FILARIA CONTROL PROGRAMME AND GLOBAL ALLIANCE OF ELIMINATION OF FILARIA
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- Title
- FILARIA CONTROL PROGRAMME AND GLOBAL ALLIANCE OF ELIMINATION OF FILARIA
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RF_DIS_7_B_SUDHA
0
iiciiniiiinoiog)
indja
{Ed. K4.L. Sood)
ISBN: 81-7089-293-7
Ig -
pp. 425-451
epidemiology and control
of filariasis
T
P.K. Das and S.P. Pani*
Vector Control Research Centre
(Indian Conned of Medical Research).
Indira Nagar, Pondicherry-605 006
filariasi s’lnF aCC°UntS
abOl,t 4'% °f lhe fi,obal bl'^en o, .vmpnat.c
of"lymphat
a
filariaX TI s isool,tm
n|10,7 ‘he W"° 1997 ,CSOk,tio" 011 elil
in^n of
epiZoS of t^ i
3 teaChniCal reVi£W °f‘be
sutjettas therefo0 b'1 ' S°Und
J
I
cauLZeTopeTThe
"™S> ?! f°re’been reviewed under the titles: epidemiology of filariasis
geographical distribution, trend of filariasis
n distribution of filariasis/fila^^Z^^^^Sr^
■
;
approach are the needs of the hour.
°W
parlnc,sh,P
Key WOrtls : Filar,asts; Ind,a; Epidemiology; Elimination; Control; Serena
hancrofli; Brugia malayi.
Introduction —Epidemiology of filariasis ----------Filariasis control------------Towards elimination of filariasis
Transmission control
Morbidity control----------Filariasis elimination cell
Conclusions--------------
References--------------------------
n
---- 425
—-— 426
- 435
---- 438
---- 440
---- 442
---- 443
---- 443
---- 444
INTRODUCTION
C/l
According to the latest global estimate, India al
of the elobal burden of Ivmnh r ri
'a alone conlrib.utes to about 41 %
oa. burden of lymphat,cfilanasts (Michael et al.. 1996). F-'ilariasis
c Intcrnauonal Book Distributors. Dehra Dun-248 001 (IndiJT
’ Corresponding author.
1
426
Helminthology in India
kSSESSSSES h
1999?I daSSed 3 reSO1UtiOn fOr the 8'0bal e,imination
Ws
disease (WHO, 1999). India .s a s.gnatory to this WHA resolution. Consequently
the current National Filariasis Control Programme (NFCP) is fast moving from
an urban oriented control programme to a comprehensive national filariasis
ehmmation programme (Das and Pani, 2000). In view of this, it is important
to review the current concepts in the epidemiology and control of the disease
based on which the elimination strategy maybe developed and implemented.
EPIDEMIOLOGY OF FILARIASIS
Filariasis problem in India
™ daTes w^y'ba'ck^rom
(desc'riptio’n
microt-l'11
11
legS (NFCP’ 1984)- Subse<Iuent discovery of
caXm^om
per,pheral blood by Lewis- “ 1872, in Kolkata led to
CruYcksXnk
i uTT, ,ln many Par‘S °f lndia by different workers l^e
Cruickshank and Wnght (1914) in Cochin, Roy and Bose (1922) in Orissa
Sg 1929? Cl R I0 9231 n 3 V‘“age
Chennai 3nd K°rke <1927al ’927b^
bancrofo
eXdemiMn
f
and,OnSSa that confirmed the wide-spread presence of
T’ yengar
1933’ 1938> ^"ducted detailed
can bn Cdr"en‘b“rden of filariasis in India in comparison to global situation
mill’ V'SUa 1Zfd frOm the follow,ng recent estimates. Globally, about 1 100
expoZ’dTthe 7 1"arfeaSendemic for ‘ymphatie filariasis (in 73 countries),
exposed to the nsk of mfecUon. There are about 120 million cases of filariasis
1996 It hansebPatent ™Cr0^laraemia or chronic fi’arial disease (Michael et al’
tn ,?' J p r" eSl’mated that in India- ‘here are 429 million people exposed
7 4 mill'J f lnf“’ 3L3 million individuals with patent microfilaraemia
for 39
12'9 milli°n hydr°Cele Cases> accounting
S J ?99M
.
% ofresPective. global estimates (M.chael
al.. 1996).The relative burden for the two parasites, Wuchereria bancrofti
42
Epidemiology and Control of Filariasis
■
and B. malayi (global and Indian estimates) are compared in 'Cable 1. India
alone contributes to about 41% of the overall global burden.
Table 1 : Relative magnitude problem due to IT. bancrofti (Wb) and B. malayi
(Bm), comparison between global and Indian estimates.
Parameters
!
Global
India
India as % of global
Wb
Bm
Wb
Bm
Wb
Bm
Microfilaria
carrieYs
73.3
10.4
29.5
1.8
40.2
17.3
Lymphoedema
cases
13.2
2.8
6.9
0.9
52.3
32.1
Hydrocele
26.8
NA*
12.9
NA*
48.1
NA*
Total cases
106.2
12.9
45.5
2.6
42.8
20.2
The total cases exclude a proportion of individuals who may have
overlapping infection/lymphoedema/hydrocele.
* not applicable, since B. malayi does not result in hydrocele.
The estimates are as per Michael et al. (1996).
The parasites
In India, lymphatic filariasis is caused by two lymphatic dwelling
nematode parasites W. bancrofti and B. malayi. These parasites exhibit cyclodevelopemental life cycle, alternating between human host and
vector mosquitoes. The adult parasites inhabit the lymphatics and lymph nodes
of man. After mating, the ovo-viviparous adult female releases microfilaria
which reach and circulate in blood, exhibiting a nocturnal periodicity (Pani
and Dhanda, 1994). Sub-periodic form of PF. bancrofti has been reported from
the Nicobar Islands (Tewari et al., 1995). The microfilaria, when picked up
by susceptible vectors, grow through three larval stages and the third stage
larvae are infective to man. This infective Lj grows through two more stages
(L4 and Ls) to become an adult, which becomes sexually mature in about a
year. 1 he fecundic life span (period for which adult female produces microfilaria)
has been estimated to be 5.4 years for IV. bancrofi (Vanamail et al., 1996) and
3.5 years for B. malayi (Sabesan el al., 1991). The life span of microfilaria is
—estimatecLto be aboutb months (WHO, 1997a).
__
I
IHUICI
1 he vectors
’
'
C'^',s Emitted to man by the ubiquit
■"osqurto breeds in pol|u[ed tX?1'5,"1OSql"10'
iMblbbon T|,|,
s vector is found abundantly ,n a 1 X
r,
b«^ppw
b,
~'W ta tadi. b
fi
gh,^an,l,ropopbilic-A
^PP- (M. annuhfera, M unif(jrnlis
7't'bydraphyi^"; ~-xt0’s br"d in'
(Tewari et al., 1995)
■I
Transmission
C^°r
subperiodic W. bi.......
^ncrofu m Nicobar islands
dynamics
‘-iiariaMs
429
Sk,ge ;,,R| af'>" sexual maturity mate and th r
,
Hie adult p
collatcra! formation etc.
-(reviewed by Parti and 1 all 1998) J1'1,1110'1-klnl<ing
inihully transient
(WHO, 1997a).
re»i. lympll„ic
...
—«=. b„, ,ubiequ„„y b„onie p«;n^ £«„
^■ntcal foHo'ngpmaoVSdme’ resultm' "7’ l'1C Pa,llOl°gy ~s ^bpUe to thls reason, many parasite carriers re^ eSCap,ng clinical Selection.
(Pamezu/.. 1991).'ImmunoIogicaIlv this is r
" asyniPtomabc for years
Ylth anti-inflammatory response and the nnX °f parasite sPecific tolerance
nne the lymphatic dilatations increase result
‘S T' reJeCted' Jn course of
‘ympltpedema. At this stage, immuno mtl i '
‘n lymPhstas‘s and clinical
in clearance of parasite. Therefore in clinic^ C.han®eS
°Ver’ resulting
WanaIlyniphoedemadonotshowe^
cases of
Depending on the site of the adult paras,te t6 °fP" (Pani e'a/- '^la).
'nv oved, the pathogenesis vary (Pam and Di J'T"
‘he ,ympha^ ~
testicular lymphatics of male Jhe most nref
7’ "4)' Adult ParaS‘tes in
gender) result in passive fluid accum .1 t
n S“e °f
bancr^ this
resulting in hydrocele, with minimal i
" be‘Ween the ,ayers
tunica
microfilaria detection being higher in |mmuno'Pathology (and therefore the
transmission unlike o7 °f facilltatlon 's observed resuX5'10 density 111
(Das et ai_ j 994. panj and ga[Xr5” COmpared l° lymphoedema)
Nn rOn' lymphat,t:s either gend™ tT8''65 '°Caled dCep inguinal
lymphoedema development Lymnhoede tlngross ‘mmuno-pathology and
becomes mreversibLe. Lrge q^fSiX'1'^
ba‘
i
nere are several quantitative estimate
P£7 bit1"8 periodS^
7 amai1 and Ramaiah 19911
Pathogenesis
S
'S;!"*1 ......... .
nd fissue spaces until late stages of lymDhOed
"traPPed 'n lymPhatic
resulting m solid oedema (Pan! and Yuvaraj 199677 7 llbr°SiS ‘akes over
secondary bacterial infection (particularly du 'i 7 Sk'n ChangeS Sradually
S‘reploCocus} jn (he
“,ydue o Group A Beta haemolyfic
lymphangitis, lymphadinitis and filariaTf '5 'n repeated attacks of
adenolymphangitis; ADL) (VCRC 200017
(described as acute
plmT0^™ Un,il elePhantiasis (rouXninTandlr1
°f ADL worsen
Pan. et al„ I995} In
of™! ^e^ng of skin) results
ypersensitive response develops directed b
oJil ‘nfection, a specific
m a allergic disease with lungs as the target383'™ ‘he nlicrofllaria. resulting
eosmophilia (TPE) (WHO. 1992)
6 '
Called tropical pulmonar^
Nature of niorhidity
Epidemiology
lymphangitis lymphadenitis, epididymo-orchitis, mastitis etc. with or without
systeimc mamfestahons such as.fever, nausea and vomiting. The other
mamfestations include TPE, filarial arthritis, endo-myocardial fibrosis
haematuna and glomerulo-nephritis. Clinical consequence of filariasis can be
teS hT
f°llOfWine facts' 11 is a leading cause of permanent and long
..
