[afro-nets] When rumours derail a mass deworming exercise

["Jawad Asghar" <jawad@alumni.washington.edu>]

The Lancet 2007; 370:465-466

DOI:10.1016/S0140-6736(07)61211-2
Comment

When rumours derail a mass deworming exercise
http://www.thelancet.com/journals/lancet/article/PIIS0140673607612112/fulltext

Alexander Dodoo  a,   Sam Adjei b,   Mary Couper c,   Bruce Hugman d and   Ralph Edwards d

The role of misleading or scaremongering news media reports in causing drug crises is well known.1 Pharmacovigilance systems can play an important educational and preventive role through safety monitoring of products and effective communication about safety issues with health professionals and the general public.2 That failure to use an existing pharmacovigilance system in implementation planning and weaknesses in communications about medication could lead to mass hysteria and civil unrest might thus seem implausible. But this reaction happened in several regions of Ghana on Feb 12, 2007.

Ghana had its first national deworming exercise, jointly organised by the Ghana Health Service, the Ghana Education Service, and UNICEF, on Feb 12–16, 2007. Trained teachers supervised the administration of a single 500 mg mebendazole tablet to nearly 4•5 million children, aged 3–15 years in 28043 public schools. The drug had been imported by UNICEF; it was manufactured in 2005 and the expiry year was 2010. Within hours of the start of the programme, there were reports on local radio stations about deaths and serious side-effects affecting several children in three administrative regions. These reports led to considerable public disorder. In some instances, teachers were attacked and schools were shut.3

The Ministry of Health immediately commissioned the independent pharmacovigilance centre at the University of Ghana Medical School to investigate.4 The investigators, in collaboration with the WHO Programme for International Drug Monitoring, found no deaths, three admissions to hospital for suspected Plasmodium falciparum malaria, and scattered reports of mild stomach aches, nausea, and cramps (know adverse events of mebendazole). The investigators also noted localized mass hysteria, including parents rushing their children to hospital or giving them palm oil in the belief that it would induce emesis,5 attacks on teachers by irate parents and carers, and attendance at hospital by over 350 children, all of whom were reassured and discharged. A possible source of the rumours was the emergency activities associated with the death of a child, killed by a falling wall, 2 h after the start of the deworming exercise.6 The report by the investigating team was presented by the Deputy Minister for Health at a press conference. The news that the Ghana Health Service had asked an independent team to investigate helped restore confidence and calm nerves. Other assurances came from UNICEF, which attested to the safety of the drug and widespread coverage of these findings in the print and electronic news media seemed to assure parents and calm the situation.

Incidents such as this one point to the need for active pharmacovigilance, excellent communication, and crisis-management planning to accompany public-health programmes that involve mass administration of a drug, especially in countries where resources are limited, rumourmongering rife, and populations volatile. The possible effects of this crisis and its management on further public-health interventions in Ghana are a worry. Interestingly, anxieties about side-effects of deworming drugs (praziquantel and albendazole) and the lack of proper communication and effective collaboration between education and health workers had been previously noted as barriers to success in a school-based deworming exercise in Ghana.7 Similar findings have been made in Turkey, where allegations that mebendazole, used in a school-based deworming exercise, caused sexual sterility and was an investigational drug being used for experimental aims by foreign researchers led to a 50% fall in drug administration.8

There are several lessons from the recent Ghana experience (panel). The political and sociological aspects of such events are also important. On the internet forum9 associated with the first press report about the incident, there was massive outpouring of anger, resentment, paranoia, and vitriol. The situation suddenly became the focus for a wide range of volatile and dangerous political and social prejudices and hatred.

•Comprehensive information about safety profiles and side-effects is needed
•Parents and the general public should be briefed about the purpose of public-health programmes that involve mass drug administration, especially in children or pregnant women
•Children and parents (in this case) should be informed about possible side-effects and how to react should they occur
•All stakeholders need effective briefing, before the start, about any programme that involves mass treatment. Such briefing should include journalists, especially in areas where ethics and good practice in reporting are weakly established. Health workers also need briefing, because in this case they were not directly involved (teachers were)
•People and their culture, and problems that could emerge, need understanding
•Independent experts with knowledge of pharmacovigilance must be on hand to quickly investigate unexpected effects
•Standing emergency committee is needed to manage sudden crises and public relations, and for rapid deployment of experts on the ground or by telephone if necessary
•General education and communication about drugs and public-health programmes is needed so that citizens can understand what is happening
•In planning and communication, provision is needed to deal with effects of poor education and knowledge, and how this might lead to irrationality and paranoia in large populations

It is worrying that a responsible activity such as the deworming programme can potentially cause huge loss of confidence in the public-health system and give rise to civil disorder. However, the Ministry of Health's rapid involvement of the country's independent pharmacovigilance centre allowed the facts to be established10 and order to be restored. The Government was seen to react urgently and effectively.

AD led the investigating team from the University of Ghana Pharmacovigilance Centre. SA is the Deputy-Director General of the Ghana Health Service. MC, BH, and RE gave advice to the investigating team and the Ghanaian Government.

Affiliations

a. Centre for Tropical Clinical Pharmacology & Therapeutics, University of Ghana Medical School, Korle Bu Teaching Hospital, Accra, Ghana
b. Ghana Health Service, Accra, Ghana
c. PSM/QSM, World Health Organization, Geneva, Switzerland d. Uppsala Monitoring Centre, Uppsala, Sweden

-- 
Rana Jawad Asghar MD. MPH.
Coordinator South Asian Public Health Forum
mailto:jawad@alumni.washington.edu      
http://www.DrJawad.com
Typhoid Net http://www.typhoid.net