Investigating the feasibility and effectiveness of integrating helminth control with seasonal malaria chemoprevention (SMC) in West African children
Lead Research Organisation:
London School of Hygiene and Tropical Medicine
Department Name: Infectious and Tropical Diseases
Abstract
Malaria and worms commonly affect children in poor countries in Africa. Both infections can cause anaemia which can, acting alone or together, lead to preventable deaths. Given natural co-existence of the two infections in many African children, holistic approach to treatment has potential to improve child survival and development. Previous efforts on mass deworming reached only a third of the children, leaving out school-aged children who form substantial proportions of the population-at-risk, whereas, a malaria prevention platform called seasonal malaria chemoprevention (SMC) successfully implemented in Sahel region, has a very high coverage and significantly reduced malaria death. The approved deworming and SMC drugs work well with minimal side-effects when used separately. Though, combined use of the two drugs are not known to have significant reactions; they have not been previously used together in clinical studies.
This fellowship therefore aims to explore the feasibility and effectiveness of an integrated treatment approach for malaria and worms using existing SMC platform to deliver deworming medications. A three-stage study is designed to achieve this goal. First, a systematic literature review on the burden of malaria and worm co-infections in African children will be conducted. Findings of this review would strengthen the rationale for evaluating innovative platforms for integrated management of malaria-helminth co-infections in vulnerable populations.
This will be followed by a survey to determine the magnitude of burden of malaria-helminth co-infections among pre-school and school-age children in Senegal. Senegal is the first country in Sahel region which has successfully implemented SMC in school-aged children. South-eastern Senegal is also known to harbour substantial proportions of children at high risk of malaria-helminth co-infections; the effects of which have contributed to school absenteeism, poor cognitive function and poor academic performance.
Finger-prick blood samples will be collected from eligible children for malaria microscopy and specialised molecular tests for species determination. An improved diagnostic performance of the circulating antigen assay by parallel testing for circulating anodic and cathodic antigens in serum and urine will be used in the detection and quantification of Schistosomes. Furthermore, stool samples will be collected to detect intestinal helminths using a highly specific multiplex real-time polymerase chain reaction which targets several intestinal helminths including schistosomes
Information generated from the second stage will serve as baseline data and will be used to develop a follow-up study that will investigate the feasibility and effectiveness of integrating SMC with helminth control in the pre-school and school-aged children. As SMC drugs are given monthly for three-to-four cycles during malaria seasons, antihelminth drugs will be co-administered with the first course of SMC in all study children. Adverse symptoms will be collected using augmented passive surveillance system following administration of SMC and anti-helminthic drugs. Haemoglobin concentration and parasite density will be determined at the end of SMC course. Also, stool and urine samples will be collected to determine the effectiveness of the anti-helminthic drugs. Cognitive skills of the study children will also be assessed.
As feasibility may include acceptability, qualitative interviews will be conducted among parents of the study children on their perceptions about effectiveness, practicalities, acceptability and barrier to using the integrated treatment approach. Also, key informant interviews will be held among SMC providers to further explore these factors. To enhance the capabilities of the applicant to become an independent researcher in malaria and NTDs, capacity building on molecular detection of malaria-helminth species and cognitive skills assessment will be included
This fellowship therefore aims to explore the feasibility and effectiveness of an integrated treatment approach for malaria and worms using existing SMC platform to deliver deworming medications. A three-stage study is designed to achieve this goal. First, a systematic literature review on the burden of malaria and worm co-infections in African children will be conducted. Findings of this review would strengthen the rationale for evaluating innovative platforms for integrated management of malaria-helminth co-infections in vulnerable populations.
This will be followed by a survey to determine the magnitude of burden of malaria-helminth co-infections among pre-school and school-age children in Senegal. Senegal is the first country in Sahel region which has successfully implemented SMC in school-aged children. South-eastern Senegal is also known to harbour substantial proportions of children at high risk of malaria-helminth co-infections; the effects of which have contributed to school absenteeism, poor cognitive function and poor academic performance.