C
auu lUllg
term disability in thp
form c
i.. .
.
. ..
°
elephantiasis (WHO, 1992, 1995), progressive hydrocele or los^ of rTsp'S
T. ■■
d Control ofFilariasis
4_
I
prevalence were compiled from the reports of the National Filariasis Control
Programme and other published data. This data from 280 districts
surveyed until 1995 was used for the preparation of filariasis distribution map
>• w;
using a GIS platform (Sabesan et al.,2000). Of the 25 states/union
territories in India, for which surveys have been carried out, 22 are endemic,
I .. and nine states (Andhra Pradesh, Bihar, Gujarat, Kerala, Maharashtra, Orissa,
Tamil Nadu, Uttar Pradesh and West Bengal) contribute to 95% of overall
burden (Table 2).
£i
1
#
■
In ^Of^!!!i^lymp^O^dema leading 10 disfig^ing J
r
i
199° 1OWHOtO199r2nip
e°sinoPhilia (TPE) (V‘Jayan et al..
vmnh ? ’ PC
e‘ fl/-1995)- Patients of fifariasis, particularly
lymphoedema suffer from episodic attacks of ADL which cause acute suffering
incapacitation, debilitating the person (Addis et al., 1994; Pani el al iggf’
Pamland Snvidya, 1995; Ramaiah et al., 1996; Dunyo et al.. 1997) Morbidity
ue to filanas^ also includes renal disease (haematuria and glomerulo-nephritis^
my0Card'al flbrosisetc- (WHO, 1992; Dreyer etal..
0
1
11
1992; Ottesen 8 <
I0
I“
I?
Prevalence, incidence and distribution
IJ
iJi
Prevalence of infection and disease in human population is measured
as proportion infected with detectable microfilaraemia (mF rate in%) and
proportion with disease (disease rate in %). The endemicity of an area or a
Theenn5’rateUOn
tO PrOpOrt'On P°sitive for infected °r diseased or both.
LorTfd
LiUT ly meaSUred in ,erms °f P°Pu'adon positive in a > ' '
night
g
.. ..
I
■-
g f
XX ’X
h 'qSU,UT
20 CUbiC (since
mm peripheral
bl00dtechniques
samPle). I1
suchX
‘he‘CChn
e has (USUa
a P°°"rysensitivity
concentration
has^beenmeuTedane f
has been used uniformly under Indian national programme, providing
mparable data. The prevalence of disease under the
national programme is
toect^bv hX0^011 °f pOPulation witb fe— fi.ar.ai patnology, otten
gross filarial pathology, often
rather than bX
7
[ qUeStlOnnaire about lymphoedema and hydrocele
’l--------------'JI V/WiC,
ramer man by any physical examination.
—*'— tFor
-* .«this
• reason, the disease prevalence
J
*
rates reported are expected to be much lower than
the
di
------ ------ isease prevalence
obtained in clinical examination by a physician
/ ' '
(Pani et al., 1991). The
occurrence of episodic attacks of ADL in’the'population is measured as
nnnnai
r.u
------- -- *“
P°Pulation is measured as
is ava
atta‘ks/1000 Population. Till-date, data on this aspect
™lab e only for research studies, since ADL surveillance has not Xen
earned out under the national programme.
I
.I
,
•
|
'■
—
Geographical distribution
Recently, the available data on the distribution of disease and infection
| J
| ?
| r
??
? f
1 f
« )
hO
|J
f
Table 2 : Lymphatic filariasis in different states and union territories of India*.
State/union
territory
States
Andhra Pradesh
Assam
Bihar
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kaslimir
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Megalaya
Nagaland
Orissa
Punjab
Rajasthan
Tamil Nadu
• Tripura
Uttar Pradesh
West Bengal
At risk
Population in million
MicroWith
filaraemics
SLF
53.47
10.38
63.95
1.28
18.25
4.51
0
3.2
11.75
31.38
23.86
18.55
0
0.39
27.05
0
- 0
38.89
0.7
99.72
20.09
3.37
0.39
4.34
0.01
1.1
0.05
0
0.05
0.75
2.49
0.56
0.95
0
0.01
1.48
0.09
5.95
0
0.14
0
0
0
0.08
2.45
0.08
0.17
0
0
1.51
0
10.79
4.87
13.81
0.20
3.91
0.97
0
0.95
3.09
20.69
3.09
0.03
7.27
0
0.09
8.18
0
0
6.57
0.20
8.71
13.71
0.01
0.03
0
0
0
0.01
0
0.01
13.90
0.40
0.01
0.67
9.12
8.37
27^09
20.83
2.39
0
0
2.45
0.1
7.02
0.98
O’
1.3
0.01
7.52
Union Territories
Andaman and Nicobar 0.22
Chandigarh
0.64
Dadra and Nagar Haveli 0.13
Daman and Diu
o. 1
Lakshadweep
0.05
Pondicherry
0.76
—TotaL------------------- 429v32-----* modified from Sabesan el al. (2000).
Average
endemicity
0.01
0.01
0.01
0.01
| Epidemiology and Control ofFUanasis
Helminthology in india
J
433
i
I
I
111
i
*
1ta““
roE.on.
of nrb’'”1"’-8
I vogue in these areas. On the other hand th
| J low and moderate endemic d^stXts and h
||Table3:
Filarial infect,on status at different years in India*.
Estimated population at risk
of infection (millions)
I f 1962
j 1970
I \ 1976
| i 1981
| j 1985
» dopiX:;
oonstel „t, is
I
I r 1989
i i 1994
I r 1995
i
|
I
I
f
“» "Xwer““““
the ^0V,e 3,1 the Population movement a?hTlani2ati°n and induafialization
the mtroductton of mfection to the newer
T W0U'd have resulted in
ased on the results of various delimitate °n'endemic) areas (Das, 1998)
lanal situation over last five decades is " SUrVeyS conducted till 1995 the
durtncts surveyed, 250 were Fou. ^0 beT' Tab'C 4 °U1 ^e 283
"b mo%>
r '"■“=*
oJ ln 100 districts and high
Urban
Total
40.16
84.91
174.08
221.92
251.80
275.36
302.87
315.11
24.08
51.39
62.05
62.08
90.56
98.94
108.78
113.17
64.24
136.30
236.13
304.00
342.36
374.30
_______________
’
’
Estimated
number of cases
(millions)
_ mF Disease
5.0
11.3
18.3
21.7
23.7
25.0
26.9
28,0
’
4.40
8.00
14.40
15.84
17.56
19.00
20.40
21.20
Number of
cases per 100
popn, at risk
mF
]Disease
7.8
’ *K.3
7.8
7.2
6.9
6.7
6.5
6.5
6.8
5.9 ”
6.1
5.2
5.1
5.1
45.0
_5.°
ing inter-country
Pondicherry.
I
Age and gender distribution of filariasis
I
important to idemlfyXXgJdiStr‘butlon 6°f the disease is
j
,dn7'«»“» PW
Rural
411.65
428.28
* Filariasis and its control in Indi;
W(
•jj
Van0US COnlr0' measures ■"
'' h ‘nCreaSe 'n t,le number of
■| s problem in some rural areas (where tl
'S C°U 1 refleCt the lncrease in the
| f the disease to newer areT
' 'S
C°nlrOl) as wel1 aa spread of
of
,I“'VS ’
s ,
'l' l“811' “< Xl The '
d,s,„ls
i | :*
Pockets m the states of Kerala Andhra Pra I h
’S Confined only small
Pradesh, West Bengal and Assam. W bancrom^^'0^^^
Ind a except m some of north and north 7
PreValent almost *11 over
Kashm^, Punjab, Haryana, Himachal Prad/heSTn S‘ateS (Hke
and
extern states like Nagaland, Manipir Trinum M t R,ajaSthan>and some north
ie microfiiaraen]ja ]eve|s
P ’ P -Megha aya, Sikkim and Mizoram
W,. Bi,,.,. AnJh„
'«>■ In so™ p.„, of
infection and disease are sig^ificTntlv h, h lntWe"110n- The Prevalence of
. (Brabin, 1990; Pani etal 199] ■ Pani and S^d1"
COmPared t0 Smales
J Young adults in age gro J of 15
VT '
"t3’
MiCheal e,al- 199d)-
i
ii
g f infection. This group alsoformed the nred reC°rded the h'8hest Prevalence of
I j Micheal et al. (] 996) estimated that alohaClaSS the P°Pulatiom
ij ? °fall microfilaria (mF) carriers 47 27 on 115 age l;Iass contr>butes to 58.5%
| hydrocele cases, and constituted 46 9% of th?total
58 3% of
I &I-3 ™8ed
6.74 m
X
434
.helminthology in India
j
and 7.70% in Ghana; contributing to 11 2% and 27 7»/ cr ii
persons in the community (Gyapong et ai Wgf Th
an‘>genaemic ,
also infected, but do not exhibit mF in th/ h! ' H T88^5 that they are ,
or other reason Therefore
r night tn peripheral blood for some ;>
will b.
