delta Region ◽

Social Settings ◽

Before And After ◽

Target Disease ◽

Health Organization

AbstractMass drug administration (MDA), targeted at school-aged children is the method recommended by the World Health Organization for the control of morbidity induced by soil-transmitted helminth (STH) infection in endemic countries. However, MDA does not prevent reinfection between treatment rounds. In countries with endemic infection, such as Myanmar, the MDA coverage, who is targeted, and rates of reinfection in given environmental and social settings will determine how effective mass drug treatment is in suppressing transmission in the long-term. In this paper, data from an epidemiology study on STH, conducted between June 2015 and June 2016 in the delta region of Myanmar, are analysed to determine the risks of STH infection in the whole community over a year which included two MDA rounds. Risk ratios (RRs) for the four-month reinfection period were below one, whereas RRs for the six-month reinfection period were above one, indicating that more people were infected after six months of exposure post-MDA. Evidence of predisposition, as measured by the Kendall Tau-b statistic, was found for all STH species and across all age groups. This study demonstrates that a six-month gap between MDA in these communities is enough time for STH infection to return to pre-MDA levels and that the same individuals are being consistently infected between MDA rounds.Author summaryMass drug administration (MDA), treating either whole communities or targeted groups without a prior diagnosis, is used as a control strategy for many neglected tropical diseases, including soil-transmitted helminth (STH) infection. MDA takes place at set intervals, aiming to reduce morbidity caused by the target disease and potentially interrupt transmission. In this study we measure STH infection in two villages in the delta region of Myanmar over the course of a year, both before and after MDA rounds, to quantify the effect of treatment on infection and to identify groups with persistent infections. We found that whilst overall prevalence of STH infection decreased over the year, intensity of infection, measured by eggs per gram of faeces, did not significantly decrease. We also found evidence to suggest that particular people are predisposed to STH infection. This is possibly due to non-compliance to MDA, or behavioural and social factors. The findings presented here will provide evidence to support continuing Myanmar’s MDA programme for STH control and using accurate diagnostics to identify and target “predisposed” people for sustained treatment.

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Coverage evaluation surveys following soil-transmitted helminthiasis and schistosomiasis mass drug administration in Wolaita Zone of Ethiopia—The Geshiyaro project

PLoS ONE ◽

10.1371/journal.pone.0260722 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0260722

Author(s):

Ewnetu Firdawek Liyew ◽

Melkie Chernet ◽

Habtamu Belay ◽

Rosie Maddren ◽

Toby Landeryou ◽

...

Keyword(s):

Drug Administration ◽

Mass Drug Administration ◽

Cross Sectional Study ◽

World Health ◽

Size Analysis ◽

Preventive Chemotherapy ◽

Cross Sectional ◽

Change Communication ◽

Sanitation And Hygiene ◽

Health Organization

Introduction The Geshiyaro project aims to break transmission of soil-transmitted helminths and schistosomiasis in the Wolaita Zone of Ethiopia through a combination of two interventions: behavior change communication (BCC) for increased water, sanitation and hygiene (WaSH) infrastructure use alongside preventive chemotherapy (PC) using albendazole (ALB) and praziquantel (PZQ), targeted to reach 90% treatment coverage. Coverage evaluation surveys (CES) were conducted post-treatment, and the resultant survey coverage was compared to reported administrative coverage. This provided a secondary confirmation of the Geshiyaro project coverages, and is used to monitor the success of each Mass Drug Administration (MDA) round. Methods A community-based cross-sectional study was conducted in 13 woredas (districts) of the Wolaita Zone. All eligible individuals from the selected households were invited for an interview. The study design, sample size, analysis and report writing were conducted according to the World Health Organization (WHO) CES guidelines for PC. Results The study interviewed a total of 3,568 households and 18,875 individuals across 13 woredas in the Wolaita Zone. Overall, the survey coverage across all studied woredas was 81.5% (95% CI; 80.9–82.0%) for both ALB and PZQ. Reported administrative coverage across all studied woredas was higher than survey coverage, 92.7% and 91.2% for ALB and PZQ, respectively. A significant portion of individuals (17.6%) were not offered PC. The predominant reason for not achieving the target coverage of 90% was beneficiary absenteeism during MDA (6.6% ALB, 6.8% PZQ), followed by drug distributors failing to reach all households (4.7% ALB, 4.8% PZQ), and beneficiaries not informed of the program (1.3% ALB, 1.7% PZQ). Conclusion Programmatic actions will need to be taken during the next MDA campaign to achieve the targeted Geshiyaro project coverage threshold across data collection and program engagement. Adequate training and supervision on recording and reporting administrative coverage should be provided, alongside improved social mobilization of treated communities to increase participation, and strengthened institutional partnerships and communication.

