Does mass drug administration for the integrated treatment of neglected tropical diseases really work? Assessing evidence for the control of schistosomiasis and soil-transmitted helminths in Uganda

Abstract

BackgroundLess is known about mass drug administration [MDA] for neglected tropical diseases [NTDs] than is suggested by those so vigorously promoting expansion of the approach. This paper fills an important gap: it draws upon local level research to examine the roll out of treatment for two NTDs, schistosomiasis and soil-transmitted helminths, in Uganda.MethodsEthnographic research was undertaken over a period of four years between 2005-2009 in north-west and south-east Uganda. In addition to participant observation, survey data recording self-reported take-up of drugs for schistosomiasis, soil-transmitted helminths and, where relevant, lymphatic filariasis and onchocerciasis was collected from a random sample of at least 10% of households at study locations. Data recording the take-up of drugs in Ministry of Health registers for NTDs were analysed in the light of these ethnographic and social survey data.ResultsThe comparative analysis of the take-up of drugs among adults revealed that although most long term residents have been offered treatment at least once since 2004, the actual take up of drugs for schistosomiasis and soil-transmitted helminths varies considerably from one district to another and often also within districts. The specific reasons why MDA succeeds in some locations and falters in others relates to local dynamics. Issues such as population movement across borders, changing food supply, relations between drug distributors and targeted groups, rumours and conspiracy theories about the 'real' purpose of treatment, subjective experiences of side effects from treatment, alternative understandings of affliction, responses to social control measures and historical experiences of public health control measures, can all make a huge difference. The paper highlights the need to adapt MDA to local circumstances. It also points to specific generalisable issues, notably with respect to health education, drug distribution and more effective use of existing public health legislation.ConclusionWhile it has been an achievement to have offered free drugs to so many adults, current standard practices of monitoring, evaluation and delivery of MDA for NTDs are inconsistent and inadequate. Efforts to integrate programmes have exacerbated the difficulties. Improved assessment of what is really happening on the ground will be an essential step in achieving long-term overall reduction of the NTD burden for impoverished communities.

Deworming Delusions? Mass Drug Administration in East African Schools

“…In other words, deworming alone was largely ineffective. Since 2005, research undertaken by the authors and their students has found comparable problems in other parts of East Africa (Aldis, 2008;Wingate-Saul & Shira, 2008;Parker et al, 2008Parker et al, , 2012Parker & Allen, 2011, 2013aOzunga, 2014;Pearson, 2016;Hastings, 2016). Field sites were located in north-western Uganda (Nebbi, Buliisa, Adjumani and Moyo Districts), south-eastern Uganda (Busia District -just across the border from where Miguel and Kremer studied deworming in Kenya), Tanzania's Ukerewe Island in Lake Victoria, Tanga Region in northern coastal Tanzania, and Morogoro Region, which lies to the west of Dar es Salaam (see Fig.…”

“…With large numbers of children in under-resourced and rural parts of Uganda failing to complete their primary education, it proved problematic to extrapolate the findings to the wider school-aged population. Indeed, the study had to be stopped after 3 years, because so many children had dropped out of school (Parker & Allen, 2011). This last point would seem to counter Miguel and Kremer's finding in Kenya that deworming was linked to improved school attendance, but it may be largely explained by another factor.…”

“…Even if there is some (probably short-term) immunity triggered in adults, without periodic re-treatment, the prevalence of infection is likely to return to baseline levels. This is reported to have been Mass drug administration in East African schools S125 the case, for example, in parts of Mali (Clements et al, 2009), north-western Uganda (Parker & Allen, 2011) and Gezira Province, Sudan. The data from Sudan are especially troubling because it was anticipated that the approach adopted by the Blue Nile Health Project from 1979 to 1990 would become a model for others to follow elsewhere.…”

“…Indeed, it would probably be viewed as completely unacceptable to roll out such treatment without securing the consent of parents beforehand. Perhaps sufficient communication and discussion occurs in some locations in Africa, but research findings from Uganda and Tanzania, as discussed further below, show that in most cases tablets are given out in schools and to the neighbouring populations with no proper consultation (Parker et al, 2008;Parker & Allen, 2011;Parker & Allen, 2013a, b). Teachers themselves almost invariably stated that they did not really know why the tablets needed to be taken on an annual basis, and very few could accurately explain the aetiology of the diseases.…”

“…In East Africa, school distributions are provided by teachers who receive minimal training, while distributions in villages Mass drug administration in East African schools S131 rely less on qualified health workers and more on volunteers (otherwise known as 'community drug distributors'). A range of problems have been reported, including the fact that poorly trained teachers and volunteers are rarely able to provide convincing explanations of the need to take medications, especially when someone has no signs or symptoms of infection (Parker & Allen, 2011;Samsky, 2012). The message to consume tablets also runs counter to other concurrent health education messages, such as those about the use of anti-malarials, which emphasize the need for individual diagnosis before consuming medicines.…”