'ref"e'
“f ““ »«"»"> i» Om V dm. { g
|
Table 4 : Trend of filariasis over past five decades in India*.
Period
Pre- 1961
1961-1970
1971-1980
1981-1990
1991-1995
No. of districts
Surveyed
Found to
(cumulative)!be endemic
<1%
l%-10%
43.
productivity and functional impainnent Hrvans et al 1993-r
Ramaiahe/u/., I997-R
j h
'
c'al- I993, Ramueta!.. 1996;
' ------........- ' namaial '
, e‘al- ’"S-Ramatahetu/.. 1999; Ramaiah e/
al.. 2000a). Recently, it has al.
840 mi!m
est,mated thaI economic loss to India is
to the lune of US $? 840
billion (Ottesen Tt al.. 1997?'per annuT"'1
10 US $ L5
filariasis control
No. and (%) of districts with endemicity of
0%
Epidemiology and Control of FUariasis
>io%
i
.. 1933' n'SXXT" “
“»«1» ».ly
erslwhile sialo of Travancore
works" was launched by the
109
3(2.7) 12(10.7) 32 (28.6) 65 (58.0) :
plants
from
the
infested
ponds
was
done^V"
°f rem°Val °f 'pistia’
152
9(5.6) 24(14.9) 47 (29.2) 81(50.3) J
state (Jaswanth Singh et al 1956) To d ^h1813" flIanasis contro1 in 'he
211
32(13.2) 60(24.7)
71 (29.2) 80(32.9) |
scale programme for the control of fih ' d
Op 3 natlonal strategy, a pilot
255
32 (11.2) 77 (26.8) 104 (36.2) 74 (25.8) s-r
z-s
■
------••
“
v.viiui
^e
control
of
filuriasis
was
launched in 1949 in the state
257
f.Orissa- 7116 objectives of the proj,
32(11.1) 76(26.3) 104 (36.0) 77(26.6) | ;
efficacy of three different'method^nf
\° ,eValU3te the suitability and
modified from Sabesan et al. (2000).
diethylcarbamazine (DCE) to all commi Cf°n r°
nlass administration of
measures and (c) recurrent anti-adult measured The
TT' ant‘darVa'
these methods were effective Mthn i
) Tbe results showed that al]
.se el
- ■
to a cumulative effect, as chronically di °
3
10 °lder 386 classes due ■ i- disadvantages. Therefore, it was recomnw td
“S °Wn advantages/
(Brabin, 1990; Pani et al 1991) Th^^^ PerS0"S rema,n life long diseased |
all the three methods was aXonr “te
ih
* 'nU'tiple appr°ach’ using
similar age pattern as chronic 1'
°f
ADL also shows a « • these findings, a countrywide National Ria
fl'arlasis' Based on
predominantly occur in persons hXtXV
b"'6’
epiS°deS °f ADL
was launched with the co-operation of I
Te
Programme (NFCP)
1996). Males record very high prevalence of d"'
(Rarnaiah etal"
Mission (now USAID) during 1955 56 mi'6 ■
r®cllnical Co-operation
occurrence of hydrocele However ifhvdrn. I • dlSeaSe Partlcularly due to
were to carry out filariasis survey in d r/
81113 objectlves of 'he NFCP
are similar for ^oth the
1W C°nS,4ered’
|
problem was known to exist, to ■mdertlkeT"' St£“e> °f-the C0Un,ry where the
the known methods of filariasis control i
P'l0t stud,es to evaluate
| and to train professional and ancillary ne "
31638 m differen‘ sla'es,
I . (NFCP, 1984). The mass treatmen w7 P*^0"116’ re<Wred for the programme
I
days with daily doses of 4 mg of DEC/k’iH °d °Vei
°f5 successive
associated with the severity and "Vt 6 C
h'811'
degree of stigma is :]
Lu et al.. 1998). There is" consIdV'tt " °fJhe dlSe3Se (EVa"S e‘ al- 19«; J
J operations consisted of both anti adult find ° Y 'V T16 mosqui'° control
mg/sq ft) and anti-larval measures twite
r^ldl'al spray of dieldrin 50
and families including sexual disabilities^f O'SOC'alstress on the individual 4?
j
genital abnormalities and of women with i° T" 3m‘Cled Wlth hydrocele or J
fc This programme was continued for 5 yelrAnd 5 6^P0.' |der’6'5% Kamtna).
(Dreyer et al 1997) Finally the
h Y’lphoedema of breasts or genitals/"
14.1 million (total of population wh^
6" nilll|O'’ persons out of
— A were covemd und X
'T'3111,116 W3S ™Piemented). in
47 control units
_
The
average of full five-davcounJ
n„" “n niass chemotherapy
c"emolneraP> programme.
progran
112
161
243
287
289
T.
j
atsi is .b;j;“ °'
•*
(Rajagopa.au and'p?n7! Wh On
6% in different
5|
covered complained of adverse reactions n
‘6-5%
ie population
i;5 £ ranged between 10 95 - 84 6°/ inn
7 rec ucllon in
ln microfilaria
microfilart density
tS « and modified from' mre to tim
has been
om ttrne to ttme. Apart from this, several research stucfassessedseveral research studies have
•| r
B-. W93>. Tde d1!ra„ is
X-
436
Epidemiology and Control ofFilariasis
Helminthology in India
437
also been ‘Undertaken, which have contributed
to the optimization of large
scale control efforts in India.
year and pregnant women) for 2-3 years (currently extended to 5 vears) It
was also decided to implement the mass chemotherapy in /vertical
approach on a single day called "National Filariasis Day (NFD)".
First five years' activity of the NFCP was reviewed by ICMR
'♦
assessment committee and it recoiimmended that the programme be modified
Information Education and Communication (IEC) for enlistimi
and
that
control
be
based
solely
on
----------------- j -n measures against larvae of vector, Culex S
co-operation of people and participation for the MDD.
fatigans (now qumqefauciatus), directed to urban endemic areas It was 3
Management of acute and chronic filariasis ,
recommended that the mass administration of DEC be abandoned There was I
through referral
services
at selective centres.
poor coverage m most areas and unpleasant reactions following «
administration. The drug failed to clear the microfilaria in some individual! $
and in some areas the reduction in microfilaraemia did not persist. The decline 1 gj. Table 5 : Epidemiological situation of filariasis in 13 districts selected for
g- ■
' mass annual single dose DEC as a pilot project.*
_______ __
State
District
Year
mF
Disease
Average
Rate
rate
The activities of the NFCP were subsequently reviewed by the second W
endemic ity
assessment committee in 1970 and it was recommended to carry outfl
Andhra
East Godavari 1983 '
16.70
8.90
25.60
Pradesh
selective chemotherapy by detection of parasite carriers (by night blood S
Srikakulam
1956
13.90
4.10
18.00
surveys) and treatment (6gm/kg/day/12 days). Apart from this, it was also-J
Bihar
Darbhanga
1958
4.50
16.30
30.80
Siwan
recommended to use temophos (abate) and pyrosene in oil as larvicides. These M
1982
2.29
4.87
7.16
recommendations have been implemented in urban areas since 1971. Although. Si
Kerala
Alappuzha
1975
13.40
8.20
W21.60
the programme was also reviewed by a third (1982) and a fourth (19^11
Kozhikode
1960
9.28
5.66
14.94
a^sessm«'‘committees, the control strategy, has not undergone any major O
•
Puri
1993
10.60
change (NFCP, 1995). The fourth committee has suggested L intr^uctfoiffl
NA
10.60
Khurda
1958
4.51
5.00
of medicated salt in a phased manner, but this has not been undertaken (except ® p; Tamil Nadu
8.96
South Arcot
1958
12.90
7.60
in one district in Tamil Nadu). Currently, a total population of 40 million in W !•
20.50
Vellore
1958
9.63
rban areas, out of 109 million in urban (37%) and 428 million in entire India S
6.20
15.60
Uttar Pradesh Gorakhpur
1962
6.65
^/o) is covered under the programme (NFCP, 1995).
11.84
18.49
Varanasi
1958
10.80
10.10
21.00
West Bengal Puruliya
NA
NA
of India
r Ti formul-at!on ofarevised
to cover large population
NA
NA
ndia (particularly in rural areas) was felt necessary. For this a WHo
WHO OSP^* comP^e^ from published
reports and literature by Dr. S.Sabesan, VCRC,
sponsored
a.„ , workshop
, - was organized by the
--lT
NICD,
“....._;Directorate
NMEP;
,ofHeallhW-‘:MAPOndiChetryand Family welfare, and tlie Government of India in January, 1996 The pilot lHpNA’ nOt avalIablestrategy is based on the hypothesis that single annual dose of DEC as a
community level administration with a reasonable coverage may interrupt the SW • Wh'le the
transmission m course of time and prevent the occurrence of new cases of lite aSS1Stance’ reviev
^■I
1976X2
I'^r38 "Ot aPPrCCiab,‘
|
-
S
fej,°rlssa
B-
I
ftOCMR) .^„MraedSMe H„,,h
.^^;ongoing NFCP programme should beTonZue(JS
^Xd0Se DEC mass chemotherapy currently called mass drug delivery >
(MDD) at dosage of 6mg/kg of body wt (excluding children below oncfl
in addition to annual MDD Tko
____
pilot scale in 13 highly endemic districts distributed in 7 states (Table 5), and
S “T Th?'"“d
•t.
438
Helminthology in India
‘ Epidemiology and Control of Filariasis
(he major focus is on NFD. The programme has undergone a mid-term review f
in early 2000 and the major challenge is to increase the compliance rates 1
through appropriate community IEC.