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‘Choking the national demos’: research partnerships and the material constitution of global health

International Journal of Law in Context ◽

10.1017/s1744552321000069 ◽

2021 ◽

Vol 17 (1) ◽

pp. 122-127

Author(s):

John Harrington

Keyword(s):

Human Rights ◽

Global Health ◽

Access To Medicines ◽

Functional Health ◽

Essential Medicines ◽

World Health ◽

Moral Principle ◽

International Human Rights Law ◽

Health Law ◽

The World

By foregrounding a widened view of the rule of law in transnational legal processes, the works under discussion in this symposium can support innovative critical perspectives on global health law –a field that has gained wide attention due to the spread of COVID-19 around the world (Lander, 2020; Bhatt, 2020). Legal and socio-legal scholars in the decade and a half before the pandemic worked on locating global health law and articulating its underlying principles. Lawrence Gostin's 2014 monograph offers a synoptic view centred on international institutions (e.g. the World Health Organization, World Trade Organization, UN Human Rights Council) and problems (e.g. infectious-disease response, tobacco control), along with an elaboration of its normative basis in universal moral principle and international human rights law (Gostin, 2014). Struggles over access to essential medicines and intellectual property in the early 2000s are, for example, represented in terms of the right to health constraining international trade law. Andreas Fischer-Lescano and Guenther Teubner's 2004 reading is oriented more by social theory than by doctrinal or ethical frames (Fischer-Lescano and Teubner, 2004, pp. 1006, 1008). A functional health regime has ‘differentiated out’, they observe, and operates as a discrete communication system across borders, albeit one that is threatened by the preponderant economic system. On this model, the battle for access to medicines amounts to ensuring, via human rights guarantees, that the rationality of the health system is not replaced by that of its economic rival in legal and policy communications (Fischer-Lescano and Teubner, 2004, pp. 1030, 1046).

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Costs of Integrated Mass Drug Administration for Neglected Tropical Diseases in Haiti

American Journal of Tropical Medicine and Hygiene ◽

10.4269/ajtmh.2011.10-0635 ◽

2011 ◽

Vol 85 (5) ◽

pp. 826-833 ◽

Cited By ~ 13

Author(s):

Ann S. Goldman ◽

Molly A. Brady ◽

Luccene Desir ◽

Abdel Direny ◽

Roland Oscard ◽

...

Keyword(s):

Drug Administration ◽

Mass Drug Administration ◽

Neglected Tropical Diseases ◽

Tropical Diseases

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Eliminating Neglected Tropical Diseases in Urban Areas: A Review of Challenges, Strategies and Research Directions for Successful Mass Drug Administration

Tropical Medicine and Infectious Disease ◽

10.3390/tropicalmed3040122 ◽

2018 ◽

Vol 3 (4) ◽

pp. 122 ◽

Cited By ~ 4

Author(s):

Alayne Adams ◽

Myriam Vuckovic ◽

Eleanor Birch ◽

Tara Brant ◽

Stephanie Bialek ◽

...

Keyword(s):

Drug Administration ◽

Mass Drug Administration ◽

Rural Areas ◽

Urban Areas ◽

Neglected Tropical Diseases ◽

Monitoring And Evaluation ◽

Population Heterogeneity ◽

Tropical Diseases ◽

Urban Settings ◽

Context Specific

Since 1950, the global urban population grew from 746 million to almost 4 billion and is expected to reach 6.4 billion by mid-century. Almost 90% of this increase will take place in Asia and Africa and disproportionately in urban slums. In this context, concerns about the amplification of several neglected tropical diseases (NTDs) are warranted and efforts towards achieving effective mass drug administration (MDA) coverage become even more important. This narrative review considers the published literature on MDA implementation for specific NTDs and in-country experiences under the ENVISION and END in Africa projects to surface features of urban settings that challenge delivery strategies known to work in rural areas. Discussed under the thematics of governance, population heterogeneity, mobility and community trust in MDA, these features include weak public health infrastructure and programs, challenges related to engaging diverse and dynamic populations and the limited accessibility of certain urban settings such as slums. Although the core components of MDA programs for NTDs in urban settings are similar to those in rural areas, their delivery may need adjustment. Effective coverage of MDA in diverse urban populations can be supported by tailored approaches informed by mapping studies, research that identifies context-specific methods to increase MDA coverage and rigorous monitoring and evaluation.

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