Revised:30.5.2015(Global version) WHO District Level Management NTD Training course Learner s Guide Module 5: Programme Operations and Logistics Session 5.4: MDA delivery and other services Part 1: Introduction Prior to implementation of mass drug administration (MDA), there is a need to check all the logistic preparations including availability of PC drugs in the community. The community members including school teachers should be taken through sensitization and health education (including information on possible adverse events/side effects) to obtain their full participation and support which will lead to increased compliance, improved uptake of services and treatment coverage. Similarly, school children should be taught the benefits of the PC (eg.sth) to them. School-aged children should be encouraged to obtain their parents consent for the PC drug administration. Session Purpose: Participants in this session would learn how to check and ensure all the required preparations for MDA delivery in the targeted communities and schools, logistics required for delivering the MDA to households members and /or schools children are in place. Prerequisite modules/sessions: Unit 5.3 on delivery of MDA by community-directed drug distributors depends on effective training provided by the district training team (of facilitators and trainers) in service delivery (module 7 and 6). Other learning modules which are pre-requisites for this module are 3, 4, 9 and 10.
Learning Objectives: At the end of the session, the learner s should be able to 1. Check the pre-mda preparations in communities and schools, and ensure availability of all the required logistics to deliver MDA 2. Deliver PC drugs to the targeted community members in the households and schools through the community drug distributors/community health volunteers. 3 Timely identification of severe side effects/adverse events and early referral to the nearest health facility; treatment follow up (absentee /mop-up MDA round) and daily reporting of treatment coverage; and maintain minimum records and continue monitoring and supervision. Abbreviations and acronyms: CDD: Community drug distributors CHV: Community health volunteers DEC: Diethyl Carbamazine Citrate IVM: Ivermectin MDA: Mass drug administration PZQ: Praziquantel SAE: Severe Adverse Events PC: Preventive chemotherapy IEC: Information, Education and Communication Definitions: Mass drug administration (MDA) is the treatment of the entire population in a geographic area with a curative dose of a simple and safe drug without first testing for infection and regardless of the presence of symptoms. Community directed distributors (CDD) are community volunteers chosen by members of the their community to distribute drugs and report back to the community.
Part 2: Key concepts Concept 1: Preparations for Mass drug administration Appropriate and adequate pre-mda preparatioins at the community and school levels are key factors in achieving maximum participation of the communities and schools in drug distribution in order to reduce non-compliance and achieve good treatment coverage. Sub-concept 1: Pre-MDA preparations Checklist The participants will learn how to make a checklist for implementing a successful MDA Availability of community drug distributors (CDD) or community health volunteers (CHV) by the nurses or health workers in consultation with the communities Completion and availability of census data for planning, implementing and reporting MDA campaign Availability of required PC medicines and related logistics and supplies for MDA delivery Availability of IEC materials (posters, hoardings/bill boards, leaflets/flyers in English/French and the local languages) The distributors and health personnel conducted sensitization and social mobilization activities including consent from the parents for MDA in the schools(module 4) Social mobilization including sensitization conducted by health workers, teachers and community drug distributors (module 4) Health education involving sensitization of community members, teachers and school children conducted on the following; o types of medicines to be given, benefits of the treatment and the possible side effects o The need of school children and household members to eat before taking the medicines in order to reduce possible abdominal side effects. o The need to drink sufficient water with medicines. o Discourage people taking medicines on empty stomach. Medicines should be swallowed in front of school teachers and community drug distributors/community health volunteers Publicity of date, day and time of visits for drug distribution in the schools/house to house or community centers etc.