Finger-prick blood samples will be collected from eligible children for malaria microscopy and specialised molecular tests for species determination. An improved diagnostic performance of the circulating antigen assay by parallel testing for circulating anodic and cathodic antigens in serum and urine will be used in the detection and quantification of Schistosomes. Furthermore, stool samples will be collected to detect intestinal helminths using a highly specific multiplex real-time polymerase chain reaction which targets several intestinal helminths including schistosomes
Information generated from the second stage will serve as baseline data and will be used to develop a follow-up study that will investigate the feasibility and effectiveness of integrating SMC with helminth control in the pre-school and school-aged children. As SMC drugs are given monthly for three-to-four cycles during malaria seasons, antihelminth drugs will be co-administered with the first course of SMC in all study children. Adverse symptoms will be collected using augmented passive surveillance system following administration of SMC and anti-helminthic drugs. Haemoglobin concentration and parasite density will be determined at the end of SMC course. Also, stool and urine samples will be collected to determine the effectiveness of the anti-helminthic drugs. Cognitive skills of the study children will also be assessed.
As feasibility may include acceptability, qualitative interviews will be conducted among parents of the study children on their perceptions about effectiveness, practicalities, acceptability and barrier to using the integrated treatment approach. Also, key informant interviews will be held among SMC providers to further explore these factors. To enhance the capabilities of the applicant to become an independent researcher in malaria and NTDs, capacity building on molecular detection of malaria-helminth species and cognitive skills assessment will be included
Planned Impact
The studies proposed in this fellowship application will make impact by achieving the following benefits:
Improved policy making: Clear evidence on the feasibility and effectiveness of integrated malaria-helminth control will be made available to policymakers at country and international levels. This will enable them to make evidence-based decisions about the implementation and sustainability of the integrated programme. Findings of the studies will provide better understanding of challenges and prospects encountered in the course of implementing the integrated malaria-helminth control and how the challenges can be addressed and optimized the programme for delivery of combined prophylactic treatment for malaria and helminth infections using an existing seasonal malaria chemoprevention (SMC) platform.
Improved policy implementation and programmatic management: National, sub-national and international policy makers will appreciate better the synergistic effects of integrated SMC and deworming programmes on child survival and development as well as the rationale driving the change from single disease control programme to the integrated control programme. This will assist them in strengthening the delivery of the control programme. Through active stakeholder engagements, this fellowship will provide evidence-based information which will ultimately increase awareness amongst national and international decision makers on the crucial need to reinforce existing malaria prevention control programme with helminth control.
Improved school-based health programmes: Findings of these studies will inform the implementation of improved school-based health programmes where school-age children who are largely left out of SMC programme can benefit improved health when they receive combined SMC and deworming drugs. This will translate to improved school attendance, improved cognition and better academic performance which ultimately will contribute to improvement in human capital development which serves as a boost to national and global economy growth.
Improved knowledge base: Findings of this study will expand the knowledge base that supports evidence-based informed decision and policy making on integrated malaria-helminth control in Africa. The study will provide evidence on how two important prevention control programmes targeting vulnerable African children are delivered through integrated approach; how challenges are addressed and structures within the health systems are utilized for optimal integrated delivery of the control programmes. This will contribute to the development of more evidence-informed and context-relevant programmes; and to the development of robust methods for implementation of integrated malaria-helminth control programmes. In addition, the study will provide evidence on newer diagnostic tools for helminth infections and this will likely inform further studies to gather more evidence that may lead to policy change in diagnosis of helminth infections in endemic countries
Improved capacity within the national control programmes: The study will support capacity development within national control programmes in monitoring and evaluation of implementation and effectiveness of integrated malaria-helminth control. This will enable them to identify in real-time challenges inherent in implementation such as supply chain, community acceptance, drug adherence etc and proffer evidence-based solutions to strengthen the operations.
Improved policy making: Clear evidence on the feasibility and effectiveness of integrated malaria-helminth control will be made available to policymakers at country and international levels. This will enable them to make evidence-based decisions about the implementation and sustainability of the integrated programme. Findings of the studies will provide better understanding of challenges and prospects encountered in the course of implementing the integrated malaria-helminth control and how the challenges can be addressed and optimized the programme for delivery of combined prophylactic treatment for malaria and helminth infections using an existing seasonal malaria chemoprevention (SMC) platform.
