Lymphatic filariasis (LF), also known as elephantiasis, results from mosquito-borne
infection with filarial worm parasites, predominantly Wuchereria bancrofti, and can
lead to severe disfigurement from lymphedema and hydrocele. The World Health Organization
(WHO) has called for the elimination of LF using the strategy of annual mass drug
administration (MDA). WHO defines adequate MDA coverage (the percentage of all residents
of an endemic area who swallow the drugs) as ≥65%. By late 2011, all areas in Haiti
where LF is endemic had received MDA, except Port-au-Prince, which was considered
the most challenging area. The first MDA in Port-au-Prince was conducted from November
2011 through February 2012. To evaluate coverage, a stratified, three-stage cluster-sample
survey was conducted. In all, 71% (95% confidence interval = 69%–74%) of persons swallowed
the MDA tablets, according to their own or a proxy respondent’s recall. Coverage was
highest (77%) among internally displaced persons (IDPs) in camps, and <65% in two
of the remaining six survey strata (urban communes). Among the 1,976 adults asked
additional questions, 88% said they heard about the MDA before it happened, 74% that
they were given tablets, and 71% that they swallowed the tablets. Only 50% of those
who did not hear about the MDA in advance swallowed the tablets. The MDA was a large
step toward the elimination of LF in Haiti but must be followed by MDA rounds that
maintain adequate coverage.
In 2010, WHO estimated that 120 million persons were infected with LF globally (1).
In the Americas, Haiti is one of four countries where LF is still endemic, accounting
for 78.7% of 12.4 million persons at risk in this region (2). In 2000, WHO called
for the elimination of LF by 2020, based on a strategy of annual MDA with drugs that
clear microfilaria, the circulating stage of the parasite in humans (3). LF elimination
guidelines are based on the expectation that five consecutive annual MDA rounds, each
achieving ≥65% coverage in the total population, will result in interruption of transmission
(3). By late 2011, at least one round of MDA using albendazole and diethylcarbamazine
had been conducted throughout all endemic areas of Haiti except the capital, Port-au-Prince.
Port-au-Prince includes the communes of Cité Soleil, Carrefour, Delmas, Pétion-Ville,
Port-au-Prince, and Tabarre, and is considered the most challenging area in which
to conduct an MDA (4). During November 2011–February 2012, an MDA was conducted for
the first time in these communes. Based on reports of doses administered divided by
the estimated population of this area, the National Program for the Elimination of
Lymphatic Filariasis estimated that 92% coverage had been achieved, varying from 79%
to 160% by commune. After the MDA, a household survey was conducted by the Ministry
of Public Health and Population and partners as an independent means of assessing
coverage and to identify ways of increasing coverage and improving coverage evaluation
of MDAs in subsequent years.
A stratified, three-stage cluster sample design was used to select households in seven
strata: the IDP camps located within the six communes (one stratum) and non-IDP camp
households in each of the six communes (six strata). The first-stage sampling frame
for the IDP camps was a list of camps and their sizes in households from administrative
records updated every 2–3 months. For non-IDP camp households, the sampling frame
was a list of census enumeration areas (sections démographiques d’énumeration [SDEs]),
with SDE sizes in households taken from a 2011 update (without enumeration) of the
2003 national census. In all, 35 IDP camps and 30 SDEs in each of the remaining strata
were selected, with probability proportional to estimated camp and SDE size. Each
selected SDE and camp was divided into two or more segments of approximately equal
size in households based on natural lines of division. A single segment was randomly
chosen within each selected SDE and camp and survey teams then selected a systematic
sample of households within the segment using a sampling interval calculated so that
all households in the same stratum had the same overall probability of selection and
provided the target sample size.
Within each selected household, a parent or guardian provided responses for children
aged <10 years, and this person or another adult provided responses for older children
and adults who were absent. Persons asked about swallowing the tablets were first
shown the tablets. A knowledge, attitudes, and practices (KAP) questionnaire was administered
to persons aged ≥18 years who were present at the time of the survey visit. Coverage
and KAP survey data were collected using questionnaires on smart phones and were cleaned
and analyzed using statistical software. Children aged <2 years, pregnant women, and
severely ill persons were ineligible for treatment during the MDA. However, coverage
was defined as the percentage of all persons who swallowed the tablets (3). Coverage
estimates for the Port-au-Prince population as a whole (all seven strata) were calculated
using sampling weights derived from the overall selection probabilities of households.
A total of 2,102 households were selected for the survey sample during the survey
fieldwork, which took place during May 3–21, 2012. In 78% of these households, with
a total of 6,345 household members, an adult member was present and agreed to participate
in the survey. In all, 63% of persons aged ≥10 years answered the question about swallowing
the MDA tablets themselves; for the remaining 37%, the question was answered by a
proxy adult household member. In a weighted analysis of all seven strata, the answer
to the question about swallowing the MDA drugs was “yes” for 71% (95% confidence interval
= 69%–74%), “no” for 23%, and “don’t know” for 6% (Table) of household members in
the sample. In all, 97% of “don’t know” answers were from proxy respondents for household
members who were absent. “Yes” answers, by stratum, ranged from 60% in Tabarre Commune
to 77% in the IDP camps. By this measure, two of the strata, Tabarre and Pétion-Ville
Communes, did not achieve adequate (≥65%) coverage. Coverage by sex was nearly the
same (71% among females, 72% among males.) Among persons aged ≥2 years, coverage was
lowest (55%) among children aged 2–4 years and highest (83%) among children aged 5–14
years, declining gradually in older age groups to 62% overall among persons aged ≥65
years. The coverage-by-age group curve for non-IDP camp residents was slightly lower,
but generally paralleled the curve for IDP camp residents, except for the oldest age
group, for which non-IDP coverage declined and IDP-camp resident coverage increased
(Figure).