’
]■
TOWARDS ELIMINATION OF FILARIASIS
India is connnilled to elimination of filariasis as she is a signatory to the i
WHA resolution on the same in 1997.
shonld consider
997. However,
However, Incha
India .should
consider this
this as
as *5 B
a priority in its health agenda as <
she alone contributes to about 40% of die i f ,
global population at risk of infectionn (Michael
___________
sial.,_ 1996). In leading to achieve 1 B
i’s billi °flce;ipTlinati0,n’ In?ia can prevent huge annual economTlossVf abow j
---- "1
"
:
1.5> billion $ (Ramaiah ez al.. 2000b). The possibility of elimination of filariasis 1
n ndia is high as man is the only primary host for lymphatic filariasis. India |
has a long standing experience in filariasis control, the necessary health (U
infrastructure (up to village level) and support of technical and
Xrheam Perl‘Se'
h3S
Va‘Uable exPerience of launching several 1
wih r i ’prOgiainmes such as universal immunization and pulse polio, which t
v 11 o. help in optimizing large scale control of filariasis. The need of the hour I
and0 1P °f1
ekhmlnat,on policy and strategy- implement the same earnestly 4
and learn from the experience by proper monitoring and evaluation. This «
ehmmation strategy should be developed based on all progress made in our I
cunent understanding and knowledge of the disease and its control. Further it t
should not depend solely on any one medrod of intervention but should consider 1
more than one type of intervention, depending on the site-specific realities.
I
E
S*
I
BI
GV ♦
Our current knowledge on these research findings is outlined below : |
There has been considerable progress in our understanding of I
I
social and economic
-v.vuue burden
uuruen of
or filariasis
niariasis to
to individuals,
individuals, communities
communities
and
nation,
t
-•"
< i ion?h®rebytheneed for undertaking control operations (Ramu
,
et,al.,
a nn
;
malah et al- 1996; Ramaiah et
1998; Ramaiah el
al 1999, 2000a; Ramaiah, 2000). Burden of filariasis is also expected A
/ i oTs6
al., 1992).
t0 C‘iniCal Syndrome such as renal damage (Dreyer et O
J
Rapid Assessment Procedures (RAP) to measure the prevalence of ®
_i ariasis in an endemic area have been developed for delimiting W
P^ez'L^lWar635^01'^''07’' I996:RamaialleZ‘'f- 1996a; «
Rapid geographical assessment of bancroftian filariasis (RAGFIl)
•- W
439
procedure for rapid delimitation and stratification of filariasis
endemic areas has been developed (WHO, 1998).
DEC as single annual dose is shown to be safe and effective drug for
mass consumption for the control of filariasis (Ottesen et al.,]99'l\
Subramayan Reddy et al., 2000; Das et al., 2000). Primarily, DEC is
a microfilaricidal drug but also known to kill up to 50% of the adu.lt
worms (OtteseQ e/ aL, 1997; Gerusa Dreyer, personal communication).
Morbidity control-foot hygiene has been found effective in the
prevention of ADL attacks (Ottesen et al., 1997; Pani and Lail, 1998).
Vector control has sustained long-term effect, hence it can be an
integral part of comprehensive filariasis control programme
(Das, 1998). In situations where transmission interruption is not
possible through mass chemotherapy, vector control becomes very
important. It can be made cost-effective by spatial and temporal
targeting, limited to specific areas and season (Appavoo et al., 1999).
New simple diagnostic tools (ICT, OG4C3 and DNA probes) are
being available (ChanteaueZ al., 1994 1994a; Weil etal., 1997;Ottesen
et al., 1997; Pani et a/.,2000). These will be of value to evaluate the
success of chemotherapy programmes directed towards the parasite
in humans.
Newer mathematical models (LYMFASIM and EPIFIL) are being
developed and validated and these will be useful for monitoring and
evaluation of control programmes and prediction of the
epidemiological trends in infection and disease (Chan et al., 1998;
Plaisier etal., 1998).
■
A
Newer implementation mechanisms are being formulated and
evaluated. These include the feasibility of drug delivery by community,
through primary health care approach or through partnership approach.
The partnership approach is being evaluated in Pondicherry urban
area. The partners include different local governmental (social welfare,
health and family welfare, state unit of NFCP, Department of
Infonnation and Publicity), central government departments (All-Jndia
Radio-AIR and Television Broadcasting Department, Doordarshan),
student volunteers (national service and Mahila sangam. M/S
Burroughs Wellcome have supplied DEC free for this annual single
dose mass chemotherapy programme. This is a good example of site
specific strategy developed locally (Annual report, VCRC, 1998).
4HU
g
Helminthology in India
Epidemiology and Control of Filariasis
441
Intervention choice for elimination
Under the current national programme in India, DEC is distributed to
parasite carriers by the daily selective therapy method (first of the above list),
the prevaTenctof infl
ap^°priate method of intervention depends upon
after detection of carriers by night blood examination. Although, it has resulted
of^m«n iSre
tran“n pattem
* ^en unit
in reduction in parasite prevalence in the areas covered, the night survey for
■ r
parasite
detection is cost-prohibitive, has low acceptability both by the
n
Mvoigus,
transmission
controi and
community
and programme managers, and finally it is not pracitical to extend
in
combination.
In
fact,
i
based on stratification, one could decide the choice of inteTvTntioto larger rural areas (Srividya et al.,2000). Technically, it is also not very
different phases of elimination for different strata:
I sound, since many of the infected individuals cannot be detected by the
technique employed (Pani and Dhanda, 1994). Currently, the most practical
TRANSMISSION control
and feasible method is mass annual single dose of DEC and this is being
attempted as a new initiative in a pilot programme (Das et a/.,1999a,b).
However, pne of the important challenges that needs attention is to be able to
decide the duration of this annual intervention. This will depend upon the level
■ 1
of endemicity, vector and human population density and the effective coverage
Parasite control
I
of target population achieved. The opportunities to decide this arise out of the
Vector control
S
data collected under the pilot projects and application of mathematical models
♦
by trend analyses. Again, the most practical approach is to initiate action in
Reduction in man-vector contact.
higlily endemic localities and learn from practical experience.
I
morbidity i„
(Ot|es„ „
”J*
1
Vector control: This is another means of transmission control, targeting either
against :
“J
immature larval stages using chemical, biological tools or by
environmental modification
adult mosquitoes by using chemical insecticides.
pi
In India, larval control is being routinely carried out in the urban areas
^covered under
------ the programme. It has apparently become costly, since it is
view of this DEC
, Pr“ent and there 1S no >dea as to its probable cost InO ^carried out routinely, without consideration of the vector seasonality and other
strategy n Tndia The« are™1"
O^hemotheraPy
the eliminationW SL factors.
ft
The observation that inspite of decrease in the community cumulative
&,.microfilarial
micro filarial load by using mass chemotherapy, effective reduction in
transmission parameters need not result, if the vector density in the community
remains high (Das et al.,2000). Therefore, vector control should be
mass annual single dose of DEC (6mg/kg)
O g. carried out particularly prior to or during peak transmission season, so that the
mass spaced monthly or semiannual single dose of DEC (6mg/kg) ' 11 gr effects of chemotherapeutic measures (which should also be done just before
transmission season) are consolidated. In view of this, focal, seasonal vector
nsTlsubrarn f DEC^^Cated saIt (°-2
to entire community at W
g. control will be required in certain specific areas, and should be considered
nsk (Subramanyan Reddy and Vengateswarlou, 1996)
O
g-’ important, component of the elimination strategy.
w^x^oariera<<i^d**l2*|
111 s
442
MORBIDITY CONTROL
Helminthology in India
I Epidemiology and Control, oj . .aiiasis
443
5
1 operational feasibility, cost effectiveness/benefit of strategies; rapid, specific,
I sensitive and affordable monitoring and evaluation procedures (of process
| and efficacy of intervention strategies); community (consumer) and provider's
perceptions, acceptability of the elimination strategy etc.
ifi-
Classically, filariasis results in acute ADL, lymphoedema leading to
gross elephantiasis and hydrocele. It has been shown recently that a majority
of the asymptomatic parasite carriers suffer from varying degrees of lymphatic
damage (Witte et al., 1993; Freedman el al., 1994; Suresh et al., 1997), which . Ifilariasis elimination cell
could progress to ovret lymphoedema. Prevention of progression of infection
In view of the activity needs towards filariasis elimination in India,
to-disease and episodic ADL attacks will not only be important from the view
I
the
Indian
Council of Medical Research (ICMR) has established a "Cell for
point of reducing morbidity but also increase the acceptance of the overall
|
Filariasis
Elimination
in India" at the Vector Control Research Centre,
programme implementation. Morbidity control/ management should, therefore, -K
|
Pondicherry
(Anpavoo
et
al., 1999; Das et al.. 2000). The cell has to work in
form an integral component of the elimination strategy. Opportunities for ®
incorporation of morbidity management in the elimination programme arise ® I close collaboration with the national/state programme managers and other
from recent progress in our understanding of disease process. The frequency ® | research institutions (NICD, New Delhi and other ICMR and non-lCMR centres)
of these attacks increases with progression of disease through stages (Pani et S |uo meet the following objectives:
al.. 1990; Pani et al.,\9S)5\ Pani and Srividya, 1995; Ramaiah et al., 1996). ®
to facilitate preparation of a blue-print of the action plan
Due to the functional blockade in lymph flow, secondary bacterial invasion, jfi
particularly with Beta haemolytic Streptococci results in acute inflammatory
to facilitate the formulation of a policy statement and preparation of
ADL (Grace et al., 1932; Liu et al., 1964; VCRC, 2000). It has also been 1
strategic plan
shown that repeated skin injury and ulceration of the oedematous part, |«
to facilitate undertaking advocacy steps at all levels
predispose ADL attacks. The following measures are currently suggested:
to foster effective linkage with all partners
♦
For prevention of ADL attacks, foot care/hygiene (Shenoy et a/., 1995;
to facilitate mobilization of resources
Pani et al., 1997) and use of antibiotics, particularly long acting ..1
to assist programme managers in the development and implementation
penicillin (Pani et al., 1997; Pani and Lail, 1998).
