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Choosing the right MDA approach

Choosing the most appropriate MDA approach in each district helps ensure that a high coverage target is achieved. Watch this video to find out how.
By the end of this presentation, you should be able to plan which mass drug administration approach to use in different settings. The decision on whether to administer antibiotics for trachoma elimination depends on the prevalence of TF in children aged 1-9 years as found in the most recent prevalence survey.
Once it is decided that mass drug administration (MDA) is required, the first action is to identify the most appropriate strategy for delivering treatments to all residents in the district. This is really important. Failure to achieve a coverage of 80% or more during each MDA event can threaten the success of the MDA programme and cause a delay in reaching our trachoma elimination goal. MDA coverage is the number of people treated with antibiotics divided by the total number of residents. This is then multiplied by 100 to give a percentage.
Planning an MDA programme is carried out as part of a country’s national trachoma action plan. At the district level, trachoma teams work in consultation with communities to identify the most appropriate strategies for communication, coordination, distribution and supervision of MDA events. An MDA distribution team can be made up of 2 or 3 people. Depending on the cultural context, a female member of the team may be needed to engage with women in the community.
MDA distributors must: - Know how many people they have to reach - Maintain a register of treatments provided - Correctly follow dosage protocols for adults and children - Observe each treatment. Each distributor should be trained to understand their role, responsibilities, key instructions and the actions they need to undertake in their location.
There are 3 approaches to MDA distribution: - House to house - Central point, - and mixed. For house to house distribution, the drug distributor - or health worker - collects drugs from a designated centre at the planned time. They then move from house to house, to find all eligible residents and give them the antibiotic. All the households are covered in this process. The distributor observes each person swallowing the azithromycin before recording it as a treatment. The house to house approach requires a lot of hard work, especially in areas where population density is low or members of households are absent during distribution. In central point administration, specific sites which are accessible to community members are selected as distribution points.
Eligible residents then come to the site and are administered the antibiotic by the drug distributor or health worker. During distribution, it is usually better if households are treated one at a time and ticked off the register.
It’s important that clean water is provided at the site during distribution so that people can swallow the drug. This can often be a logistical challenge. Because central point administration is often less convenient for community members, it’s likely to achieve lower coverage than a house to house approach unless people are already accustomed to gathering at the distribution point.
At each distribution point, the process includes: - Organising the crowd - Managing the flow of people to receive treatment - Providing health education information and answering questions on what the antibiotic is for - Registration. - Determining the required dose - Observing and recording treatment. Children can be anxious and resist treatment, particularly in public environments. This needs to be managed patiently. It is also important to respect participants’ time and critical that no harm comes to any member of the community through their attendance at the distribution point or from forcing treatment onto people who do not want to take the drug. Sometimes house to house and central site approaches to MDA can be used together.
Where the main method is house to house, central point administration can be used to reach people who were absent at the time of distribution, or vice versa.
Special populations are individuals, families or sections of the population that are administratively connected to the community but socially or geographically isolated from it. An MDA campaign should plan to reach special populations at appropriate distribution points.
For example: - Displaced persons in refugee camps - Students in schools - Factory workers and prisoners. Areas where the community gathers, such as religious places, markets, bus parks and fairs or festivals are often suitable for reaching particular groups. Respectful discussion with appropriate community leaders can help to identify such opportunities. And foster a sense of ownership of the MDA campaign amongst leaders, who may then promote and advocate for it.
Community registers are very helpful: - They guide drug distributors to follow up with untreated residents, and - allow treatment coverage to be calculated. Registers are not available everywhere during the first MDA cycle. In these settings, the distributors must be trained to create an adequate record, at household level, on who has been treated and how many households have been covered each day over the MDA campaign.
Nomadic and migratory populations present special challenges for MDA campaigns. Reaching these populations (or even finding them) can be difficult. To ensure that such populations are adequately treated,
managers can: - Schedule campaigns around their movement, or - Co-ordinate campaigns along shared borders with the trachoma programme from the neighbouring country. Achieving high coverage is important for MDA campaigns to be effective. To be able to detect problems which could lead to low coverage it’s important to put in place supervision of MDA activities. Debriefing provides the distribution teams with an opportunity to share successes and challenges. This meeting should be held immediately after each round of MDA. Best practice must then be incorporated in the next round. If programmes are involved in MDA for other diseases, some integration may be established if the drugs are available at the same time.
Unfortunately, present guidance is to allow a one-week interval between azithromycin MDA and MDA with other drugs. This may mean that only the training for MDA can be integrated. Evidence that could allow this guidance to be changed is now being sought.
In summary, you should now understand: - The need to choose a distribution approach that will achieve high coverage in different settings - The need for adequate record keeping in order to be able to calculate treatment coverage.

In each district, choosing the most appropriate approach to mass drug administration (MDA) will help ensure the MDA teams achieve the high coverage target (≥ 80% of the population) needed for trachoma elimination.

As you watch this presentation consider the challenges to motivate and prevent attrition of community drug distributors.

Perspectives of a community health extension worker in Ethiopia who conducts azithromycin MDA for trachoma

“This was our second year of distribution, so all the log books were already filled, one page per family. In my team, we were three people, two volunteers to measure children and organise families, while I administered the drug and recorded the treatment.
After the sensitization my little team waited at crossroads in the community and treated families as they came to us. After three days of sitting in the busiest parts of the village, we used our log books to move from house to house, visiting those who had not come to us. We had a target of 1226 people to treat during the week. When a group assembles at a distribution point, I stop what I am doing and use it as an opportunity to provide health education for trachoma.”
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Eliminating Trachoma

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