The effect of compliance on the impact of mass drug administration for elimination of lymphatic filariasis in Egypt

We studied effects of compliance on the impact of mass drug administration (MDA) with diethylcarbamazine and albendazole for lymphatic filariasis (LF) in an Egyptian village. Baseline microfilaremia (mf) and filarial antigenemia rates were 11.5% and 19.0%, respectively. The MDA compliance rates were excellent (> 85%). However, individual compliance was highly variable; 7.4% of those surveyed after five rounds of MDA denied having ever taken the medications and 52.4% reported that they had taken all five doses. The mf and antigenemia rates were 0.2% and 2.7% in those who reported five doses of MDA and 8.3% and 13.8% in those who reported zero doses. There was no significant difference in residual infection rates among those who had taken two or more doses. These results underscore the importance of compliance for LF elimination programs based on MDA and suggest that two ingested doses of MDA are as effective as five doses for reducing filariasis infection rates.     

The Leogane, Haiti demonstration project: decreased microfilaremia and program costs after three years of mass drug administration

To support the global program to eliminate lymphatic filariasis (LF), well-monitored demonstration projects are important for defining the relationship between coverage and reductions in microfilaremia. We are using mass treatment with diethylcarbamazine (DEC) and albendazole in an effort to eliminate LF from Leogane, Haiti. Wuchereria bancrofti microfilaremia prevalence at baseline ranged from 0.8% to 15.9% in four sentinel sites. After three rounds of DEC-albendazole mass drug administration (MDA), both microfilaremia prevalence and intensity decreased dramatically. Mild and moderate adverse reactions after treatment were common, especially after the first MDA, but decreased after subsequent MDAs. Drug coverage for the first year was estimated to be 72%, but concerns about adverse reactions appeared to decrease drug coverage in the second MDA. As a result of community education efforts that focused on providing a greater understanding of adverse reactions, coverage increased dramatically for the third round. Program efficiency increased substantially; the costs per person treated for three rounds of MDA were 2.23 US dollars, 1.96 US dollars, and 1.30 US dollars per person, respectively. The Leogane experience highlights the importance of adapting community education and mobilization campaigns to achieve and maintain good coverage.     

Predictors of compliance in mass drug administration for the treatment and prevention of lymphatic filariasis in Leogane, Haiti

The global strategy for the elimination of lymphatic filariasis (LF) is based on annual mass drug administration (MDA) to interrupt transmission. Noncompliance with MDA represents a serious programmatic obstacle for the LF program because systematically noncompliant individuals may serve as a reservoir for the parasite and permit recrudescence of infection. Using a survey questionnaire concerning practices, beliefs, and attitudes towards MDA, we assessed differences between noncompliant individuals and compliant individuals in Leogane, Haiti (n = 367) after four years of treatment. A logistic regression model showed the odds of being noncompliant were significantly increased for women (odds ratio = 2.74, 95% confidence interval = 1.12-6.70), as well as for people who lacked knowledge about both LF and programs to eliminate infection. Public health programs should be designed to target people who are at risk for systematic noncompliance.     

Pattern of community compliance with spaced, single-dose, mass administrations of diethylcarbamazine or ivermectin, for the elimination of lymphatic filariasis from rural areas of southern India

Current programmes to eliminate lymphatic filariasis (LF) are largely based on annual mass administrations of single doses of antifilarial drugs. The level and pattern of compliance by the target population are important determinants of the success of such mass drug administrations (MDA). Community compliance was therefore investigated during a study in southern India of the effects, on Wuchereria bancrofti microfilaraemia and transmission, of spaced MDA based on diethylcarbamazine (DEC) or ivermectin (IVM). During six rounds of MDA, the frequency of compliance in the target populations, in the five study villages given DEC and the five given IVM, ranged from 55%-77%. Analysis of the relevant cohort data indicated that about 30% of the villagers had complied with treatment during all six rounds, but 3.5% of those in the DEC arm and 4.0% of those in the IVM arm had never complied with treatment. Most of the villagers (>90%) had received treatment at least once, however, and >60% had each received treatment in at least four of the six rounds. Overall, there was a significant negative correlation (r=-0.78; P=0.008) between the size of the village, in terms of the number of villagers, and the mean frequency of compliance over the six rounds of MDA. The pattern of community compliance was found to be 'semi-systematic', laying between random and systematic. In terms of the elimination of LF, a semi-systematic pattern of compliance is worse than random compliance but better than systematic. The relevance of the levels and patterns of compliance to LF control or elimination is discussed.     