Improved policy implementation and programmatic management: National, sub-national and international policy makers will appreciate better the synergistic effects of integrated SMC and deworming programmes on child survival and development as well as the rationale driving the change from single disease control programme to the integrated control programme. This will assist them in strengthening the delivery of the control programme. Through active stakeholder engagements, this fellowship will provide evidence-based information which will ultimately increase awareness amongst national and international decision makers on the crucial need to reinforce existing malaria prevention control programme with helminth control.
Improved school-based health programmes: Findings of these studies will inform the implementation of improved school-based health programmes where school-age children who are largely left out of SMC programme can benefit improved health when they receive combined SMC and deworming drugs. This will translate to improved school attendance, improved cognition and better academic performance which ultimately will contribute to improvement in human capital development which serves as a boost to national and global economy growth.
Improved knowledge base: Findings of this study will expand the knowledge base that supports evidence-based informed decision and policy making on integrated malaria-helminth control in Africa. The study will provide evidence on how two important prevention control programmes targeting vulnerable African children are delivered through integrated approach; how challenges are addressed and structures within the health systems are utilized for optimal integrated delivery of the control programmes. This will contribute to the development of more evidence-informed and context-relevant programmes; and to the development of robust methods for implementation of integrated malaria-helminth control programmes. In addition, the study will provide evidence on newer diagnostic tools for helminth infections and this will likely inform further studies to gather more evidence that may lead to policy change in diagnosis of helminth infections in endemic countries
Improved capacity within the national control programmes: The study will support capacity development within national control programmes in monitoring and evaluation of implementation and effectiveness of integrated malaria-helminth control. This will enable them to identify in real-time challenges inherent in implementation such as supply chain, community acceptance, drug adherence etc and proffer evidence-based solutions to strengthen the operations.
Publications
Afolabi MO
(2022)
Prevalence and distribution pattern of malaria and soil-transmitted helminth co-endemicity in sub-Saharan Africa, 2000-2018: A geospatial analysis.
in PLoS neglected tropical diseases
Afolabi MO
(2023)
Provider and User Acceptability of Integrated Treatment for the Control of Malaria and Helminths in Saraya, South-Eastern Senegal.
in The American journal of tropical medicine and hygiene
Afolabi MO
(2023)
Prevalence of malaria-helminth co-infections among children living in a setting of high coverage of standard interventions for malaria and helminths: Two population-based studies in Senegal.
in Frontiers in public health
Afolabi MO
(2022)
Caregivers' perception of risk for malaria, helminth infection and malaria-helminth co-infection among children living in urban and rural settings of Senegal: A qualitative study.
in PLOS global public health
Afolabi MO
(2021)
Malaria and helminth co-infections in children living in endemic countries: A systematic review with meta-analysis.
in PLoS neglected tropical diseases
| Description | Report on studies conducted to determine the feasibility and safety of integrating helminth control with seasonal malaria chemoprevention among Senegalese children Preamble: Malaria and parasitic worms frequently co-exist among children living in low-and middle-income countries (LMIC). Prominent among the worms are soil-transmitted helminths (STH) and schistosomes. The additive effects of infections with malaria and helminths in children lead to anaemia, poor physical and cognitive developments and preventable deaths. Existing control programmes for helminths are not operating at optimal levels, despite the commitments and support that followed the 2012 London Declaration on Neglected Tropical Diseases (NTD), which aimed to eliminate some NTDs by 2020. On the other hand, a malaria chemo-preventive programme called Seasonal Malaria Chemoprevention (SMC), introduced in the same year (2012), has averted 75-85% cases of uncomplicated and severe malaria in children. This encouraging development supports the need to explore the possibility of integrating helminth control programmes with other successful delivery platforms such as SMC. Additionally, in line with the strategies of