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PubMed1983

Changes in malaria incidence after mass drug administration in Nicaragua.

Mass drug administration (MDA) in 1981 reduced the incidence rates of both Plasmodium vivax and P falciparum infection in Nicaragua. Impact on P vivax cases lasted for four months and on P falciparum for seven. Subtherapeutic primaquine doses, the shorter extrinsic cycle of P vivax in the insect vector, and the timing of MDA at a high-transmission period of the year may explain the limited effects of the campaign. Positive results of the anti-malaria campaign included improvements in case-finding and routine surveillance, the apparent prevention of at least 9200 malaria cases, the training of some 70 000 antimalaria volunteers, and the participation of about 70% of the population in anti-malarial activities.

Adolescent↗

PubMed2004

Mass drug administration to eliminate lymphatic filariasis in India.

Mass drug administration (MDA) to eliminate lymphatic filariasis is already in place in 32 out of 83 endemic countries. Expansion of the MDA programme to other countries and within large countries such as India is necessary to achieve the goal of lymphatic filariasis elimination. However, expansion and sustenance of the global campaign to eliminate lymphatic filariasis requires commitment and allocation of funds by governments and donor agencies. This could be achieved, at least to some extent, by highlighting the benefits of the programme in relation to costs. On the basis of various studies in south India, this article assesses the costs, effectiveness and economic and social benefits of the MDA programmes aimed at eliminating lymphatic filariasis.

Animals↗

PubMed2006

Symptoms reported after mass drug administration for lymphatic filariasis in Leogane, Haiti.

Mass drug administration (MDA) for lymphatic filariasis (LF) can cause adverse reactions from microfilarial and adult worm death. Symptoms after the fifth annual MDA in Leogane, Haiti, were studied to determine whether they resulted from parasite death. Persons reporting post-MDA systemic symptoms at 5 of 148 drug distribution posts and men reporting scrotal pain at any post were interviewed. Participants were tested with immunochromatographic tests (ICTs), and men with scrotal symptoms were examined. At the five posts, 3,781 persons took anti-filarial medication. Of these, 314 (8%) returned with symptoms; the most common were headache (36%) and gastrointestinal complaints (28%). Of the 294 (94%) who consented to ICT testing, 47 (16%) were positive. Of 69 men with scrotal symptoms who consented to ICT testing, 18 (26.1%) were positive. After Leogane's fifth MDA, most symptomatic persons had undetectable levels of filarial antigen by ICT. Free symptomatic treatment may motivate some people to report symptoms and seek care.

Anthelmintics↗

PubMed1972

Experience with mass drug administration as a supplementary attack measure in areas of vivax malaria.

Mass drug administration was introduced in Syria to supplement DDT spraying after the main malaria vector Anopheles sacharovi had developed considerable resistance to the insecticide. Mass administration of weekly doses of chloroquine and pyrimethamine was carried out in the Ghab area from August to October, the coverage obtained being over 80% for most of the time. The number of cases with positive blood films declined rapidly from August onwards. Entomological observations showed that the house-resting density decreased shortly after the second round of DDT spraying but soon regained its previous level. Some relapsing cases were detected in 1969 but none were found in 1970, and it is considered that the possibility of relapses should not deter authorities from using mass drug administration in emergency situations.

Anopheles↗

PubMed2006

Integration of mass drug administration programmes in Nigeria: The challenge of schistosomiasis.

PROBLEM: Annual mass drug administration (MDA) with safe oral anthelminthic drugs (praziquantel, ivermectin and albendazole) is the strategy for control of onchocerciasis, lymphatic filariasis (LF) and schistosomiasis. District health officers seek to integrate treatment activities in areas of overlapping disease endemicity, but they are faced with having to merge different programmatic guidelines. APPROACH: We proceeded through the three stages of integrated MDA implementation: mapping the distribution of the three diseases at district level; tailoring district training and logistics based on the results of the mapping exercises; and implementing community-based annual health education and mass treatment where appropriate. During the process we identified the "know-do" gaps in the MDA guidelines for each disease that prevented successful integration of these programmes. LOCAL SETTING: An integrated programme launched in 1999 in Plateau and Nasarawa States in central Nigeria, where all three diseases were known to occur. RELEVANT CHANGES: Current guidelines allowed onchocerciasis and LF activities to be integrated, resulting in rapid mapping throughout the two states, and states-wide provision of over 9.3 million combined ivermectin-albendazole treatments for the two diseases between 2000 and 2004. In contrast, schistosomiasis activities could not be effectively integrated because of the more restrictive guidelines, resulting in less than half of the two states being mapped, and delivery of only 701,419 praziquantel treatments for schistosomiasis since 1999. LESSONS LEARNED: Integration of schistosomiasis into other MDA programmes would be helped by amended guidelines leading to simpler mapping, more liberal use of praziquantel and the ability to administer praziquantel simultaneously with ivermectin and albendazole.