Registers, summary forms, SAE forms should be available Tools for handling SAE and other side effects including forms, drugs and involvement of community distributors and clinical health workers secured Availabiity of equipment for monitoring and supervision such as motor cycles, bicycles, and vehicles Availability of place and materials for training and drug distribution eg. Tables/chairs/waste disposal bags/pens/drinking water bottles, glasses Hand cleaning materials(soap/ liquid sanitizers/tissues) Concept 2: Mass drug administration (MDA) Sub-concept 2. 1: Mass drug administration (MDA) to community In this section, the participants will learn how to deliver mass drug administration (drug distribution) to the community members (households) and school children in the schools for the following diseases. The details of drugs, dosage, adverse events and side effects are learnt in the training session (Module 7) Table 1: Drug dosage schedule of preventive chemotherapy Disease requiring PCT Lymphatic Filariasis(LF) in non-onchocerciasis areas Onchocerciasis(Oncho) + Lymphatic Filariasis(LF) Specific PCT drug( available tablet) DEC 100mg + Albendazole 400mg Ivermectin(Mectizan) 3mg + Albendazole 400mg Average number of tablets per person 2.5 1 3 1 Dose as per the WHO PC manual DEC 6mg/kg IVM ( 150 µg/kg) according to height (3 tablets in Mectizan drug application form) Soil transmitted helminthiasis(sth) Albendazole(400mg) or Mebendazole 500mg 1 400mg(ALB) or 500mg(MBD) Schistosomiasis(SCH) Praziquantel(600mg) 2.5(Children) PZQ 40mg/kg Trachoma (TRA) Azithromycin 500mg 3 (above 5 years) AZT 20mg/kg 10ml(less than 5 years)
The epidemiology and co-endemicity of NTDs determines the drug package to be distributed to a given community. Dosage depends on the height of individual s using dose poles. House-to-house drug distribution method should be applied by community drug distributors (CDD)/health workers School children(pupils) should be treated by school teachers/cdd/health workers in school and in communities for out-of-school children Community level: Community members should be involved in deciding on the day and time of the drug distribution Sufficient social mobilization activities involving health education, display of posters, distribution of leaflets and flyers, radio programmes where available and community meetings should be conducted prior to the distribution exercise Drug intake should be directly observed by ensuring individuals swallow the tablets in front of the CDDs or teachers Cases of moderate to severe discomfort or adverse events following ingestion of the drugs should be reported to the CDDs, community health workers or the nearest health facility without panicking Record of absentees should be kept and follow up conducted to ensure they are treated on their return to the communities School children who receive treatment at home should have their treatment recorded in school as well in order to prevent a second dose in school At the end of the MDA, unused drugs need to be stored as appropriately depending on the local conditions. Unused drugs should be returned and stored appropriately at the sub-district, district or regional levels as will be determined Schools level Permission of the education department and parental consent should be obtained before delivering drug treatment in schools Prior education on possible side effects should be provided to teachers and students as part of the sensitization and health education
Parents should be informed the type of drugs administered, benefits for their children and possible side effects. To build confidence among pupils, class teachers should swallow drugs in the presence of students. School treatment registers should be prepared from school attendance registers, and children are lined up and drugs administered in the presence of CDD/health workers. Absent children will receive next day or subsequently and dose should be left with school teachers. Tablets for children who are absent on day of treatment should be left behind for them to take when they return to school. Sub-concept 2.2.: Non-compliance/ refusal to take treatment In this section, the participants learn how to deal with non-compliant/treatment refusals both in the community and schools even if it is a small number. In this section, participants will learn how to manage treatment refusals and non-compliance in both community and school MDAs Do not force any individual who refuse treatment to swallow drugs if they are reluctant This may cause serious legal issues in the event that a side reaction occurs Revisits for treating refusals should involve community leaders, household head, teachers or parents with appropriate counselling, however if all efforts fail this can then be noted in the treatment register for reporting and future reference Sub-concept 2.3: Treatment follow up/ Absentee visits/mopping-up round In this section the participants will learn the importance of mopping up or follow up treatment for absentee treatment Note that mopping up increases the community confidence in the MDAs as subsequent visits improves the rapport between the communities and the CDDs/CHV Absentee visits ensure to increase the treatment coverage by 10-15% both on the schools and community.
