Epidemiological monitoring survey to assess the impact of mass drug administration with triple-drug regimen in lymphatic filariasis elimination programme in an endemic district in Southern India.

BACKGROUND

Mass Drug Administration (MDA) with triple-drug regimen (Ivermectin, Diethylcarbamazine, and Albendazole- IDA), recommended by the World Health Organization (WHO) was introduced in India in 2018, as an alternate strategy to two drug regimens (Diethylcarbamazine, and Albendazole- DA), for accelerating lymphatic filariasis (LF) elimination. By December 2023, IDA-MDA has been implemented in 63 LF endemic districts in India. The currently followed monitoring and evaluation (M&E) guidelines for DA may not be suitable to this new strategy. The WHO is developing a new M&E guideline for IDA-based MDA which recommends surveys referred to as Epidemiological Monitoring Survey (EMS) before the IDA Impact Survey (IIS), similar to pre-transmission assessment survey (preTAS) and transmission assessment survey (TAS) for DA-based MDA. The National Centre for Vector Borne Disease Control (NCVBDC) recently revised its M&E guidelines and downsized the evaluation unit to the health block from district level. In the present study, an EMS was conducted in two health blocks of Bidar district in Karnataka, India, in July 2023, following two effective rounds of IDA-MDA to assess its eligibility for an IIS.

METHODS

Two sentinel and one random site in each block were selected for the EMS, as per NCVBDC guidelines. A minimum sample of 300 individuals aged ≥20 years was tested for circulating filarial antigen (CFA) using filariasis test strips (FTS) in each site. Night blood smears were collected from CFA-positive individuals and examined for microfilaria (Mf). A Mf prevalence threshold of <1% in each site was used as a decision rule on whether to stop MDA and proceed with IIS or continue with MDA in the health block. The data were expressed as proportions with 95% confidence intervals, and a p-value <0·05 was considered statistically significant.

RESULTS

The number of individuals tested for CFA ranged from 303 to 314 in each of the six sites selected for EMS. The prevalence of CFA was above the threshold of 2% (3·6% to 31·1%) in all sites in both health blocks. Overall, 1846 individuals were screened, of which 343 (18·6%) were positive for CFA. Of the 320 individuals screened for microfilaremia, 71 were positive for Mf. All four sentinel sites in the two blocks had Mf prevalence above the threshold of 1%, ranging from 3·7 to 7·4%. The Mf count was 1-242 per 60µl of blood per positive person, and the geometric mean Mf density was 0·83 (±3·5) in the four sentinel sites. Both CFA (30·7%) and Mf (8·5%) prevalence was significantly higher in males. Nearly 42·0% of respondents self-reported not participating in both rounds of IDA-MDA, and it was significantly higher among males (52·4%). Also, the infection rates (CFA and Mf) were higher among those who did not participate in the two IDA-MDA rounds.

CONCLUSIONS

Both the health blocks in Bidar district are not eligible for stopping MDA after two rounds of IDA-MDA, indicating the need for at least two additional rounds of MDA as per WHO guideline. The study suggests that the EMS strategy is operationally feasible which the other IDA-MDA districts can follow.