Recommendations for Safely
Restarting MDA for NTDs in
Settings with Heightened Risk of
COVID-19 Community Transmission
The following are recommendations and best practices to consider when developing plans for safely
restarting mass drug administration (MDA) campaigns in the context of COVID-19. This document ismeant to supplement WHO’s guidance note entitled, Considerations for implementing mass treatment,
active case-finding and population-based surveys for neglected tropical diseases in the context of the
COVID-19 pandemic,1 released on 27 July, 2020. This document should only be used after a thorough
COVID-19 risk-benefit assessment (including assessment of community acceptance and readiness) has
been completed and the decision has been made to proceed with MDA. Considerations for a risk-benefit
assessment can be found in the WHO guidance cited above.
These recommendations were designed for settings that are potentially at higher-risk of community
transmission of COVID-19, with limited testing capacity and availability of reliable surveillance data.
Countries experiencing these conditions may opt for a more conservative approach to resumptionof MDA, as reflected in this document. In order to minimize potential risks in these settings, therecommendations were developed with two key principles in mind. First, that an absence of cases in aregion or village does not necessarily indicate absence of risk of COVID-19 transmission. As such, mask
wearing (as well as other appropriate Personal Protective Equipment [PPE] and proper hand hygiene)should be mandatory during all activities that involve person-to-person interactions.
Second, that the COVID-19-related risks associated with an MDA at a fixed location are greater forcommunity members than MDA conducted house-to-house. House-to-house MDA is therefore prioritizedin the considerations below. These recommendations are not meant to serve as a comprehensive
standard operating procedure, but rather should supplement existing NTD/MDA SOPs so that they canbe adapted for the local setting, both in terms of the NTDs being targeted and the COVID-19 situation. In
particular, social mobilization strategies and communication messages will need to be crafted based on
the context in which the MDA will take place.
1. Considerations for implementing mass treatment, active case-finding and population-based surveys for neglected tropicaldiseases in the context of the COVID-19 pandemic 27 July 2020. Geneva: World Health Organization; 2020 https://www.who.int/
publications/i/item/WHO-2019-nCoV-neglected-tropical-diseases-2020-1

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Recommendations for Safely Restarting MDA for NTDs in Settings with
Heightened Risk of COVID-19 Community Transmission

Planning
NTD programs considering a resumption in MDA should recognize that additional planningof distribution activities will be required to adequately prepare drug distributors andcommunities for changes in the way that MDA is conducted. Community ownership andengagement - including involvement of the community in the planning and decision making
process and tailoring approaches to the local context - will be key to ensuring that MDA
activities can resume safely and effectively. As described below, special consideration should
be given to the delivery of health messages and to provision of training for drug distributors
and community health workers on skills that they will need to deliver MDA safely.
Conduct a COVID-19 risk-benefit assessment in relevant areas to determine if MDA should
resume/commence.
• In addition to assessment of risk, planning teams should thoroughly assess
community acceptance of (and readiness for) MDA activities in the COVID-19 context.
• Careful consideration should be given to stigma associated with community healthworkers or mask wearing to ensure the safety of CDDs during the MDA.
Local field teams in areas where MDA will take place should be consulted during theplanning process so that operational realities are considered.
Efforts should be made to learn from other health campaigns that have already been
restarted to determine what has/has not worked well and what can be adapted for MDA.
Information sharing and planning should be conducted remotely as much as possible tolimit human contact.
• The use of available technology (e.g., mobile phones) should be optimized toenhance remote supervision by national or regional levels.
When possible, remote joint planning meetings with other health programs should beprioritized.
If in-person meetings are unavoidable, appropriate precautionary measures should be taken.
Use of masks during all MDA activities that involve person-to-person contact (including
planning and training) is recommended. This will require additional planning andcommunication with local teams.
Extending MDA timelines should be considered to reduce time pressure on drug
distributors.
Local health staff should be advised about the timing of MDA and informed about thepotential for and nature of treatment related adverse events.

Supply chain/drug delivery
Potential risks of virus transmission exist at each step of the supply chain. Appropriate
attention to safe delivery of drugs is essential to prevent inadvertent introduction of thevirus into areas without transmission.

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Considerations for Safely Restarting Mass Drug Administration campaigns
for Neglected Tropical Diseases in the Context of COVID-19

Adequate inventory of drug stock and supplies is necessary to ensure that orders are
made only once and to minimize the quantities of drugs that are returned after treatment.
This will require accurate estimation of drug needs based on treatment targets establishedduring planning at the district, health area and community level.
Drug packages transported to and from the field should be properly disinfected with WHOapproved cleaners upon arrival at storage facilities and before distribution in the field. The
same process should take place during reverse logistics when drugs return from the field.
PPE (including masks and gloves) and hand sanitizers should be provided to thosefacilitating end to end transportation of drugs and use should be mandatory.
• Those transporting drugs and materials should adhere to physical distancing
guidance at all stops along the journey and wear PPE when interacting with others.
Efforts should be made to reduce the number of people involved in transport of drugs andmaterials. Consider coordination with other health campaigns when possible.
Fliers and pamphlets, if being distributed before/during the MDA, should also be handled
and stored in a manner consistent with infection prevention guidelines.