the WHO road map to end NTDs by 2030 , a need exists to develop an integrated approach that combines malaria and helminth control in a safe, acceptable, easy to deliver and effective manner. To achieve these goals, Malaria and NTD researchers from the London School of Hygiene & Tropical Medicine, United Kingdom collaborated with their colleagues from the University of Thies (Prof Jean Louis Ndiaye); Université Gaston Berger de Saint-Louis (Prof Doudou Sow); and from the Ministry of Health and Social Action, Senegal were Dr Babacar Gueye (Head of Diseases Control Unit), Dr Doudou Sene, (Coordinator, National Malaria Control Programme); Dr Ndeye M'backé Kane (National Coordinator, NTD Control Programme) and Dr Boubacar Diop (National Coordinator, Schistosomiasis & STH Control Programme). Study implementations: • Two population based surveys were conducted in Saraya and in Diourbel in June and November 2021, respectively, to determine the burden of malaria-helminth co-infections among children aged 1-14 years in the two districts. Two qualitative studies were also conducted along with the surveys to explore the risk perception of the parents/caregivers of the children about malaria-helminth co-infections. • In June 2022, we conducted a randomized controlled trial (RCT) in Saraya in which children aged 1-14 years were randomized into three equal groups to receive either SMC drugs (Sulphadoxine pyrimethamine and Amodiaquine) on Days 1-3 (control group); or praziquantel on Day 0, followed by SMC drugs on Days 1-3 (treatment group 1); or albendazole and praziquantel on Day 0, followed by SMC drugs on Days 1-3 (treatment group 2). Safety assessments were conducted in all children and changes in the levels of haemoglobin and parasites of malaria, schistosomiasis and soil-transmitted helminths were measured before and after the interventions, using conventional and improved diagnostic methods such as PCR. • Within the context of the RCT, we also conducted a qualitative study to assess the acceptability, barriers and enablers of combining the treatment with anthelminthic and SMC drugs among the children, their parents/care-givers, health care providers, malaria and NTD programme managers from the Ministry of Health and Social Action, Senegal. Findings of the studies: 1. Integration of MDA for helminths with SMC was feasible and safe among Senegalese children as no safety concerns were reported after active and passive surveillance of the interventions. Also, we found that combining SMC drugs with anthelminthics during the SMC campaign reduce the malaria parasite density for children who received the two drugs. Similarly, children who received praziquantel and SMC drugs had a lower risk of developing severe anaemia than their counterparts who received SMC drugs alone. 2. The integrated malaria-helminth treatment approach was generally acceptable by parents/care-givers of the children, health care providers, trial staff, malaria and NTD programme managers. 3. The burden of the co-infection involving malaria and STH was low (<2%) among the children in Saraya and Diourbel, despite the use of conventional and improved diagnostic methods. This confirms that Senegal has attained the goal of eliminating morbidity associated with STH (i.e., elimination as a public health problem, defined as a moderate-to-heavy intensity infection prevalence of <2%). 4. On the other hand, the burden of the single infection involving schistosomiasis was high (30%) among the children. Also, the burden of intestinal protozoans was very high (about 50%) among the children. 5. Majority of the parents/caregivers of the children demonstrated a high perception of risks as well as acceptable health-seeking behaviour for malaria, but had low risk perception and misconceptions about the causative factors of malaria-helminth co-infection. For example, most parents interviewed said that a combination of excessive consumption of sugary food and mosquito bites was responsible for combined malaria parasitic worm infection among the children. 6. The awareness about handwashing was high among the parents and caregivers of children, but the practice was poor as most of the parents used ashes and sand to clean their hand after using toilets. Recommendations for a plan of actions: 1. The finding of low burden of malaria and parasitic worms in the children could represent chronic parasitic infections which might play a major role in multiple morbidities, the impact of which are often sub-clinical acting as reservoirs that make interruptions of cycles of infection transmission and subsequent elimination of the two diseases impossible. Therefore, integration of the MDA for helminth with SMC will be an important strategy to achieve elimination of malaria and helminth co-infection in Senegal. 2. The finding of a high burden of single infection with schistosomiasis should be tackled with paediatric formulation of praziquantel which is expected to be available from 2024. 