Ji
of site-specific strategy
♦
For reduction or arrest of progression of lymphoedema, monthly J
to provide guidelines for monitoring and evaluation of the programme
courses of DEC (6mg/kg/day in 3 divided doses) and community based )l
to facilitate required training and human resource development
physiotherapeutic measures including manual massage (Pani et al., J
1997; Pani and Lail, 1998).
1
to facilitate the documentation of the process at all levels, and
■
By
ir
t-
to provide technical information on filariasis and its control to all
Several other activities need to be carried out, if India has to move 1
concerned.
towards its goal of filariasis elimination. The political will-shown by India by 5
becoming a signatory of the WHA resolution 1997, needs to be strengthened
CONCLUSIONS
by demonstration of technical will. Towards this, the Government of India
and the States should spell out the policy statement on filariasis elimination. J
B .
India alone contributes to about 41% of the global burden of lymphatic
This should be followed by the preparation of national, state and district level 1
filariasis. Although, not a cause of mortality, it is responsible for great
strategic plans. Resource mobilization for the implementation of these strategic j]
plans and for appropriate monitoring and evaluation will be the next challenge. 1 H economic loss to the nation, apart from being an important cause of
lliis requires a partnership approach at all levels. Operational research need 4 B physical disability and social burden. The physical, psychological and social
sufferingsioto me
theyaucnu>
patientsanu
andiauu.»vo
familiesu.v
are heart
rendering.
Yet, it is possible to
to be carried out concurrently on several issues viz., development of advocacy
sunerings
--------o
‘
; on its epidemiology
and 1EC materials and mechanisms; intervention, implementation mechanisms;
eliminate this disease because of newer understandings
I’
444
Helminthology in India
Epidemiology and Control of Filariasis
443
and control There has been considerable progress in our knowledge of thei^^^ Das, RK. (2000) Role of vector control in elimination of lymphatic filariasis, Journal
epidemiology and control of the disease*, and there are major developments
’
of Communicable Diseases (submitted).
several decision support tools such as rapid assessment procedures, rapid^^L.
Manoharan A Srividya, A.,GreenfeU, B.T.,Bundy, D.A.P. and Vanamail,
mapping techniques, day-time diagnostics, mathematical models etc. Thes<^O» ’ ' p (1990) Frequency-distribution of Wuchereria bancrofti relationships
can be utilized intelligently for the elimination of this disease. If the politicalwith
and sex Parasitology. 101:429-34.
commitment is supported by technical will, partnership approach; national^®?
g P (2000). Towards elimination of lymphatic filariasis in India:
state and local actions and finally the community will, it will surely be possibleiO^ ’
Xle^s challenges, opportunites and new initiatives. Journal of
Sr,. International Medical Sciences Academy (special Issue; emerging and reto eliminate the scourge of filariasis from the face of India by the target^^
year
'
-’ 'Wllijemerging
parasitic iniesiauons
infestations m
in India),
emerging parasitic
luuidj, a13: 18-26.
io-z.v.
SK
■
is
Das, P.K., Pani, S.P., Krishnamoorthy, K. and Srividya, A. (1999a). Report of a training
workshop on "Collection, processing and analyses of data relating
operational aspects of filariasis control with speical reference to mass
drug delivery" 2O‘h-24lh April, 1998, held at Vector Control Research Centre,
Pondicherry. Vector Control Research Centre, pp. 1-17.
filariasis elimination in India: Hope for the next millenium. (Departmentof
Ill-Das, P.K., Pani, S.P., Krishnamoothy, K. and Yuvaraj, J. (1999b). Report of a national
Public Health and Preventive Medicine, Government of Tamil Nadu and^SX
’
workship on "Community oriented chemotherapy strategies for filariasis
Vector Control Research Centre, Pondicherry), l-20pp.
control", organized under the auspices of the ICMR and WHO/SEARO,
Brabin, L. (1990). Sex differentials in susceptibility to lymphatic filariasis
17-19th February, 1999, held at Vector Control Research Centre, Pondicherry.
implication for maternal child immunity. Epidemiology and Infection, 105:-^0
Vector Control Research Centre, pp 1-11
335-353.
fe|gj
Das, P.K., Ramaiah, K.D., Vanamail, R, Pani, S.R, Yuvaraj, J., Balarajan, K. and Bundy,
Chan, M.S., Srividya, A., Norman, R.A., Pani, S.P., Ramaiah, K.D., Vanamail/|tO
D.A.P. (2000). Placebo controlled community trial of our cycles of single
P., Michael, E., Das, P.K. and Bundy, D.A.P. (1998). EP1FIL : A dynamic!®
dose diethyl carbamazine or Ivermectin against Wuchereria bancrofti
•
model of infection and disease in lymphatic filariasis. American Journal of
infection and transmission in India. Transactions of Royal Society of
Tropical Medicine and Hygiene, 59: 604-614.
Tropical
Hygiene
(submitted).
xriz^».v-L** Medicine and -zo--------- '-------'
Chanteau, S., Glaziou, P., Luquiaud, R, Plichart, C., Moulia-Pelat and Cartel,
fesDas, P.K., Srividya, A., Pani, S.P., Ramaiah, K.D., Vanamail, P. and Dhanda,
(1994a). Og4C3 circulating antigen, anti-Brugfa malayi IgG and IgG4 titrdf^J
’
V. (1994). Cumulative exposure and its relationship with chronic filarial
in Wuchereria bancrofti infected patients, according to their parasitological^^
disease in bancroftian filariasis. Southeast Asian Journal of Tropical
status. Tropical Medicine Parasitology, 45: 255-257
Medicine and Public Health, 25: 516-521.
Chanteau, S., Moulia-Pelat., J. P., Glaziou, P., Nguyen, N.L., Lugquiaud, P., PlicharVtO ® Dreyer•,’ G., Noroes, J. and Addis, D. (1997). The silent burden of sexual disability
C., Martin, P.M.V. and Cartel, J.L. (1994). Og4C3 circulating antigen:
associated with lymphatic filariasis. Acta Tropica, 63: 57-60.
marker of infection and adult worm burden in Wuchereria bancrofti filanasisJjfOj O Dreyer, G., Ottesen, E.A., Galdino, E., Andrade, L., Rocha, A., Medeiros, Z., Moura,
Journal ofInfectious Disease, 170: 247-250.
'
'
I., Cassimiro, M. I.,Beliz,M.F. andCountinho, A. (1992) Renal abnormalities
Cruickshank, J. A., Cunningham, J. et al. (1923). Studies in filariasis. No. 1. A filarial
in microfilaraemic patients with bancroftian filariasis. American Journal of
survey with a statistical enquiry into the relationship between filariasis
Tropical Medicine and Hygiene, 46:745-751.
and elephantiasis. Indian Journal of Medical Research 11:
Dunyo, SJC, Ahrlu, C.K. and Simonsen, RE. (1997). Scarification as a risk factor for
79-91’
.i||
rapid progression of filarial elephantiasis. Transactions of Royal Society
Cruickshank, J.A. and Wright, R.E. (1914). Filariasis in Cochin. Indian Journal of
of Tropical Medicine and Hygiene, 91: 446.
Medical Research, 1:741-785.
"
•
Evans, D.B., Gelband, H. and Vlassoff, C. (1993). Social and economic factors and
Das. P.K. (1998). Changing environment and its impact on filariasis in®J
* 'the
the control of lymphatic filariasis: A review. Acta Tropica.
Tropica, 53: 1-26.
India. In : Proceedi.igs of the National Seminar on Environment and Health, *1^
7-9 July, 1998. New Delhi, pp. 1-43.
REFERENCES
'
Addiss, D.G., Eberhard., M.L and Lammie, P.J.( 1994): "Filarial" adenolymphangitis^|
without filarial infection. The Lancet, 343 : 597.
Appavoo, N.C., Pani, S.P. and Das, P.K. (1999). The science and art of lymphati^W
K
ife.
ft
i-
Epidemiology and Co
lel'minthology in India
""'B!SSi=3S£==i
I oj riiuruiMs
Bundy, D.A.P. and Grenfell, B.T. (1996). Re-assessing the
global prevalence and distribution of lymphatic filariasis. Parasitology.
122:409-428.
RnFCP (1984). National Filaria Control Programme: Operational manual (eds. R.S.
Sharma, H. Biswas and N.B.L. Saxena), NMEP, New Delhi, 152 pp.
Si-NFCP (1995). National Filaria Control Programme in India: Operational manual, eds.
||feR.S. Sharma, H. Biswas, and N.B.L. Saxena, NMEP, New Delhi, 127pp.
RNICD/NMEP (1996). Revised strategy for the control of lymphatic filariasis in India,
45pp.
’
GyaPOnThJe°-’ GyaPT M- Evans’ D-B- Aikins> M-K- and Adjei S (1996a) 1
The economic burden of lymphatic filariasis in northern Ghana, li^f |||ottesen, E.A., Duke, B.O.L., Karam, M. and Behbehani, K. (1997). Strategies and
tools for the control/elimination of lymphatic filariasis, WHO Bulletin.
lopical Medicine and Parasitology, 90: 39-48.
ffifc
75:491-503.
GyaP°n papw MoorfadU’ K-
R'H-(1998)' Evaluati°" °f
filter!
Pani, S.P., Balakrishnan, N., Srividya, A., Bundy, D.A.P. and Grenfell, B.T. (1991a).
Clinical epidemiology of bancroftian filariasis: Effect of age and gender.