Training
Teams of drug distributors will face new challenges in safely delivering MDA, including
the need to wear masks and practice hand hygiene. These skills should be practiced
in training, if possible. In addition, drug distributors should be prepared to deliver
appropriate messages on COVID-19 and to respond to community fears that may betriggered by the pandemic. Development of appropriate training materials will require
some time and effort.
Training Planning and Venue• Trainings should be conducted locally in order to prevent travel between regions asmuch as possible. Trainers should be from the local areas to the extent possible tolimit spread of the virus from other geographical zones.
° If trainers from outside the local area are needed, COVID-19 screening should
be conducted before they visit local teams.

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° Trainings that involve trainers from outside local areas should be limited toas few participants as possible. Those who have been trained can then trainothers locally.
Training meetings should be conducted outdoors when possible. If a meeting is
conducted indoors, it should be in a large, well-ventilated room.
The numbers of participants in a meeting/training should be limited depending on
the size of the venue so that safe distancing of at least 1 metre can be maintained at
all times. This may require holding multiple training sessions with fewer participants.
All participants and trainers should adhere to proper COVID-19 precautionary
measures throughout the training including wearing masks, physical distancing andpracticing hand hygiene prior to and following the training.
All high touch surfaces and materials should be disinfected with WHO-approved
cleaning materials prior to and following the training.

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Recommendations for Safely Restarting MDA for NTDs in Settings with
Heightened Risk of COVID-19 Community Transmission
Training Participants• Participants should not attend the training if they have had a fever or respiratory
symptoms within the past week, or if they have had recent contact with a known
COVID-19 case. If possible, participants’ temperature should be taken upon arrival at
the training.
• Consideration should be given to age restriction of trainees (both health workers
and volunteers) and trainees with pre-existing health conditions. A cut off age of 60
years should be adopted because of age-related vulnerability to COVID-19.
• CDDs with prior experience conducting MDA campaigns should be prioritized over
new CDDs so that errors can be minimized since supervision by regional or national
teams may be limited.
Training content• In addition to all normal MDA training components, training content should capture
infection prevention measures for COVID-19 during MDA and COVID-19 related
knowledge and messaging to be shared with those receiving MDA.
• Trainings should be scheduled for longer periods of time than they would normallyto account for the addition of COVID-19-related content.
• CDDs should be trained on proper donning/doffing of PPE including masks andgloves as well as proper hand hygiene techniques.
• Role play should be used to provide drug distributors with an opportunity topractice new physical distancing skills when delivering drugs at the household level.
• Training should include an increased emphasis on how to inform communities
about drug-related adverse events to make sure that post-treatment side effects do
not trigger concerns at the community level.
• Training content should be made available as both hard and soft copies whenpossible to facilitate access to information while in the field.

Community Sensitization and Mobilization
Development of appropriate messaging is critical to resuming MDA without creating
confusion or concern among community members about the purpose of MDA. Messages
should address COVID-19 prevention as well as the rationale for resuming MDA.
Community members and leaders should be actively involved in this process to help craft
messaging that is most appropriate and to preemptively address community concerns.
One-on-one discussions should be held with community leaders (conducted with appropriate
COVID-19 precautionary measures) to inform them of the campaign and solicit input on ways tomove forward with MDA plans. Large community meetings should not be held.
Letters should be sent to community-based organizations, religious bodies, and socialgroups to inform them of the campaign and to highlight the safety measures that will be
implemented during the MDA.

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Recommendations for Safely Restarting MDA for NTDs in Settings with
Heightened Risk of COVID-19 Community Transmission

All MDA messaging (which should be delivered on diverse platforms) should systematically
include education messages about both NTDs and COVID-19 in settings where this isdeemed acceptable to the community.
• Messaging about MDA and COVID-19 should be carefully designed to take into
account community anxieties, concerns, rumors and fears about COVID-19 and thepotential for misinformation, reluctance and resistance among community members.
• Messaging should address concerns about side effects of medication (which may
be similar to COVID-19 symptoms), as well as concerns that CDDs may be spreading
COVID-19.
• Messaging should stress that MDA is not a COVID-19 intervention and clearly
differentiate between COVID-19 and NTDs of interest. Emphasize that MDA has been
conducted in the past and that the only change is conducting MDA in a safer way
due to COVID-19 context.
Consider maintaining a team of mediators (made up of MDA program staff, district leadersand local social leaders) who may intervene on the behalf of CDDs if community resistanceand threats of physical harm should arise.
The use of mass media and social media should be prioritized to reach a wider audience
over a longer period of time (at least one week before and throughout the campaign).
Capitalize on proximity sensitization and mobilization through town criers and othercommunity mobilizers - in addition to announcing the start of the MDA, criers will also
share simple messages about COVID-19 prevention. Town criers should be included in
pre-MDA training.
Open-air campaign launch events should be avoided to prevent formation of large crowds.
Smaller events could be organized, recorded, and aired over different mass and social
media platforms.