3. Given that the very high burden of intestinal protozoans could be due to lack of efficacy of the preventive chemotherapy to the organisms, we recommended an addition of a single-dose of tinidazole to the current preventive chemotherapy, as it appeared that albendazole given to treat intestinal worms in the children was not effective against the intestinal protozoans. 4. The qualitative findings of low risk perception underscored the need to promote awareness about the risk and complications of malaria-helminth co-infections in children. This approach would assist in addressing the parents and caregivers' misconceptions about the co-infection and may improve their uptake of the strategic interventions developed to achieve elimination of malaria and helminth co-infections in Senegal. Below are the publications from the findings of the studies: 1. Afolabi MO, Sow D, Agbla SC, Fall EHB, Sall FB, Seck A, Manga IA, Mbaye IM, Loum MA, Camara B, Niang D, Gueye B, Sene D, Kane NM, Diop B, Diouf A, Gaye NA, Diouf MP, Lo AC, Greenwood B, Ndiaye JLA. Feasibility and safety of integrating mass drug administration for helminth control with seasonal malaria chemoprevention among Senegalese children: a randomized controlled, observer-blind trial. Malaria Journal: 2023;22:348. doi: 10.1186/s12936-023-04784-z 2. Afolabi MO, Diaw A, Fall EHB, Sall FB, Diédhiou A, Seck A, Camara B, Niang D, Manga IA, Mbaye I, Sougou NM, Sow D, Greenwood B, Ndiaye JLA. Provider and User Acceptability of Integrated Treatment for the Control of Malaria and Helminths in Saraya, South-Eastern Senegal. American Journal of Tropical Medicine & Hygiene. 2023: 18;109(5):1047-1056. doi: 10.4269/ajtmh.23-0113 3. Afolabi MO, Sow D, Mbaye I, Diouf MP, Loum MA, Fall EB, Seck A, Manga IA, Cissé C, Camara B, Diouf A, Gaye NA, Colle Lo A, Greenwood B and Ndiaye JLA. Prevalence of malaria-helminth co-infections among children living in a setting of high coverage of standard interventions for malaria and helminths: Two population-based studies in Senegal. Frontiers in Public Health. 2023; 11:1087044. doi: 10.3389/fpubh.2023.1087044 4. Afolabi MO, Sow D, Ndiaye JLA, Greenwood B. Safety and effectiveness of delivering mass drug administration for helminths through the seasonal malaria chemoprevention platform among Senegalese children: study protocol for a randomised controlled trial. Trials. 2022; 23:627. doi.org/10.1186/s13063-022-06579-0 5. Afolabi MO, Adebiyi A, Cano J, Sartorius B, Greenwood B, Johnson O, Wariri O. Prevalence and distribution pattern of malaria and soil-transmitted helminth co-endemicity in sub-Saharan Africa, 2000-2018: A geospatial analysis. PLOS Neglected Tropical Diseases. 2022 Sep 30;16(9):e0010321. doi: 10.1371/journal.pntd.0010321 6. Afolabi MO, Sougou NM, Diaw A, Sow D, Manga IA, Mbaye I, Greenwood B, Ndiaye JLA. Caregivers' perception of risk for malaria, helminth infection and malaria-helminth co-infection among children living in urban and rural settings of Senegal: A qualitative study. PLOS Glob Public Health. 2022 Aug 12;2(8):e0000525. doi: 10.1371/journal.pgph.0000525 7. Afolabi MO, Ale BM, Dabira ED, Agbla SC, Bustinduy AL, Ndiaye JLA, Greenwood B. Malaria and helminth co-infections in children living in endemic countries: a systematic review with meta-analysis. PLOS Neglected Tropical Diseases. 2021.15(2):e0009138. doi:10.1371/journal.pntd.0009138 |
| Exploitation Route | The outcomes of this funding have a cascading effect on other researchers and the entire scientific community, influencing various aspects of academia, technology, and society. It fosters a dynamic and collaborative environment that drives the continuous evolution of knowledge and understanding in transmission dynamics between malaria and NTD, which is currently being fuelled by extraneous factors such as climate change. My fellowship has advanced the body of knowledge in the integration of malaria and NTD control and contributes to a deeper understanding of phenomena, uncovering new principles, or challenging established theories. My innovative work can also inspire other researchers to explore related or complementary areas, stimulating new ideas and directions for investigation in other disciplines such as pharmacological development of new molecules for fixed dose combination drugs for malaria and helminths. The increased visibility generated from my high-impact publications can attract attention from other researchers, policymakers, and industry professionals, thereby addressing challenges that extend beyond national borders. This can attract attention from researchers around the world and stimulate international collaborations, leading to the development of interdisciplinary studies that draw from multiple areas of expertise. My fellowship can also impact and influence academic curricula, leading to changes in how malaria and NTD control programs are taught. |