Anthelmintics↗

PubMed2006

Successful integration of insecticide-treated bed net distribution with mass drug administration in Central Nigeria.

In Africa anopheline mosquitoes transmit malaria and lymphatic filariasis (LF); insecticide-treated bed nets significantly reduce transmission of both. Insecticide-treated bed net provision to children under 5 (U5) and pregnant women (PW) is a major goal of malaria control initiatives, but use in Africa remains low because of cost and logistics. We therefore integrated insecticide-treated bed net distribution with the 2004 LF/onchocerciasis mass drug administration (MDA) program in Central Nigeria. Community volunteers distributed 38,600 insecticide-treated bed nets, while simultaneously treating 150,800 persons with ivermectin/albendazole (compared with 135,600 in 2003). This was subsequently assessed with a 30-cluster survey. Among surveyed households containing U5/PW, 80% (95% CI, 72-87%) owned > or = 1 insecticide-treated bed net, a 9-fold increase from 2003. This first linkage of insecticide-treated bed net distribution with mass drug administration resulted in substantial improvement in insecticide-treated bed net ownership and usage, without adversely affecting mass drug administration coverage. Such integration allowed two programs to share resources while realizing mutual benefit, and is one model for rapidly improving insecticide-treated bed net coverage objectives.

Adolescent↗

PubMed2006

Participation in three consecutive mass drug administrations in Leogane, Haiti.

OBJECTIVES: In the global effort to eliminate lymphatic filariasis, mass drug administrations (MDAs) are organised annually. The success of this strategy depends on achieving high levels of drug coverage, which reduce the number of persons with circulating microfilariae and consequently transmission. Persons who consistently fail to participate in MDAs represent a potential threat to the goal of filariasis elimination. We wanted to know the drug coverage, the proportion of persons who were systematically non-compliant and factors associated with this behaviour. METHODS: We conducted three surveys following the third annual MDA of a filariasis elimination program in Leogane, Haiti: (1) a total population survey to determine coverage; (2) an adult survey to determine non-compliance and associated factors and (3) an urban survey to make a rural-urban comparison. RESULTS: During the third MDA, the overall surveyed coverage was 78.5% [95% confidence interval (CI) 74.4-82.6] A survey among adult population showed coverage estimates for persons >14 years old of 59.4% (95% CI 52.0-66.7), 61.0% (95% CI 55.0-67.4) and 67.3% (95% CI 60.5-74.0), for the first, second and third MDA respectively. The coverage in rural areas (78.3%) was significantly higher than in urban areas (68.3%, P < 0.05). Of the population > 14 years of age, 18% never took the drugs during any of three MDAs. These persons did not differ significantly from MDA participants by age, gender or other characteristics that we assessed. CONCLUSION: More research is needed to identify characteristics of systematically non-compliant persons in order to refine health education messages and improve distribution strategies to increase drug coverage.

Adolescent↗

PubMed2004

Impact of two annual single-dose mass drug administrations with diethylcarbamazine alone or in combination with albendazole on Wuchereria bancrofti microfilaraemia and antigenaemia in south India.

A two-arm community-based lymphatic filariasis elimination trial is being carried out in Tamil Nadu state, India to assess the effect of 2 annual single-dose mass drug administrations of diethylcarbamazine + albendazole (DEC + ALB) on microfilaraemia and antigenaemia in one arm, and diethylcarbamazine(DEC) alone in the other arm. In a cross-sectional survey at each time-point, 450-650 subjects in childhood (2-9 years old) and young adulthood (10-25 years old) were screened from each treatment arm. After 2 annual mass drug administrations, microfilaraemia prevalence in the 2-drug arm was reduced by 54% and 62% in the 2-9 year old and 10-25 year old groups respectively; and corresponding figures for the single-drug arm were 26% and 37%. Though higher reductions were recorded for geometric mean intensity of microfilaraemia in the 2-9 year old groups for both treatment arms, reduction was more pronounced in the 2-drug arm than the single drug arm (74% vs. 24%) in the 10-25 year old group. The reduction in the antigenaemia prevalence in the 2-9 year old group was evident in both treatment arms, but in the 10-25 year old group the reduction was only 16.8% in the 2-drug arm. Our results suggest that the annual, single-dose combination (DEC + ALB) mass treatment regimen has an enhanced effect against bancroftian filariasis compared to single-drug therapy.