Drug Administration
As noted above, risk of virus transmission should be assumed. This will help set the stage
for adoption of masks and physical distancing as drug distributors engage household
residents.
MDA Strategy• Door to door distribution is preferable to fixed post/fixed mobile distribution
because the former can be managed more effectively with physical distancing.
• Drug administration should be done outdoors rather than indoors, to minimize
transmission risk.
• Neighbors or other visitors should be requested to not enter the area where drugs
are being distributed to an individual/family during MDA.
• People at higher risk of transmitting COVID-19, or at higher risk of developing severe
illness from COVID-19, should preferably not participate in the MDA.

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Considerations for Safely Restarting Mass Drug Administration campaigns
for Neglected Tropical Diseases in the Context of COVID-19

CDD Precautions• If a community drug distributor (CDD) has had a fever or respiratory symptoms in
the previous week, or develops any COVID-19 symptoms during the MDA, she must
not take part in the distribution and should self-isolate at home until symptoms
have resolved (or seek medical attention if necessary).
• CDDs who are identified as contacts of COVID-19 cases should not participate in the
MDA.
• Consideration should be given to age restriction of CDDs, as well as those with preexisting health conditions. A cut off age of 60 years for CDDs should be adopted
because of age-related vulnerability to COVID-19.
• CDDs should be provided with supplies to distribute drugs safely, including handsanitizer, gloves, and spoons or small plastic bags to dispense drugs.
• CDDs must maintain hand hygiene by washing their hands with soap and water, or
using hand sanitizer before and after each household they visit.
• Masks should be worn by CDDs at all times. If a CDD must remove her mask to speak
clearly, extra distance from household members should be maintained.
During house-to-house distribution• CDDs should deliver messages on COVID-19 to the household members and explain
the reasons for the protective measures, before measuring height or dispensing
drugs. CDDs should answer questions first, treat second.
• Height measurement on dose poles should be carried out with physical distancing.
The dose pole can be placed against a wall or held at arm’s-length by the CDD.
The CDD should record the number of tablets required while observing physicaldistancing.
° If the dose pole is touched by a household member at any point, the CDD
must wipe the dosing pole and their hands with hand sanitizer after finishing
MDA at the household.
• The CDD must not touch the tablets by hand, but use a spoon to count them andtransfer them onto a clean plate provided by the family; she should then step backwhile the person takes and swallows the tablets.
° In a situation where both the household member and the CDD are wearing
masks, the CDD may deposit the tablet directly into the hand of the household
member using the spoon while both stand at arm’s-length, taking care not to
contaminate the spoon by touching the recipient’s hand.
° Household members should be encouraged to drink from different cups
instead of using the same cup.
• If the CDD observes someone with COVID-19 symptoms, she should counsel that
person in a discreet and respectful manner about what course of action they shouldtake so as not to alarm family member or neighbors.
° Individuals should be encouraged to self-isolate at home until symptoms
resolve unless symptoms are severe enough to require medical attention.
• It should be emphasized that COVID-19 symptoms are very similar to other common
illnesses and that most people experience mild illness and are able to recover athome. It is important that CDDs balance the real and perceived risk of COVID-19 andconsider the local COVID-19 epidemiological situation in the area when discussing
this level of risk.

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Recommendations for Safely Restarting MDA for NTDs in Settings with
Heightened Risk of COVID-19 Community Transmission

Supervision and Monitoring
Maintaining appropriate levels of supervision during the pandemic may be morechallenging because of the shift in MDA venue and the absence of supervisors from thecentral level. Nonetheless, adequate supervision is an essential component of the safedelivery of drugs during MDA. Supervisors should be attentive to safety considerations
throughout the MDA process.
Mobile technology should be used when possible to facilitate supervision by local andnational teams.
If supervisors from outside the local area are needed, COVID-19 screening should be
conducted before they visit local teams.
Supervisors should wear masks and ensure community volunteers are properly wearing
PPE during distribution.
A checklist to assess adherence to safety measures and MDA SOPs should be provided toall supervisors.
Supervisors must refer any CDD or member of the public showing symptoms of COVID-19 to
the nearest health facility for examination.
Given the unprecedented nature of MDA during a pandemic, consider integrating
qualitative methods into a formal MDA evaluation, which may include in-person or phonebased interviews, rapid observation during MDA and/or a quantitative KAP study.

Post-MDA Activities
After the MDA, it is important to collect coverage data and to ensure appropriate
management of unused drug stocks, in addition to assessing best practices and lessons
learned from the adapted MDA. In the pandemic context, this follow up plays animportant role in ensuring that community concerns about the MDA have been identified
and that misinformation or rumors are addressed.
Post-MDA review meetings should be restricted to district teams only, with remote support
from regional/national NTD teams. Meetings should be limited in size and observe physicaldistancing recommendations.
All leftover drug containers should be properly disinfected prior to transport or storage.
Lessons learned from the current campaign should be well documented for adoption
during subsequent campaigns.
• Feedback should also be solicited from MDA recipients and community leaders toassess impressions of the MDA.
• Any community concerns or misinformation/rumors that are discovered should bequickly addressed in a manner that reaches the entire community.
Any paper data collection forms or other supplies should be handled and shared using
proper hygiene protocols.