Long-term population migration: an important aspect to be considered during mass drug administration for elimination of lymphatic filariasis

Annual 2-drug, single-dose mass drug administration (MDA) to 80-90% of the eligible population for 4-6 years are pre-requisites for the successful elimination of lymphatic filariasis (LF) from endemic communities by interruption of transmission and eventual elimination of new infections. In an experimental intervention project on the control of LF in Villupuram district of Tamil Nadu state, India, migration patterns of the villagers were investigated to determine the appropriate timing to implement MDA in order to attain high coverage in a village-level study. Between January and December 1997, 16 observations took place at 3-week intervals, following MDA with two drugs viz., diethylcarbamazine and ivermectin, in July-August 1996. The migrants from the village constituted 17-27% at different points of time and both short-term and long-term migrating patterns were observed. More villagers were available during the agricultural season (September-January), peaking around mid-January [83%; significantly higher (P < 0.05)] than during most of the remaining months, including a substantial portion of the migrant population. There is an urgent need to reschedule the yearly MDA in this area to take place in January and to plan mopping up operations by involving local self-help groups to include migrants (both short-term and long-term) in the LF elimination efforts.     

滕州市消灭丝虫病的技术措施

目的　总结滕州市消灭丝虫病的技术措施。　方法　将滕州市 4 0余年丝虫病防治研究资料进行整理分析。　结果　通过流行病学调查、普查普治、全民食用乙胺嗪药盐 ,达到基本消灭丝虫病的标准。之后 ,对原微丝蚴血症者开展复查复治 ,于 1995年达到了消灭丝虫病的标准。　结论　确立以消灭传染源为主的防治策略 ,落实监测方案 ,可达到消灭丝虫病的目标。     

The Impact of Two Semiannual Treatments with Albendazole Alone on Lymphatic Filariasis and Soil-Transmitted Helminth Infections: A Community-Based Study in the Republic of Congo

Implementation of mass drug administration (MDA) with ivermectin plus albendazole (ALB) for lymphatic filariasis (LF) has been delayed in central Africa because of the risk of serious adverse events in subjects with high Loa loa microfilaremia. We conducted a community trial to assess the impact of semiannual MDA with ALB (400 mg) alone on LF and soil-transmitted helminth (STH) infections in the Republic of Congo. Evaluation at 12 months showed that ALB MDA had not significantly reduced Wuchereria bancrofti antigenemia or microfilaria (mf) rates in the community (from 17.3% to 16.6% and from 5.3% to 4.2%, respectively). However, the geometric mean mf count in mf-positive subjects was reduced from 202.2 to 80.9 mf/mL (60% reduction, P = 0.01). The effect of ALB was impressive in 38 subjects who were mf-positive at baseline and retested at 12 months: 37% had total mf clearance, and individual mf densities were reduced by 73.0%. MDA also dramatically reduced the hookworm infection rate in the community from 6.5% to 0.6% (91% reduction), with less impressive effects on Ascaris and Trichuris. These preliminary results suggest that semiannual community MDA with ALB is a promising strategy for controlling LF and STH in areas with coendemic loiasis.     

A randomized clinical trial comparing single- and multi-dose combination therapy with diethylcarbamazine and albendazole for treatment of bancroftian filariasis

The Global Program for Elimination of Lymphatic Filariasis calls for mass drug administration for endemic populations outside of sub-Saharan Africa with a single dose of diethylcarbamazine (DEC) and albendazole (Alb) annually for 4-6 years. Single-dose DEC/Alb dramatically reduces blood microfilaria (MF) counts, but most treated subjects fail to completely clear MF after a single dose. A more effective regimen might reduce the number of years required for elimination programs. We performed a randomized clinical trial in Egyptian adults with asymptomatic microfilaremia to compare treatment with seven daily doses of oral DEC (6 mg/kg) and Alb (400 mg) with a single dose of the same combination. We also studied the effect of re-treatment with single-dose DEC/Alb 12 months after the first treatment course. Multi-dose DEC/Alb was significantly more effective than single-dose therapy for reducing and clearing microfilaremia (mean reduction in MF/ml relative to pretreatment counts at 12 months, 99.6% versus 85.7%, with complete clearance in 75% versus 23.1%). The two regimens had similar activity against adult filarial worms, as indicated by serial ultrasound assessments. Neither regimen resulted in complete clearance of filarial antigenemia. There was no difference in adverse events, which were mild to moderate. Blood microfilaria and parasite antigen clearance rates increased following re-treatment. Multi-dose DEC/Alb may be a useful option for filariasis elimination programs, especially in the first year (when enthusiasm for mass drug administration and coverage rates are high), to quickly reduce community MF loads and transmission rates.     