Adolescent↗

PubMed2006

A campaign of "communication for behavioural impact" to improve mass drug administrations against lymphatic filariasis: structure, implementation and impact on people's knowledge and treatment coverage.

In the mass drug administrations (MDA) that form the principal strategy of the Global Programme to Eliminate Lymphatic Filariasis, treatment coverages of at least 65%-80% will be needed if the programme is to be successful. In the Indian state of Tamil Nadu, where treatment coverages were typically <65%, a comprehensive strategy of advocacy and communication, called the "communication for behavioural impact" (COMBI) campaign, has been developed and implemented, in an attempt to improve treatment coverage. This strategy combined advocacy, aimed at state-, district- and village-level administrations, with communication activities targeted at individual communities. The main aim was to alter the behaviour of many of those included in the rounds of MDA, so that they would be more likely to accept and consume the diethylcarbamazine tablets offered to them. The COMBI campaign had two variants, COMBI(+) and the more intensive COMBI(+ +), each of which has been implemented in six districts. Both the variants included the "personal selling" of treatment, via door-to-door visiting by a total of 113,500 filaria-prevention assistants. These assistants were able to visit 34%-49% of the households in each target community. In the COMBI(+ +) districts, up to 44% and 38% of households received information on lymphatic filariasis and its elimination via television commercials and posters, respectively. Overall, 78% of the villages in the COMBI(+ +) districts and 33% of those in the COMBI(+) districts were considered to have had good exposure to the communication campaign. At the end of this campaign about 30% more people (than pre-campaign) believed that lymphatic filariasis could be eliminated and many of those targeted considered lymphatic filariasis to be a dreadful disease, knew that a particular day had been designated "Filaria Day", and thought that the tablets offered in MDA should be consumed to prevent or eliminate the disease. Apparently as the result of the COMBI campaign, drug consumption increased, from 33% of those living in endemic communities, to 37% in the COMBI(+) districts and to 49% in the COMBI(+ +). Coverages as high as 65%-73% were recorded among those who had had the maximum exposure to the communication campaign. These results indicate that the COMBI campaign favourably changed the perception and behaviour of the people towards the elimination of lymphatic filariasis. The costs of the COMBI(+) and COMBI(+ +) strategies were only U.S.$0.002 and U.S.$0.009 per capita, respectively.

Attitude to Health↗

PubMed2002

The PacELF programme: will mass drug administration be enough?

The Pacific Programme to Eliminate Lymphatic Filariasis is a regional, mass drug administration-based campaign in 22 countries and territories with the aim of eliminating filariasis transmission and alleviating the suffering caused by Wuchereria bancrofti. The challenges to filariasis elimination campaigns based on mass drug-administration alone are reviewed in this article. These challenges together with the previous successes of mosquito control campaigns in eliminating filariasis from regions in the Pacific argue for inclusion of entomology components in the control of filariasis and the monitoring of filariasis elimination programs.

Animals↗

PubMed2002

Entomological monitoring of annual mass drug administrations for the control or elimination of lymphatic filariasis.

Together, the interruption of transmission, through annual mass treatments with antifilarial drugs, and the alleviation of suffering in chronic cases form the principal strategy of the Global Programme to Eliminate Lymphatic Filariasis (GPELF). Entomological monitoring of the annual mass drug administrations is necessary to assess transmission levels and progress towards control or elimination of lymphatic filariasis. However, the traditional procedures for entomological monitoring, such as the dissection of mosquitoes caught manually, either as they come to bite at night or as they rest by day, are cumbersome, cost-prohibitive and often not feasible in large-scale control programmes. The collection of mosquitoes in traps and the assessment of their infection status using PCR-based assays offer promise and need to be established as a routine part of control programmes. It is proposed that-to verify the interruption of transmission or determine the prevalence of mosquito infection-1% of the villages/communities in each intervention unit be sampled, mosquitoes be collected from at least 100 households in each study village, and 10 female mosquitoes or all of those collected (whichever is the lower number) from each study house then be checked for infection.