Transactions of Royal Society of Tropical Medicine and Hygiene, 85:
260-264.
m
J Pani, S.P. and Dhanda, V. (1994). Natural history and dynamics of progression of
clinical manifestations of filariasis. In : Proceedings of the CSIR Golden
in Trivandrum.
Jubilee symposium on Tropical Disease. Molecular biology and control
strategies, CDRI, Lucknow (eds. S. Kumar, A.K. Sen, G.P. Dutta and R.N.
Sharma), New Delhi, Publications and Information Directorate, CSIR, pp.
1-8.
TTa^core Cochin state II, shemlla^^dian Journal^Malario^, j O- Pami, S.P., Hoti, S.L., Elango, A., Yuvaraj, J., Lail, R. and Ramaiah, K.D. (2000).
Evaluation of the ICT whole blood antigen card test to detet Infection due
to noctumally periodic Wuchereria bancrofti in-south India. Tropical
KOrke’ W„!/!927/a)’ °bS,e7ati0ns °n filariasis in some areas in British India Part
Medicine and International Health., 5: 359-363.
. Indian Journal ofMedical Research, 14: 717-732.
Pani,
S.P.,
Krishnamoorthy, K., Rao, A.S. and Prathiba, J. (1990). Clinical
•|S1 Bsc
.
.
n-1
• 1 • . r. _ * ■ _ r.. .J:T-------- 1
Korke, V.T. (1927b). Prevalence of filariasis in some areas
manifestations
in malayan
filarial
infection. Indian Journal oj/
in British India. -O
ransactions ofFar East Association of Tropical Medicine. 3: 305-310
Medical Research, 91: 200-207.
orke, V T (1928). Observations on filariasis in some
Pani, S.P. and Lail, R. (1998). Clinical features, pathogenesis and management of
areas in British India. Part
II. Indian Journal of Medical Research, 15: 187-198.
lymphatic filariasis, ICMR Bulletin, 28: 41-51..
K°rke' India Part HI °b.SerVations/0" filanasis in some areas in British
Pani, S.P. and Srividya, A. (1995). Clinical manifestations of bancroftian filariasis
ia.. Partill. Indian Journal ofMedical Research, 16: 695-715
with special reference to lymphoedema grading. Indian Journal ofMedical
TntecSm SU:Chen™d Tai’ TZe'yIng (1964)' The role of streptococcal I
Research., 102: 114-118.
1
ilanasis. Chinese Medical Journal, 83: 17-22.
Pani, S.P., Srividya, A. and Rajagopalan, P.K. (1991b). Clinical manifestations ol
G AstinW of V B ’]L'a8as’L’’Aballa. L- and Postrado, L. (1998). Filariasisbancroftian filariasis in relation of microfilaraemia and diethylcarbamazine
therapy. National Medical Journal of India, 4: 9-14.
Sochi and^
•8e’ attltUdeS
practices °fthe People of Sorsogon |
bancroftiaE 10nrmeth°d
detectin8 °g4C3 circulating antigen in I!
Sr
'y'nB,r'Z^,l'S:)mlS““‘n **»«—. -*—
xstsr—*■—1 ft’
ft
ut 'll R-
8
1 w-
B
E
1IJi
4
I
li?
css aECJ.*-
448
Helminthology in India
i
ps Epidemiology and Control of Filariasis
449
Pam, S.P. and Yuvaraj, J. (1996). Epidemiology Epidemiology of filarial lymphoedema. Proceed^
jerence of Lymphology Society of Indin
.... J W; Ramaiah, K.D., Vijaya Kumar, K.N., Ramu, K., Pani, S.P. and Das, P.K. (1997). Functional
g
impairment caused by lymphatic filariasis in rural areas of South India.
| •
Tropical Medicine and International Health, 2: 832-838.
iy,
With banerofliM filariasis. Z?7L7'llS 7, lymhhoedema lo-paiienis 1 f Ramaiah, K.D., Ramu, K., Guyatt, Helen, Vijaya Kumar, K.N. and Pani, S.P. (1998).
Direct and indirect costs of the acute form of lymphatic filariasis to
of Royal ^Society
of Tropical
Tropical W
Medicine and Hygiene, 89: 72-74
ociety °f
!■W ;
households in rural areas of Tamil Nadu, South India. Tropical Medicine
Pam, S.P., Yuvaraj, J., Vijayalakshmi, G.
and International Health, 3: 108-115.
Vector Control Research Centre, :
Cllniclans- p°ndicherry, 1 K ■' Ramaiah, K.D., Guyat, Helen, Ramu, K., Vanamail, P, Pani, S.P. and Das, P.K. (1999).
Treatment cost and loss of work time to individuals with chronic filariasis
Pa
ni, S.P., Srividya, A, Krishn;
Pani,
Krishnamoorthy K Das P K
nr, u ,
1^’
in rural communities in South India. Tropical Medicine and International
Assessment Procedures tRAp\f i
uK dDhanda’V-(1997a)-Rapid I B?
Heplth, 4:19-25.
aa
3i
'’
r1 Subra17n>'ainReddy. G. (1997). I fc
Plasier, A.P., Subramanian S Das pr c
® B Ramaiah, K.D., Vanamail, P., Yuvaraj, J., Pam, S.P. and Das, P.K. (2000a). A community
level trial ofDEC and Ivermection co-administration: Effect of three rounds
Ploeg, C.P.B., Ha’be^nma’jDF andean O
Furtado’ A-F'’vander 3 g■;
annual mass treatment on Wuchereria bancrofti microfilaraemia and
^^^RASISM simulationprOgr^rma^^”i9,Ortn}arss®11’ G R (1998). The 1 fe. ■
S
transmission in India. Tropical Medicine and International Health
Ip
(submitted).
...........
:
Rajagopalan, P.K., Kazmi, S.J. and Mani TR (1977)
t
Ramu, K., Ramaiah, K.D., Guyatt, H. and Evans, D. (1996). Impact of lymphatic
ofWrcAereriaZrancrq/rrandecologvofthe ’
aSpects of^ansmission I
g .
filariasis on the producitivity of male weavers in a South Indian village.
S
Transactions of Royal Society of Tropical Medicine and Hygiene, 90:
J
669-670.
I Roy, S.K. and Bose, S.C. (1922). Filariasis at Puri. Indian Medical Gazette, 57:281286.
t
Kamaiah, K.D., Das, P.K. andDhanda V (1994) mm-™,f
ji
transmission of bancroftian filariais ba^d™ nofpcnnisslbleRvelsof | |
p
J
ntral villages in Tamil Nad Tim
mfcction in
1
amaiah,K.D Das, P.K., Vanamail, P. and Dhanda V (1996a) Ranid
I
• rural lymphatic filariasis situation throuah kev'd aSSessment°f 3
Biomedicine, 13: 13-16.
Sy informants. Tropical
Sabesan, S.» Krishnamoorthy, K.» Panicker, K.N. and Vanamail, P. (1991a). The
dynamics of microfilaraemia and its relation with development of disease in
periodic Brugia malayi infection in South India. Epidemiology and
Infection, 107:453-463.
Sabesan, S., Pradeep Kumar, N., Krishnamoorthy, K. and Panicker, K.N. (1991b).
Seasonal abundance and biting behaviour of Mansonia annulifera,
Mansonia uniformis and Mansonia Indiana and their relative role in the
; transmission of malayan filariasis in Shertallai (Kerala State). Indian Journal
ofMedical Research, 93 (A): 253-258.
Sabesan, S., Palaniyandi, M., Das, P.K. and Michael, E. (2000). Mapping of lymphatic
filariasis in India. Annals of Tropical Medicine and Parasitology, 94: 591Sasa, M. (1976,). Human Filariasis: A global survey of epidemiology and control.
University of Tokyo Press : 336-371.
Sharma., R.S., Biswas. H. and Saxena, N.B.L. (1995) (eds.). National Filaria Control
Programme, India, 1995: Operational Manual, New Delhi, Directorate of
National Malaria Eradication Programme^ 127pp.
430
A
Hehmnlhology in /nfa
Shenoy,R.K.,Sandhya,K s
Epidemiology and Control of Filariasis
TK
1
&L
A V (1995). A preliminary S; ,v
-........
J0Urn
°l
of Tropical Medicine and Public Health, 26 ■ Vo 1 -305
nV‘
1
t^loXntt^apid a3"111’K” HOd’ S L ’Pani S P- ‘
S?5:S;asis’endemic
sss
“'■"dec JftS "J SS'Xr’T M“ *-*—« K
WH0 (1 dSLefw'S
f°;r hOpe' Division Control of tropical
3
D FIL/97.4 ;ror/r/ Health Organization 1-20
Subrann.nian Reddy, G., Vengateswariou, N Das PK v
1 WH°
The application
Sasikala and Pani, S.P. (2000) Sinai.. J
1
’ Vanaraa11. P-. Vijayan, &
"
K.ic
Ivermectin in the clearance of Wuch ' A
Carbamazine PEC) w
■
s„,„
HO ('^^^'ZckgroM*1 P78"'™e
lymphllic (ibrasis.
Paiasitology, H6: 243-255.
nder neural conditions.
Suresli, S.» Kuniaraswanii, V. Suresh I v ■ k
Arunachalam, R. and Gopakajan, R (1997) Ukn GaneSan’ S‘’ Vadive’u. Y,
sub-chntcal filariasis. J0urTO/o/w^.o?^aS0“0graphic diagnosis of i |
f »««. WE.
S Wi||
, W|iie c Kumrajwm. y McNcU
i In h.',n.n 42.1 d2'd 2" 'I”3’' LY"”h“iC •b"«'"»»l«
‘ta«™z
................ ..,
J; ZJ
mlj,.,!