How endemic countries can accelerate lymphatic filariasis elimination? An analytical review to identify strategic and programmatic interventions

Lymphatic filariasis (LF) is endemic in 81 countries in the world, and a number of these countries have targeted for LF elimination. This review of literature and analysis was conducted to identify additional and sustainable strategies to accelerate LF elimination from endemic countries. This review noted that adverse events due to mass drug administration (MDA) of diethyl carbamazine (DEC) tablets, poor knowledge and information about LF amongst health workers & community members, and limited focus on information, education & communication (IEC) activities and interpersonal communication are the major barriers in LF elimination. The new approaches to increase compliance with DEC tablets (including exploring the possibility for DEC fortification of salt), targeted education programmes for physicians and health workers, and IEC material and inter personal communication to improve the knowledge of community are immediately required. There is a renewed and pressing need to conduct operational research, evolve sustainable and institutional mechanisms for education of physicians and health workers, ensure quality of trainings on MDA, strengthen IEC delivery mechanisms, implement internal and external monitoring of MDA activities, sufficient funding in timely manner, and to improve political and programmatic leadership. It is also time that lessons from other elimination programmes are utilized to accelerate targeted LF elimination from the endemic countries.     

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.     

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.     

Urban lymphatic filariasis in the city of Tanga,Tanzania, after seven rounds of mass drug administration

Urban lymphatic filariasis (LF) has been listed among the challenges to the ongoing global efforts to eliminate LF. This is partly because the control strategies developed for rural areas – where most LF occurs – do not easily comply with human organization and behaviour in urban areas, and partly because the urban vectors thrive and proliferate in poorly planned urban settlements. This study investigated LF infection, disease and transmission in the medium-sized city of Tanga (approx. 300,000 inhabitants), Tanzania, after seven rounds of mass drug administration (MDA). Three representative sites with varying distance from the city centre were selected for the study. Pupils from one public primary school at each site were screened for circulating filarial antigens (CFA; marker of adult worm infection) and antibodies to Bm14 (marker of exposure to transmission). Community members were examined for CFA, microfilariae and chronic manifestations. Questionnaires were administered to pupils and heads of community households, and vector surveys were carried out in selected households. Although there was evidence of considerable reduction in infection and transmission, there was still LF in the city, with mf and CFA prevalences well above the cut-off levels for stopping MDA. In this respect, the LF situation resembled that seen in nearby rural areas outside the city. The study emphasizes the importance of motivating the urban individuals to engage and comply with the full range of LF intervention measures (MDAs, use of mosquito proofing measures including bed nets, environmental sanitation to prevent vector breeding) in order to reach successful LF control in the city. The high LF disease burden noted, despite the reduction in infection and transmission, moreover emphasizes the importance of allocating resources for morbidity management, to ensure true elimination of LF as a public health problem.     

Community-wide reduction in prevalence and intensity of intestinal helminths as a collateral benefit of lymphatic filariasis elimination programs

Annual mass treatment with antifilarial drugs is the cornerstone of the global program to eliminate lymphatic filariasis (LF). Although the primary goal of the program is to interrupt transmission of LF, additional public health benefits also are expected because of the known anthelminthic properties of these drugs. Since rapid re-infection with intestinal helminths occurs following treatment, annual de-worming may not be sufficient to produce a lasting reduction in the prevalence and intensity of these infections. We conducted stool examinations in four sentinel communities before and approximately nine months after each of two rounds of mass drug administration (MDA) with diethylcarbamazine and albendazole in the context of an LF elimination program in Leogane, Haiti. At baseline, overall Ascaris, Trichuris, and hookworm infection prevalences were 20.9%, 34.0%, and 11.2%, respectively (n = 2,716 stools). Nine months after the second MDA, Ascaris, Trichuris and hookworm prevalences had decreased significantly, to 14.1%, 14.6%, and 2.0%, respectively (n = 814 stools). Infection intensity decreased significantly for all three parasites as well. These results demonstrate that substantial reductions in intestinal helminth infections are associated with mass treatment of filariasis in Haiti and are consistent with the conclusion that high levels of coverage for the LF program can decrease transmission of geohelminths.     

A community-based trial for the control of lymphatic filariasis and iodine deficiency using salt fortified with diethylcarbamazine and iodine.