Organize the visits as per the availability (timings-early morning / evening / holidays) of community members. Make alternate day visits to assigned area for about a week (especially holidays) following MDA to cover the absentees depending on the geographic accessibility. If any case with side effects are reported, provide them with symptomatic treatment (if possible) or refer them to the nearest health facility or inform rapid response team in the district/sub-district level for appropriate treatment/hospitalization if needed. Compile the records and send it to immediate supervisor(health workers/nurse etc) Sub-concept 2.4: Improving treatment coverage The participants learn how to increase treatment coverage. Ensure that the date and time of MDAs are clearly indicated during public announcements, in public places, during community meetings, radio announcements etc. Do not change the date and time of the MDAs after the public announcements The benefits of MDA on morbidity management and disability prevention should be mentioned as part of sensitization and health education The benefits of treatment with albendazole and mebendazole on school performance should be mentioned Inform the target group on the overall benefits of all PC drugs in stopping/reducing the transmission of a disease and protection given to the new-borne children. Sub-concept 2.5: MDA to migrant population groups: Practising MDA annually with high treatment coverage and compliance in the mobile/migrant/refugee population groups needs a lot of public awareness, motivation of consumers and treatment distributors. Note that population migration could be within the district/states/neighboring countries ( eg. Myanmar refugees in Thailand). PC-NTD programme personnel need to coordinate treatment delivery with migrant population group management officials, education, immunization and nutrition etc.
Sub-concept 2. 6: Management of severe adverse events Please refer to Module 7 and Unit 4 of the Module 5 for the management of SAE in loa loa co-endemicity and other PC-NTDs. Concept 3: Supervision and Monitoring The participants learn importance and methods of practicing supervision and monitoring of MDA activities and logistics. They learn what data is to be collected and validated and processing and interpretation of data in relation to specified programme indicators. In this section the participants learn the methods of undertaking supervision and monitoring of MDA activities including drugs and logistic management. The data to be collected, compiled interpreted and presented in the available formats regarding the required programme indicators Please refer to module 10 on Monitoring, evaluation and surveillance Concept 4: Delivery of Morbidity management and disability prevention services Please refer to Module 6 and Module 7 for delivering services for morbidity management and disability prevention services. Power point slides: Slide 1: Title of the Module 5 Slide 2: Purpose of the Unit Slide 3: Learning objectives Slide 4 and 5: Pre-MDA preparations Slide 6: Associated activities during MDA Slide7: Registration and recording during MDA Slide 8: Expected treatment coverage for each PC disease Slide 9: How to increase treatment coverage Slide 10: Why these field operations important? Slide 11: Key messages
Part 3: Session Activities Role play: Participants are divided into 2 groups. One group will act as community members/school pupils who refuse treatment and other group as CDD/CHW The learner will learn how and what to communicate with the treatment refusals (counseling) The facilitators will guide the counseling process Case study: MDA Delivery from a country where it is implemented Role play Group exercise Demonstration of MDA or MMDP service delivery if field operation is in practice in the area Part 4: Summary Job aide related to this module( include where applicable) Key words (maximum 10) Treatment delivery-mass drug administration (MDAs) Community education Key action points for district level personnel Checking for specific and adequate drug stock at the drug distribution point, registers etc.calculate number of individuals requiring treatment by community registers and school enrollment records Train staff to implement MDAs Produce information, education, communication materials to inform communities about MDAs. Availability of leaflets/handouts/posters etc Part 5: References and Additional Resources References: 1.National School-Based Deworming Programme: Teachers training booklet. Ministry of Education and Ministry of Public Health and Sanitation
2.Lymphatic Filariasis elimination programme: Training module for drug distributors in countries where lymphatic Filariasis is co-endemic with onchocerciasis: Part 2: Tutor sguide.who 2001 3. Community-Directed Treatment with Ivermectin (CDTI): A Practical guide for Trainers of Community Directed Distributors. APOC/WHO 1998 4. Interventions (CDHI): Partnering to deliver an Integrated Package to ensure improve access, coverage and sustainable health service delivery (Draft from APOC/WHO) 5. Lymphatic Filariasis elimination programme: Training module for drug distributors in countries where lymphatic Filariasis is co-endemic with onchocerciasis: Part 1: Learner s guide. WHO 2001 6. Schistosomiasis: Progress Report 2001-2011 and Strategic Plan 2012-2020. WHO. 2013 7. Elimination of Lymphatic filariaisis: Guidelines for drug distributors. National Vector Borne Diseases Control, MoH, India 8.Soil Transmitted Helminthiasis: Eliminating Soil-Transmitted Helminthiasis as a public health problem in children: Progress Report 2001-2010 and Strategic Plan 2011-2020. WHO 2012 9.Lymphatic Filariasis: A manual for National Elimination Programmes. WHO 2011 10. Trachoma control: A guide for programme managers. WHO 2006 Annexes and additional resources: Annexes can include tables and guidelines. Resources should include links to WHO and national guidelines