A total of 1,976 adults were interviewed with the KAP questionnaire. Because 70% of
the respondents were women, who were more often at home than men, the following results
were weighted according to selection probabilities and nonresponse rates by gender.
In all, 88% of respondents said they heard about the MDA before it began; 74% said
they were given tablets during the MDA, and 71% said they swallowed the tablets. Only
50% of those who did not hear about the MDA in advance swallowed the tablets, compared
with 74% among those who heard about the MDA in advance. The most commonly mentioned
preferred means of communication for those who did not hear about the MDA in advance
were television (30%), radio (28%), community resource persons (17%), and a vehicle
with loudspeaker (15%).
Most respondents who received tablets got them at a distribution post (85%); less
common sites were home (8%) and school (4%). When asked about the distance to the
nearest distribution point from their home, 77% of those who did not receive tablets
answered that they did not know or were not aware of a distribution point, as compared
with 6% of those who received tablets. The most common reason for not swallowing tablets
that were received was concern about safety or becoming ill (61%). Among all persons
given tablets at a distribution post, 76% swallowed them at the post; 13% reported
that no water was available at the post (because of the threat of cholera, the program
sought to offer a source of safe drinking water at distribution posts by purchasing
water in small plastic bags from commercial sources; persons seeking treatment were
given the tablets to swallow at home when distributors ran out of the plastic bags
of water). Among all those who swallowed the drugs, 34% reported having adverse events
within a day, most often nausea or vomiting (62%), and fatigue (42%).
What is already known on this topic?
Haiti is one of four countries in the Americas where lymphatic filariasis is still
endemic. Approximately 9.7 million persons are at risk for lymphatic filariasis in
Haiti. By late 2011, at least one round of mass drug administration (MDA) with albendazole
and diethylcarbamazine had been conducted in all endemic parts of the country except
the capital, Port-au-Prince.
What is added by this report?
A household survey conducted after the first MDA in Port-au-Prince showed that overall
coverage with albendazole and diethylcarbamazine was 71% and that five of the seven
populations within Port-au-Prince surveyed (residents of six communes and of camps
for internally displaced persons) achieved adequate coverage (≥65%). The survey also
showed that informing a greater percentage of adults in advance about the MDA and
more effectively addressing concerns about safety and side effects might increase
coverage. In addition, it showed that coverage estimates for the Port-au-Prince area
based on tallies of the number of persons treated and population estimates were inaccurate.
What are the implications for public health practice?
Haiti’s National Program for the Elimination of Lymphatic Filariasis will intensify
the dissemination of specific health education messages before subsequent MDAs in
Port-au-Prince and rely on household surveys to measure the coverage achieved in the
Port-au-Prince area.
Editorial Note
The 71% MDA coverage calculated by the household survey in Port-au-Prince demonstrates
that despite substantial obstacles posed by recent natural disasters and public health
emergencies, Haiti has taken an important step toward meeting the challenge of LF
elimination. Future MDA efforts should incorporate strategies that were identified
in this analysis as potentially important to increase coverage and sustain program
success.
MDA coverage, as determined by survey results, was inadequate (<65%) among permanent
residents of Tabarre Commune (60%) and Pétion-Ville Commune (62%). This classification
is conservative because these communes had the highest proportions of “don’t know”
answers to the coverage question (11% and 7%, respectively), the consequence of accepting
adults as proxy respondents for household members not available when the survey team
visited. If only persons who responded “yes” or “no” are considered, then the coverage
estimates for these communes would be ≥65%. For future MDA coverage surveys in Port-au-Prince,
survey teams could reduce the percentage of “don’t know” answers by making repeat
visits, including in the evening and on subsequent days, if needed, even if doing
so within resource constraints requires smaller sample sizes or combining strata.
Although the coverage survey results might have been lowered slightly by “don’t know”
answers, they likely present a more accurate estimate of coverage than the 92% derived
from reports of doses administered and estimated population sizes. Such estimates
of coverage (sometimes called “administrative”) can be in error because of inaccurate
denominators, inaccurate reporting of doses administered, and treatment of persons
outside their area of residence. The administrative result of 160% for Tabarre Commune
clearly reflects one or more of these problems. At present, administrative coverage
appears to be too inaccurate to be of value in Port-au-Prince; additional household
surveys are planned to track MDA coverage.
Coverage estimates among adult respondents who stated that they heard about the MDA
before it began were higher than among those who had not heard about it, suggesting
that broadening the reach of pre-MDA communication, including by the means preferred
by those who did not hear about the MDA in advance, might increase coverage. The survey
also showed that the majority of respondents who did not receive tablets either were
not aware of a distribution point or did not know how far away it was. Guidance on
narrowing this knowledge gap might be provided by a follow-up study focused on the
reasons for the lack of awareness, in particular, on whether post locations were systematically
announced by megaphone throughout each post’s catchment area daily during the MDA,
as intended. Further efforts to disseminate information on the safety of the drugs
also might increase coverage by addressing concerns about safety and becoming ill,
which were the most common reasons for not swallowing tablets that had been received.
These interventions for increasing coverage might help sustain progress toward national
LF elimination. The 2011–2012 MDA in Port-au-Prince demonstrated that Haiti has the
capacity to achieve this goal.