To evaluate the effectiveness of salt fortified with diethylcarbamazine (DEC) and iodine for elimination of Bancroftian filariasis and iodine deficiency, all consenting residents of Miton, Haiti (n = 1,932) were given salt fortified with 0.25% diethylcarbamazine and 25 ppm of iodine for one year. Wuchereria bancrofti microfilaria prevalence and intensity, antigenemia, and urinary iodine were measured before and one year after salt distribution began. To measure the effect of DEC-fortified salt on adult worm motility, 15 microfilaria-positive men were examined by ultrasound of the scrotal area. Entomologic surveys were conducted to determine the proportion of W. bancrofti-infected Culex quinquefasciatus. After one year of treatment, the prevalence and intensity of microfilaremia were both reduced by more than 95%, while antigenemia levels were reduced by 60%. The motility of adult worms, as detected by ultrasound, was decreased, but not significantly, by DEC-fortified salt. The proportion of vector mosquitoes carrying infective stage larvae decreased significantly from 2.3% in the nine months before the intervention to 0.2% in the last three-month follow-up period. Iodine deficiency, which had been moderate to severe, was eliminated after one year of iodized salt consumption. The DEC-fortified salt was well accepted by the community and reduced microfilaremia and transmission to low levels in the absence of reported side effects. Based on these results, salt cofortified with DEC and iodine should be considered as a concurrent intervention for lymphatic filariasis and iodine deficiency elimination programs.     

Predictors of compliance with a mass drug administration programme for lymphatic filariasis in Orissa State,India 2008

Objectives To assess the performance of an educational campaign to increase adherence to a mass‐administered DEC regimen against lymphatic filariasis (LF) in Orissa, and to identify factors that could enhance future campaigns. Method Randomized cluster survey, comparing areas that did and did not receive the educational campaign, using a household coverage survey and knowledge, attitudes and practices (KAP) survey. Results LF MDA coverage for the entire population (n = 3449) was 56% (95% CI: 50.0–61.9). There was no statistical difference between the areas that did and did not receive the educational campaign. The most common barriers to adherence were fear of medication side effects (47.4%) and lack of recognition of one’s risk for LF (15.8%). Modifiable, statistically significant, multivariable predictors of adherence were knowing that DEC prevents LF (aOR = 2.6, 95% CI: 1.4–5.1), knowing that mosquitoes transmit LF (aOR = 1.9, 95% CI: 1.1–3.2), and knowing both about the mass drug administration (MDA) in advance and that mosquitoes transmit LF (aOR = 5.4, 95% CI: 2.8–10.4). Conclusions India needs to increase compliance with MDA programmes to reach its goal of interrupting LF transmission. Promoting a simple public health message before MDA distribution, which takes into account barriers to and predictors of adherence, could raise compliance with the LF MDA programme.     

Relationship between male hydrocele and infection prevalences in clustered communities with uncertain transmission of Wuchereria bancrofti on the Thailand-Myanmar border

A cross-sectional community-based study was conducted in three clustered communities, belonging to a single small village in Mae Chan subdistrict, Umphang district, Tak Province, close to the Thailand-Myanmar border, where regular night blood survey have been discontinued since 1997 and no epidemiological study had been conducted. In order to understand prevalences of distribution of male hydrocele and infection in clinically diagnostic and epidemiologic implications in uncertain transmission of Wuchereria bancrofti, we analyzed the relationship between male hydrocele and community infection prevalences in 219 (90.5% coverage) subjects aged > or =1 year old, including 54.8% migratory and 45.2% local Karen inhabitants. Migratory inhabitants tended to have high prevalence of antigenemia (p < 0.05) and hydrocele. Overall rates of 23.7% antigenemia, 3.7% microfilaremia, and 4.6% male hydrocele were observed. Male hydrocele prevalence was significantly correlated (r = 0.348, p < 0.0001) with antigenemia prevalence, but not with microfilaremia prevalence (r = 0.065, p = 0.493). However, high antigenemia prevalence in local inhabitants was evident, particularly antigenemia prevalence in children suggesting that transmission in the village may have occurred in recent years.     

A laboratory-based surveillance system for Wuchereria bancrofti in Togo: a practical model for resource-poor settings

One goal of the Global Program to Eliminate Lymphatic Filariasis (GAELF) is interruption of disease transmission through annual mass drug administration (MDA) in areas where LF prevalence is greater than 1%. After MDAs are completed, the World Health Organization (WHO) recommends a period of passive surveillance before final certification of LF elimination is achieved. Guidelines for such a surveillance system have yet to be developed. This paper describes a surveillance system launched in Togo in 2006. The system uses existing laboratories with technicians on call at night who, among other activities, prepare nocturnal thick blood smears for malaria diagnosis that can also be used for LF diagnosis. During its first 2 years (2006-2007), the system provided geographically disperse sampling nationwide, and 1 of 750 people residing in Togo was tested. Over the same period, the system detected two cases of LF, both from areas previously considered non-endemic. This system could be a cost-effective, sustainable model for WHO-mandated passive surveillance after cessation of MDA.     