Animals↗

PubMed1987

The influence of permethrin-impregnated bednets and mass drug administration on the incidence of Plasmodium falciparum malaria in children in Sabah, Malaysia.

A small-scale trial was carried out in the Upper Kinabatangan district of Sabah, Malaysia, to determine the effect of using permethrin-impregnated bednets on malaria transmission. A total of 306 nylon bednets with cotton borders, impregnated at a dose estimated to have been 0.062 g permethrin/m2 of nylon netting, were distributed to 139 households in five villages. At the time of distributing bednets, mass drug administration with Fansidar plus primaquine was also administered to the human population to clear all parasitaemias due to Plasmodium falciparum Welch. In another village, for comparison, mass drug administration was the only intervention. After intervention measures in December 1984 and January 1985, the parasite rates in children declined in all villages during the first month, significantly more in the villages with impregnated bednets than in the control, thus proving that the nets had an impact on malaria. However, after about 2 months, parasite rates started to increase again. After 4-6 months, parasite rates in the villages with bednets approached the rate in the control village without nets. The increase in parasite rates was paralleled by a significant deterioration in the quality, physical condition and the degree of non-utilization of bednets. Entomological evaluation proved the efficacy of permethrin-impregnated nets for controlling Anopheles balabacensis Baisas and other anophelines. Bioassays (1 h exposure) of permethrin-impregnated bednets gave 100% mortality initially and 44-61% mortality after 85-106 days. Mosquito collections in treated bednets were significantly reduced for at least 217 days. The project failed to achieve prolonged suppression of malaria transmission for a combination of entomological, sociological and practical reasons which are discussed in relation to the objectives and implementation of future bednet studies.

Animals↗

PubMed2003

Inadvertent exposure of pregnant women to ivermectin and albendazole during mass drug administration for lymphatic filariasis.

The current strategy for the interruption of transmission of lymphatic filariasis in areas where the disease is co-endemic with onchocerciasis is repeated annual mass treatment of endemic communities with ivermectin and albendazole. These drugs are not recommended for use in pregnancy. Pregnant women are excluded on the basis of their last menses. This exclusion criterion based on recall carries some inherent errors, leading sometimes to inadvertent exposure of foetuses to these drugs. This study set out to document the extent of inadvertent exposure of pregnant women to albendazole and ivermectin and assess the relative risk of congenital malformations because of inadvertent treatment with these drugs in early pregnancy. The study was conducted in the Ahanta West District of Ghana. Local pregnancy revelation norms were studied, followed by a household survey of women aged 15-45 years to assess drug administration coverage. All infants born within 42 weeks of the mass drug treatment were examined to document any congenital malformations. Mothers who had lost any such infants responded to a verbal autopsy to ascertain the probable cause of death. Health facilities and local Traditional Birth Attendants were also visited to review maternity records. Of 2985 women of childbearing age (15-49 years) who were interviewed, 343 were pregnant during the mass drug administration. The sensitivity of the last menstrual period in detecting pregnancy and thus being excluded from treatment was 0.854 (293 of 343). Some pregnant women 50 of 343 (14.6%) had thus been inadvertently treated. This represents 1.7% of women in fertile age group (15-49 years). Of the six children found with some congenital malformations in these communities, one had been exposed to the drugs in-utero. The relative risk for congenital malformation after exposure was 1.05 (P=1.0). Two of nine reported spontaneous abortions had been exposed to the drugs (P=0.62). We conclude that the local mode of excluding pregnancy in the current programme, while not perfect, is sufficiently effective and reliable for such a public health intervention; and importantly, that there is no evidence of a higher risk of congenital malformation or abortions in those who are inadvertently exposed.

Abnormalities, Drug-Induced↗

PubMed2007

Qualitative analysis of the impact of a lymphatic filariasis elimination programme using mass drug administration on Misima Island, Papua New Guinea.