’ I>'mPl»"S'<»tin»S"pliy. J,dm, af
‘iwnquefasciatus and its rdation^f?'"^011^13'.index of Culex |
Pondicherry, indmn don
“^^"aria penodicity “ j |
Vanaman, P„ Ramaiah> K D Par.
93: 379-383.
j |
D.A.P. (1996). Estimation o/the fecmtditic'hf’
B T' 3nd Bundy I
I
i ti
fe
I
E
j
VCR^“,“'ZS“" 42™ 4“°f2i
ajalofa*™™,
" feJStol rap( 'onsc to
g-
ft
l.32z No.5 & 6
jr-
Moy-June 2002
—
■
PROSPECTS OF ELIMINATION OF LYMPHATIC FILARIASIS IN INDIA
Lymphatic filariasis is a vector-bome parasitic disease
caused by three lymphatic dwelling nematode parasites
viz., Wuchereria bancrofti, Brugia malayi and Brugia timori.
The disease manifests as progressive lymphoedema
leading to disfiguring elephantiasis in both genders,
hydrocele — the predominant manifestation in males or
loss of respiratory function due to tropical pulmonary
eosinophilia (TPE)1-2. Filariasis patients sufferfrom episodic
^^^lolymphangitis (ADL), which causes acute suffering
and incapacitation 3 4. The other health problems due to
filariasis include renal disease, arthritis, endomyocardial
fibrosis, etc.2-5-6. Filariasis is considered a hidden disease
as lymphoedema is the only visible manifestation and
hydrocele, the predominant manifestation in males as
also other presentations are not obvious. Filariasis is a
disease of the poor and is a cause and effect of poverty.
The majority of the people at risk of filariasis live in rural
areas. Poor sanitary conditions associated with low socio
economic status of the community make the environment
conducive for proliferate breeding of vector mosquitoes
facilitating transmission. While year round transmission
of filariasis occurs in urban and semi-urban areas,
transmission is seasonal in rural areas. The mosquito
vectors involved in filariasis transmission include different
species of Culex, Aedes, Mansonia and Anopheles in
1
J
the world7 In India, IV. bancrofti is transmitted by the
ubiquitous mosquito, Culex quinquifas-ciatus8; and
B.malayi is transmitted by Mansoma mosquitoes
(M.annulifera, M.uniformis, and M.indiana)9. Aedes
(Finlaya) niveus is the vector of subperiodic W.bancrofti
in Nicobar Islands10 Filariasis has been identified as one
of the six diseases (among over hundred considered), which
could be targeted for elimination /’ eradication based on
considerations that human beings are the only reservoir
of infection, diethylcarbamazine (DEC) is an effective drug
acting on the parasite (without report of resistance in past
5 decades) and mass annual single dose community drug
administration with selective vector control could result in
the effective elimination of infection by interruption of
transmission11. This led to the articulation of the World Health
Assembly Resolution for the global elimination of lymphatic
filariasis’2. Based on this, the WHO has called for targeting
filariasis elimination by 2020. Sincelndiaisthelargestfiiariasis
endemic country in the world, the prospects of global
elimination of filariasis will very much depend on its success
in the Indian sub-continent. This write-up describes the
filariasis situation in India, the progress in research in filariasis
which has led to the optimism for its elimination; and the
major opportunities and challenges ahead in achieving the
goal of elimination of filariasis in India.
■7
Division of Pubiication & Information, ICMR, New Delhi - 11002!
V \
\
42
ICMR Bulletin
The terms elimination, eradication and control need
to be understood in proper perspective. The eradication
and reaching a
situation where eradication is possible6.
Control
Bringing down the transmission and burden of
filariasis to a level, where its public health impacts
are at a manageable level
Leads to
Elimination
Reducing the transmission of filariasis to a very low
level (by reducing the prevalence of infection and/or
vector density), so that the transmission will cease to
occur in course of time provided there is no
rein trod uction of transmission
Leads to
Eradication
Complete disappearance of infection/disease
Current Filariasis Situation
According to the estimates made in 1995, globally
there are nearly 1,100 million people living in areas
endemic for lymphatic filariasis and exposed to the risk
of infection; and there are 120 million cases of filariasis,
either having patent microfilaraemia or chronic filarial
disease13. W. bancrofti accounts for approximately 90%
of all filariasis cases in the world, followed by B. malayi
and B. timori. B. timori is restricted to few islands in
Indonesia. India contributes about 40% of the total global
burden of filariasis and accounts for about 50% of the
people at risk of infecrion. Recent estimates have shown
that out of the 25 states/union territories in India (before
bifurcation of states of Bihar, Madhya Pradesh and Uttar
Pradesh), for which surveys were carried out, 22 were
found endemic for filariasis, and nine states (Andhra
Pradesh, Bihar, Gujarat, Kerala, Maharastra, Orissa, Tamil
Nadu, Utter Pradesh and West Bengal) contributed to
about 95% of total burden of filariasis. A total of 289 districts
in India were surveyed for filariasis until 1995; out of which
257 were found to be endemic. In India a total of 553
million people are at risk of infection and
there are
approximately 21 million people with symptomatic filariasis
predominant species accounting for about 98% of the
national burden, widely distributed in 17 states and 6
union territories. B. malayi is restricted in distribution,
with decreasing trend. An overview of the traditional
endemic foci shows concentration of.infection mainly
around river basins, and eastern and western coastal
parts of India (Map)11?.
Filariasis Control Under the National Programme
,M India
A National Filaria Control Programme (NFCf/ was
launched in India in 1955, based on the pilot scale trials
carried out by the Indian Council of Medical Research
(ICMR) in Orissa. The Programme has been reviewed
from time to time by the ICMR and the strategy modified
on the basis of recommendations8. Currently, the NFCP
covers a population of about 40 million (7% of the
population at risk), restricted to urban areas only. The
current strategy includes selective chemotherapy (DEC
6mg/kg/day for 12 days) by detection of parasite carriers
by night blood survey and larval control of vector
mosquitoes. Although this strategy has resulted in the
reduction in filariasis prevalence in areas where it has
been implemented, it is inadequate for sustained control
leading to elimination. The major constraints of the NFCP
are that it does not cover the vast majority of population
at risk residing in rural areas and that the strategy
demands detection of parasite carriers by night °God '
surveys, which is less sensitive, costly, time consuming
and poorly accepted by the community15. It is thus
pertinent that any proposed elimination strategy should
be able to get over these constraints.
<
Research Findings and Challenges for the Development of
Filariasis Elimination Strategy
Socio-economic Burden of Filariasis
Filariasis causes long-term suffering and morbidity
as well as high social and economic burden to individuals,
communities-and the nation16-21. Since filariasis is not a
direct cause of mortality, it does not get due priority by
the planners and policy makers. It has been estimated
that the annual economic loss due to filariasis is close
to 1 billion US $(approximately Rs. 5000 crores) for the
country 20. Estimation of the socio-economic burden of ’
the disease is important not only to understand the burden
i
I
I
May-June 2002
FILARIASIS DISTRIBUTION IN INDIA - 1995
43
and the community*(consumers) to
accept the programme-and create a
felt need for compliance.
Filarial Disease and Pathogenesis
i
Morbidity management/control is
an important component of filariasis
elimination. It is essential to
understand the disease spectrum
and pathogenesis in order to develop '
appropriate morbidity management j
strategies. Fiiariasis results in hidden
infection; as most asymptomatic
carriers have sub-clinical lymphatic
damage22 and hydrocele, the
predominant manifestation of
bancroftian filariasis23 is also not
revealed normally, unless it results
in gross scrotal enlargement.
Children show high prevalence of
filariasis antigeneamia8,24 making
them
important target for
intervention.
Recurrent attacks of episodic
adenolymphangitis result in pro
Endemicity (Rate in %)
;v
| '
| No data
• J
gression of chronic lymphoedema
LTTj Low endemic ( < 1)
from early reversible to late
Moderately endemic (1-10)
elephantiasis1,23,25. Thus prevention
Highly endemic ( > 1 0)
LsjtJ Non endemic
of acute disease will not only bring
%
down the suffering of patients, but
also check progression of lympho
600 Kilometers
200
0
200
400
edema to disfiguring stages.
Bacterial infections, particularly due
to beta haemolytic streptococci are
important in the causation of acute episodic ADL
on individual patients and their families,- but also for
attacks26. In filarial lymphoedema, there is progressive
providing information crucial for developing advocacy
persistent inflammation (chronic dermatitis) as a result
material for mobilization of resources and commitment
of invasion of bacteria in the skin. Parasite per se has
for its control. As the estimates made so far are based
little role if any, in the skin changes27,28. These
on limited surveys, it is necessary to workout the national
observations
are essential to formulate strategy for
burden of filariasis using appropriate indicators (like
morbidity prevention, development of principles of
Disability Adjusted Life Years - DALY, Quality Adjusted
Life Years - QUALY and others) Vn order to compare the
disease marragement, empower the diseased persons
for self help and develop modalities for networking
burden across the diseases to facilitate the planners to
healthcare facilities by strengthening the existing filariasis
prioritize diseases for control. These findings will be useful
clinics through training (human resource development)
in setting up priority for filariasis against other diseases,
and modernization of treatment facilities for individual
preparation of advocacy materials for resource
patient care leading to enhanced community acceptance
mobilization, generation of political will, sensitization of
of
the elimination programme.
policy makers, planners, programme managers, media
%
ICMR Bulletin
Diagnostics
Diagnosis of filariasis is important for programme
managers for situation analyses, for monitoring and
evaluation of intervention measures; and for physicians
in case detection and treatment/management. The
problems related with the method of night blood smear
examination, used under the current NFCP have already
been highlighted. A need has been felt for the
development of rapid, specific, sensitive and reproducible
diagnostic methods for field application for the detection
of infection (microfilaraemia or adult parasites) both in
humans and in vector mosquitoes. A rapid day blood
immuno-chromatographic card test (ICT) for detection
of infection, developed elsewhere29 has been found
highly specific and more sensitive in India also in
comparison with the night blood smear examination-’0.