The impact of six rounds of single-dose mass administration of diethylcarbamazine or ivermectin on the transmission of Wuchereria bancrofti by Culex quinquefasciatus and its implications for lymphatic filariasis elimination programmes

Lymphatic filariasis (LF) is targeted for global elimination. Transmission interruption through repeated annual single-dose mass administration of anti-filarial drugs is the mainstay of the LF elimination strategy. This study examined the ability of six rounds of mass administration of diethylcarbamazine (DEC) or ivermectin (IVM) to interrupt transmission of Wuchereria bancrofti by Culex quinquefasciatus, the predominant parasite and vector species, respectively. After six rounds of mass drug administration (MDA), received by 54-75% of the eligible population (> or =15 kg body weight), the resting vector infection and infectivity rates fell by 83% and 79% in the DEC arm, 85% and 84% in the IVM arm and 31% and 45% in the placebo arm, respectively. The landing vector infection and infectivity rates fell by 83% and 94% in the DEC arm, 63% and 75% in the IVM arm and 1% each in the placebo arm, respectively. The filarial larval load per resting mosquito declined by 92% and 93% and per landing mosquito by 83% and 69% in the DEC and IVM arms, respectively. The annual infective biting rate (AIBR) fell from 735 to 93 (87%) in the DEC arm, 422 to 102 (76%) in the IVM arm and 472 to 398 (16%) in the placebo arm. The annual transmission potential (ATP) declined from 2514 to 125 (95%), 1212 to 241 (80%) and 1547 to 1402 (9%) in the DEC, IVM and placebo arms, respectively. However, mosquitoes with infection [microfilaria/larva 1/larva 2 (Mf/L1/L2)] were found in all study villages. Three of five villages in the IVM arm and two of five in the DEC arm recorded no resting mosquitoes with infective-stage (L3) larva. Although the ATP, after six rounds of MDA, fell substantially and remained at 125 and 241 in the DEC and IVM arms, respectively, the cumulative exposure to infective stage larvae (ATP) during the treatment period of 6 years was as high as 2995 in the DEC arm and 1522 in the IVM arm, because of considerable level of transmission during the initial (1-3) rounds of MDA. We conclude that (i) six rounds of MDA, even with 54-75% treatment coverage, can reduce LF transmission very appreciably; (ii) better treatment coverage and a few more rounds of MDA may achieve total interruption of transmission; (iii) high vector densities may partly nullify the reductions achieved in vector infection and infectivity rates by MDA and (iv) achievement of 'true zero' Mf prevalence in communities and 0% infection rate (mosquitoes with Mf/L1/L2) in mosquitoes may be necessary to totally interrupt Culex-transmitted LF.     

Bancroftian filariasis infection,disease, and specific antibody response patterns in a high and a low endemicity community in East Africa

Bancroftian filariasis infection, disease and specific antibody response patterns in a high and a low endemicity community in East Africa were analyzed and compared to assess the relationship between these parameters and community transmission intensity. Overall prevalences of microfilaremia and circulating filarial antigenemia were 24.9% and 52.2% in the high and 2.7% and 16.5% in the low endemicity community, respectively. A positive history of acute attacks of adenolymphangitis was given by 12.2% and 7.1% of the populations, 4.0% and 0.9% of the adult (> or = 20 years old) individuals presented with limb lymphedema, and 25.3% and 5.3% of the adult males had hydrocele, in the high and the low endemicity community, respectively. Both infection and disease appeared earlier and reached much higher levels in the high than in the low endemicity community. The observed overall and age-specific infection and disease patterns in the two communities were in agreement with the view that these are primarily shaped by transmission intensity. No statistically significant relationships between infection status of fathers and mothers and that of their children were observed in any of the communities for either microfilaremia or for circulating filarial antigenemia. The overall levels (prevalence and geometric mean intensity) of filarial-specific IgG1, IgG2, IgG4, and IgE were significantly higher in the high endemicity community than in the low endemicity dommunity. Surprisingly, the opposite pattern was found for IgG3. Community transmission intensity thus appears to be an important determinant of observed inter-community variation in infection, disease, and host response patterns in Bancroftian filariasis.     

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.