BACKGROUND: Papua New Guinea is the only endemic country in the Western Pacific Region that has not yet introduced a countrywide programme to eliminate lymphatic filariasis. However, on Misima Island in Milne Bay Province, government and private sectors have collaborated to implement a pilot elimination programme. Although interim evaluation indicated that the programme has been parasitologically successful, an appreciation that sustainable health gains depend on understanding and accommodating local beliefs prompted this qualitative study. METHODS: We investigated Misima community members knowledge and attitudes about lymphatic filariasis and the elimination programme. A combination of focus groups and key informant interviews were used to explore participants perceptions of health; knowledge of the aetiology and symptoms of filariasis, elephantiasis and hydrocele; attitudes towards the disease and mass drug distribution; and the social structure and decision-making protocols within the villages. RESULTS: Focus group discussions proved inferior to key informant interviews for gathering rich data. Study participants did not consider lymphatic filariasis ("pom") a major health problem but were generally positive about mass drug administration campaigns. A variety of conditions were frequently and incorrectly attributed to filariasis. Participants expressed the belief that individuals infected with filariasis always had visible manifestations of disease. A common misconception was that taking drugs during campaigns provided long-term immunity against disease. The role of mosquito vectors in transmission was not generally appreciated and certain clinical presentations, particularly hydrocele, were associated with supernatural forces. Multiple adverse events were associated with mass drug administration campaigns and most study participants mentioned community members who did not participate in campaigns. CONCLUSION: Important issues requiring educational intervention and elimination activity modification in the Misima region were identified during this study. Research outcomes should assist Papua New Guinea in developing and implementing a national elimination strategy and inform discussions regarding the appropriateness of current elimination strategies.

Journal Article↗

PubMed2005

Situation analysis in a large urban area of India, prior to launching a programme of mass drug administrations to eliminate lymphatic filariasis.

The main strategy now adopted for the elimination of lymphatic filariasis (LF) is based on mass drug administrations (MDA). Annual administration of antifilarial drugs to 65%-80% of the population at risk of the disease is believed to be necessary if LF is to be eliminated, at least as a public-health problem, within a reasonable time-frame. To facilitate the development of drug-delivery strategies that are sufficient to ensure such high treatment coverages in large urban areas, a situation analysis was undertaken in the Indian city of Chennai. The subjects interviewed came from households with high, moderate, low or very low incomes. A lack of information on the prevalence and socio-economic impact of the disease meant that LF was not viewed as a major pubic-health problem in the study area, even though cases of elephantiasis and hydrocele were detected in 2%-8% and 7%-20% of the households investigated. Overall, 40% of the interviewees from very-low-income households and 78% of those from middle-income households knew that (the parasite causing) elephantiasis was transmitted by mosquitoes. Only 4% of the subjects from high-income areas and 1% of those from low-income areas were aware that filarial infection was a major cause of hydrocele. Most of the subjects (>55% of each of the four socio- economic groups considered) felt that they were not at risk of developing elephantiasis. When specifically asked, only 35% of the subjects from high-income households but 84% of those from low-income households said that they would be willing to consume tablets of an antifilarial drug (diethylcarbamazine) in MDA to eliminate LF. It is therefore unclear whether high-income households in urban areas should be included in MDA programmes. The interviewees felt that an intensive campaign of information, education, communication and advocacy would be necessary if an effective MDA-based programme were to be implemented. Drug distribution through the health services was the most preferred option.Clearly, factors such as a lack of appreciation of the socio-economic impact of LF, a general belief that the risk of elephantiasis is low, doubts about the need to include all sectors of the eligible population in MDA, and a common dependence on private practitioners make successful MDA against LF in urban areas a challenging task. On the positive side, however, an urban population is often covered by a huge network of colleges, private practitioners, non-governmental organizations and residents' associations, and such networks provide new opportunities in the development of effective drug-delivery strategies.

Animals↗

PubMed2005

A rapid method to assess the coverage of the mass drug administration of diethylcarbamazine in the program to eliminate lymphatic filariasis in India.

A rapid method to assess the coverage of mass drug administration (MDA) in the program to eliminate lymphatic filariasis needs to be developed for monitoring and evaluation of the program. This study attempted to develop and test a method of rapid assessment of coverage by using the existing resources of the program. This is based on the data obtained from the randomly selected health workers and drug distributors involved in the drug distribution process and the data of a household coverage survey of the program. The MDA coverage rate obtained through the evaluation survey was highly correlated with the rates obtained from health workers and drug distributors as a rapid assessment. Thus, MDA coverages assessed through health workers and drug distributors can give a good coverage estimate. The involvement of the existing human resources of the program in this rapid method of assessing MDA coverage was cost-effective.