| Sectors | Healthcare |
| URL | https://pubmed.ncbi.nlm.nih.gov/37957702/ |
| Description | Notable findings from this award included an incidental discovery of a high prevalence of intestinal parasitoses. I recommended adding appropriate medication to the current preventive chemotherapy in the MDA. The Senegal Ministry of Health adopted the findings, thereby underscoring the importance of country-specific evidence to guide the development of cross-cutting approaches to address the critical gaps in implementation of strategies for malaria-NTD elimination. The finding of the clinical trial I conducted also established the safety and feasibility of the integrated treatment model for malaria and helminths among preschool and school age children, and contributed to the adoption of the model by the Senegal Ministry of Health. |
| First Year Of Impact | 2024 |
| Sector | Healthcare |
| Impact Types | Policy & public services |
| Description | Malaria Research Capacity Development Consortium (MARCAD) |
| Organisation | University Cheikh Anta Diop de Dakar |
| Country | Senegal |
| Sector | Academic/University |
| PI Contribution | I collaborated on a Wellcome Trust-DELTA Africa grant application with Malaria Research Capacity Development for Central and West Africa (MARCAD+) which has progressed well to the final stage with favourable feedback received at every stage. One of the work packages of the application focuses on malaria-NTD integration, which fits perfectly with my fellowship project. The Malaria Research Capacity Development Consortium (MARCAD) seeks to train a core group of African scientists in West and Central Africa who will be able to provide relevant answers for the control and elimination of malaria. One PhD and two post-docs fellows are hosted at each partner institution across five African countries (Mali, The Gambia, Cameroon, Ghana and Senegal). |
| Collaborator Contribution | I serve as a co-supervisor for doctoral and post-doctoral MARCAD fellows whose studies focus on the intersection between malaria and neglected tropical diseases. |
| Impact | No output yet |
| Start Year | 2024 |
| Description | Dissemination of project progress reports at the 2020, 2021 and 2022 UKRI Fellows' meeting |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | I made oral presentations of the project deliverables at the annual fellows' meetings of the UKRI FLF, which generated a lot of interest and collaboration talks with Fellows who are working in similar area of research. |
| Year(s) Of Engagement Activity | 2020,2021,2022 |
| Description | Knowledge Transfer Club, Department of Tropical Diseases Biology, Liverpool School of Tropical Medicine |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | I was invited by the Head of the Tropical Diseases Biology department, Liverpool School of Tropical Medicine (LSTM) to present my fellowship project at their Knowledge Transfer Club seminar. I made the presentation on 18 February 2021 which was attended by a cross-section of researchers in infectious diseases, neglected tropical diseases, epidemiology, and public health. The presentation generated a lot of questions from the attendees, following which I had one-on-one engagement meetings with different research groups including the Director of the Center of Neglected Tropical Diseases, LSTM, where plans for possible collaborations were made. |
| Year(s) Of Engagement Activity | 2021 |
| Description | Presentation of the study findings at the 2020, 2021, 2022 and 2023 ASTMH meetings |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | I submitted an abstract on the project outputs to the American Society of Tropical Medicine & Hygiene meetings in 2020, 2021, and 2022. The abstracts were accepted for poster presentation and I made the presentations at the meetings which were well received and generated many follow-up questions from the audience to know more about the final project outputs. |
| Year(s) Of Engagement Activity | 2020,2021,2022 |
| Description | Stakeholder engagements with Senegal Ministry of Health, NMCP, SMC and NTD programmes |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Professional Practitioners |
| Results and Impact | I had a face-to-face engagement workshop with the officials of the Senegal Ministry of Health, Coordinators and Managers of National Malaria Control Programme (NMCP), Seasonal Malaria Chemoprevention (SMC) programme and Neglected Tropical Diseases (NTD) programme on 29 January 2021 where the implementation plan of my fellowship project was presented and logistical issues were extensively discussed. Valuable inputs were made by the attendees, including a suggestion to set up a steering committee to include members of the Ministry of Health, NMCP, SMC and NTD programmes, to ensure their continuous participation in the study implementation |
| Year(s) Of Engagement Activity | 2021 |