Discussion
STH infections, NDD, anemia
ONCHOCERCIASIS, SCHISTOSOMIASIS, ANEMIA, TRACHOMA, REINFECTION, DISEASES
The current WHO and national guidelines for STH focus on the elimination of STH as a public health problem [Overall, all three states included in this multi-method study indicated a highly favorable policy environment, effective leadership structure, adequate material resources, demonstrated technical capacity, and adequate community infrastructure needed to launch a STH cMDA program. Availability of trained human resources in all the three states and financial resources in Odisha and Sikkim were indicated as currently inadequate for effective delivery. Similar findings were observed in readiness surveys in Tamil Nadu, India [Stakeholders were skeptical that cMDA could eliminate STH due to lack of WASH access and risk of reinfection, yet there was notable commitment to implement cMDA for the purposes of anemia reduction, an STH-associated morbidity. Should a policy change occur, further aligning STH goals and operational guidelines with comorbidities (such as anemia and sanitation related diseases) could ensure that new programs are a high political priority.Changes in organization policy and process are likely to be needed at all levels of government to shift from NDD to cMDA. Stakeholders explained that process changes can be expedited when strong evidence of effectiveness is presented to decision makers. These findings highlight the importance of dissemination of trial findings to STH policymakers at a national level. Additionally, many stakeholders stressed the importance of gaining consensus from local and religious leaders prior to launching cMDA and their inclusion in ‘coordination committees’. Mechanisms need to be built across all levels of leadership to ensure that local leaders are not only consulted prior to implementation but are further engaged in planning [Overall, Goa had highest readiness for implementing STH cMDA, followed by Odisha and Sikkim. The states reported both common and unique challenges to launching STH cMDA. Human resources were the most common challenge across states. Evidence from LF MDA programs in Mali, Nigeria, and Sierra Leone indicates that low motivation and an insufficient number of drug distributors can negatively influence treatment coverage [Unique state-level challenges to launching cMDA for STH include that Goa would need to hire and train male CDDs due to safety concerns in urban areas. In Sikkim, stakeholders expressed concerns about the drug supply chain and vehicle expenses in Sikkim’s hilly terrain. In Odisha, stakeholders indicated potential challenges in the drug supply chain, district-level leadership, incentivizing and motivating NTD personnel for cMDA, and bolstering resources to develop quality sensitization materials. Concerns about side-effects and misinformation about STH and its treatment was an issue in all the states. The participants, however, did not discuss potential emergence of drug resistance as being a challenge to implementing cMDA for interrupting STH transmission. While well described in veterinary medicine, the clinical relevance of drug resistance markers to benzimidazoles detected in human STH infections is unclear but remains a potential risk of cMDA [This study investigated opportunities to integrate STH with LF programs and to build upon LF programs that have successfully achieved elimination and are in the process of de-implementation. Through triangulation of program mapping, readiness surveys, and key informant interviews it was evident that there are significant overlaps between NDD and LF campaigns, and LF platforms provide numerous opportunities for launching STH cMDA. Specific LF efforts that can be leveraged include drug procurement processes, supply chain management, and community delivery infrastructure. A systematic review similarly found that integrating NTD (onchocerciasis, schistosomiasis, and trachoma) program activities with LF MDA streamlined coordination, resource distribution, and incentivization of CDDs across programs [The results of this study may also be generalizable to other Indian states considering transitioning from NDD to cMDA. The process itself, of attempting to preemptively understand readiness and implementation processes, may also be replicable across Indian settings that are considering a transition from NDD to cMDA and seeking to identify context-specific opportunities and challenges to doing so. The states with lowest STH prevalence as well as those phasing out the LF program could consider the transition to cMDA. However, the results of this study could differ across states implementing school-based deworming, and there could be variations in implementing cMDA at district-level within a state depending on the district-level STH prevalence and readiness to implement cMDA.