Cluster Analysis↗

PubMed2026

Effect of repeated mass drug administration on the transmission of yaws: a retrospective genomic epidemiology study.

BACKGROUND: Yaws, a neglected tropical disease caused by Treponema pallidum subspecies pertenue (T p pertenue), has evaded eradication, in part due to a high proportion of asymptomatic cases. Repeated mass drug administration (MDA), whereby an entire population is repeatedly treated irrespective of disease, could provide a solution. Here, we aimed to investigate the effect of MDA on the genomic epidemiology of T p pertenue. METHODS: We conducted a retrospective genomic epidemiology study on samples collected during a cluster-randomised trial of mass administration of azithromycin for yaws eradication in the Namatanai District of Papua New Guinea. Participants were in 38 wards (administrative units encompassing several villages) in three local-level government areas (LLGs). The experimental group received an initial round of MDA followed by two further rounds 6 months and 12 months after the first round. The control group received one round of MDA followed by two rounds of treatment targeting clinical cases and contacts only, on the same schedule as the MDA in the experimental group. A follow-up survey on both groups was done 18 months after the first MDA round. Swab samples were collected at each round from ulcerative and nodular skin lesions, and blood was collected by finger-prick for serological testing at 18 months. Metadata on ulcer size (cm) and duration (days) were recorded at each round, and treponemal and non-treponemal antibodies were recorded at 18 months. Samples from swabs positive for T p pertenue underwent library preparation and whole-genome sequencing. We examined the phylogenetic relationships between genomes, linking them with geospatial and patient metadata to understand the impact of MDA on T p pertenue diversity and transmission. FINDINGS: Swabs collected from 297 individuals with active yaws from April 30, 2018, to Nov 2, 2019, yielded 222 good-quality Tp pertenue genomes. We identified 20 sublineages of T p pertenue in the control group and 21 in the experimental group at the beginning of the study. At the end of the study, there were 13 sublineages in the control group and three in the experimental group, of which two persisted in both groups. Three sublineages not detected at baseline were observed in the control group after commencing MDA. The two sublineages that persisted in both groups had non-synonymous mutations in penicillin-binding proteins. One of these sublineages evolved macrolide resistance in three individuals and was associated with lowered treponemal antibody (p=0·0036) and longer ulcer duration (p=0·015). Despite the study taking place within a small island, sublineages were geographically clustered, with pairs of samples from the same ward (odds ratio 7·1, 95% CI 5·7-8·8; p<0·0001) or neighbouring wards (4·3, 3·3-5·4; p<0·0001) more likely to share the same sublineages compared with pairs from different LLGs. Additionally, older individuals were more likely to share sublineages than were younger individuals (1·5, 1·2-1·9; p<0·0001). INTERPRETATION: Repeated MDA was successful in reducing and maintaining the genetic diversity of T p pertenue at a low level but was associated with the development of macrolide resistance. Yaws re-emergence after MDA was attributed to multiple sublineages, of which the majority were detected in the population before MDA. Participants within the same ward were more likely to share sublineages than those that were more widely geographically separated, suggesting that re-emergence was driven by local transmission. These findings could inform future yaws elimination strategies. FUNDING: European Research Council, EU, Provincial Deputation of Barcelona, Barberà Solidària Foundation, Wellcome, and Fundació "la Caixa".

Adolescent↗

PubMed2004

Coverage, compliance and some operational issues of mass drug administration during the programme to eliminate lymphatic filariasis in Orissa, India.

This paper reports the coverage, compliance and other operational issues of mass drug administration (MDA) of diethylcarbamazine and albendazole under a programme to eliminate lymphatic filariasis (LF) in Orissa state of India. Both quantitative and qualitative methods were used to collect data from 90 villages and nine urban areas of four districts of Orissa, India. In Orissa, 67% of people older than 2 years had received the drugs during MDA and 42% had consumed them. About 25% of people had not taken the tablets although they received them. Urban areas recorded lower rates than rural areas. The paper discusses some policy/health system-, community- and drug-related issues that influenced coverage and compliance of MDA. It is essential to improve compliance in future rounds of MDA to achieve targets of control and eventual elimination of LF in a reasonable time frame.

Adolescent↗