Although it is costlier, it has the advantage of on the
spot day blood detection of parasite carriers in large
numbers (compared to the night blood smear
examination). By appropriate sampling design, if the
sample size could be minimized, it can be useful for the
detection of infection in individuals or for delimitation of
areas or for evaluation of interventions. The antigeneamia
detection has been recommended for certification of
elimination by using a lot quality assurance sampling
(LQAS) design31'32. The other newer diagnostics include
Og4C3 antigen assay in human whole blood and sera30
and DNA probes for infection detection in vector/man33-36.
Currently the vectors are collected and dissected
manually for entomological parameters. Thus rapid and
sensitive methods are necessary for overcoming these
difficulties. A mosquito collection trap has been
developed37 to overcome the problem of manual
collection. The challenge ahead is in proper
operationalization of these diagnostic and collection
techniques in large-scale control programmes.
The development of new diagnostic tools are useful
for the rapid detection of endemic areas and mapping,
monitoring and evaluation of interventions, sensitive tests
such as ICT kits are useful for rapid verification of
attainment of end point of elimination through costeffective sampling designs. However, there are challenges
to be addressed which include identification of parasite
stage specific diagnostic tools, methods to sample vector
population for xenodiagnosis and simple and costeffective methods of rapid detection of endemic areas.
Decision Support Tools
iNv
Tools for decision support are crucial fo. the
programme managers. Considerable efforts have been
made in the development of these in the past decade.
Rapid assessment procedures (RARs) to measure the
prevalence of filarial disease/infection in an area have
been developed and found useful for delimiting filariasis
endemic areas38. Physical examination of adult males
by trained health workers is most useful to assess the
hydrocele prevalence. Methods for rapid epidemiological
mapping of filariasis (REMFIL) for rapid delimitation and
stratification of filariasis endemic areas using grid sampling
procedure have become available using fixed grid
sampling of 25 kms3£M0. However, it is necessary to
optimize the size of the grid or to develop alternate
sampling designs in order to get the real situation of the
distribution of filariasis. The filariasis distribution map of
India developed on CIS platform using historical database
(NFCP and other published data) may be
in
prioritizing areas for intervention14.
Mathematical models have been developed to predict
the epidemiological trends of infection and disease and
the effect of interventions and these models are based
on the following .conceptual framework:
Microfiiaraemic
Infection from
the vector
(input)
Process of parasite
dynamics in human.
(A black box - since there
is little or no direct evidence)
Loss of infection
Gain of infection
Disease
development
and progress
Amicrofilarae mic
J
[
I
May-June 2002"
Mathematical models are important for diseases
like filariasis where several aspects of dynamics -of
infection, transmission and disease make the
predictions of intervention measures difficult. The
models provide a tool to solve several of these
questions for which direct measurements cannot be
done. Parameter estimations viz.estimation of fecundic
life span of parasite41, understanding the progression
of infection and disease through stages, and
understanding the distribution of infection and disease
at household and community level (clustering
phenomenon) are important outcome of development
of mathematical models. Models are also useful for
prediction of outcome of different intervention measures
m different endemic/epidemiological situation.
45
Transmission control
Mass drug administration
Mass annual single dose treatment with either a single
drug (DEC or ivermectin)
or in
ivermectin) or
in combination
combination with
with
albendazole is recommended
for
filariasis
control/
recommended for filariasis control/
elimination. Use of DEC fortified salt is another intervention
recommended for filariasis control. These drugs reduce
parasite load in the community thereby reducing the
number of parasites available for the vector population. |
Consequently, transmission is reduced and hence these ;
measures are considered as transmission control tools. '
Single dose of DEC, ivermectin or albendazole, and coadmimstration of DEC either with -ivermectin or
albendazole in microfilaria carriers has been found to
be safe and effective in reducing microfilaria intensity
at the end of one year in hospital based studies45-19
Two mathematical models namely EPIFIL and
LYMFASIM developed by the Vector Control Research
Centre (VCRC), Pondicherry in collaborationTith oTord
University, UK and Erasmus University Rotterdam
respectively are be.ng validated and refined undeTthe
™ttOlerat)ility and efficacy of dru9s and their
admimstraticn were not signif.cantly different between
I ‘
'ndependent of a9^ However, the
field conditions. These models can be used as a
thTn tT
0 SC°re
albendazoie was much less
iP
, 6, soT U9S' TheSe reSUltS and Other comrnurW
- ” •
~
suggest the utility of mass single annual
SUaaeSt
- -------and semiannual dose of DEC in the transmission control.
to monitor and evaluate various intervention options42The evaluation of the impact of mass drug administration
44 as a feedback to the programme. A management
(MDA) with DEC or ivermectin or both on transmission
information system (MIS), which is essential for the
of bancroftian filariasis is being carried out by the VCRC
programme managers at different levels is also being
i he results show that DEC is as effective as ivermectin
developed by the VCRC which is expected to be an
m drastically reducing the levels of transmission after
important decision support tool for situation analysis
six successive rounds of mass administration. Four rounds
and for taking corrective measures, so that the
of co-administration of DEC with ivermectin resulted in
-tervention reaches the target. Establishment of an
reduction in the levels of transmission' comparable with
idemiological information system will be useful for
the
six rounds of individual drugs, indicating that the
rapid dissemination of data and information on key
two
drugs together are better compared to any single
indices. This web based information system and
drug.
Complete interruption of transmission was not
database can be used as a rapid feedback by
achieved in any of the trials, indicating that six rounds
programme managers and also for planning/replanning
of single drug or four rounds of co-administration
intervention measures as well as for monitoring/taking
of both the drugs are not adequate for achieving
mid course corrective measures. The VCRC has
elimination52-53. These also suggest that dependence on
established a website www.pon.nic.in/fil-free for this
any single method of intervention is not realistic to achieve
purpose.
the desired results. Interruption in the transmission of
filariasis was also possible with DEC medicated salt54.’55,
Intervention. Tools and Strategies
, although there3 are many operational problems relating
to the distribution mechanisms and community
Forfilanasis control/elimination, intervention tools are
acceptance of DEC medicated salt in different parts of
directed either towards transmission control (by targeting
India. To enhance the effect of mass annual single dose
parasite and/or vector) or morbidity management for
treatment, it is essential to identify methods to enhance
preventing disease progression and reduce morbidity.
coverage of drug distribution and community compliance.
decision making tool to select intervention(s) and plan
implementation strategies. These can also be used
■
46
ICMR Bulletin
Table I. Comparison of effibacy and tolerability of single dose DEC, ivermectin or albendazole alone or ii
combination on prevalence and intensity of mf of W.bancrofti carriers in Pondicherry.
Drug
Dose
(Single)
No. of
carriers
Adverse reactions
Incidence (%)
Efficacy (% reduction at
360 days)
Mean score
Prevalence
Intensity
DEC47
6mg
29
65.5
0.5
8.3
83.7
DEC*
12mg
20
85.0
1.8
52.6
99.5
Ivermectin47
400/jg
30
93.3
1.5
34.8
97.0
Albendazole47
400mg
19
42.1
1.8
26.3
Sec'
DEC + Ivermectin*
6mg + 200.ug
20
90.0
5.6
60.0-
99.7
DEC + Ivermectin*
6mg+400 pg
20
100.0
6.7
94.6
99.9
DEC+Albendazole48
6mg+400 mg
18
61.1
6.6
27.8
95.4
Superscript nos. refer to the sl no. in the reference list
*VCRC, Unpublished data;
Vector control
Vector control can bring in sustained effect and hence
it can be an integral part of comprehensive filariasis control
programme. In situations where transmission interruption
is not possible through mass chemotherapy alone, vector
control becomes very important. It can be made costeffective by spatial and temporal targeting (limited to
specific areas and season)27 56. Long-term operational
effectiveness of integrated vector management (IVM)
strategy for the transmission control of bancroftian filariasis
was demonstrated in Pondicherry67-59. Bacillus sphaericus,
a bio-control agent in bancroftian filariasis control has
shown to be effective in reducing vector density and
transmission60. The utility of vector control in combination
with mass annual treatment needs to be explored. Vector
control can be aimed to bring down the vector density
below the critical level27 and this can be achieved through
selective vector control.
Morbidity prevention/management/control
As many clinically asymptomatic infected individuals
have lymphatic abnormalities, they may be at risk of
developing the disease. The DEC treatment in these cases
is expected to clearthe infection and make them infection
free, so that it is expected that the pathology will not
progress to overt disease . However, scientific evidence
needs to be generated in support of this, and currently
Dose: DEC mg/kg, Ivermectin pg/kg, Albendazole m<
this remains more empirical. As already mentioned, th<
prevention of repeated episodic attacks of ADL will b<
important not only to prevent sufferings of patients (thu
reduce the burden of disease) but also for the preventioi
of progression of existing chronic disease. Thoug!
available data suggest that regular foot hygiene prevent
incidence of episodic ADL attacks5 46, there is a need tZgenerate comparative data on foot care versus nature
trend of ADL incidence. Co-administration of da^~\ wit!
DEC results in significant reduction of tViarie
lymphoedema61. Surgical management of lymphoedem.
is indicated in certain specific cases, and prevention c
acute attacks after surgery is important for sustainin<
the benefit of surgery.
Operational Issues
Drug delivery mechanisms are important for mas
drug administration. Drug delivery by community (calle
community directed treatment: COMDT) was compare
with the drug delivery through primary health car
approach (using the existing health infrastructure) . Th
current experience in rural India suggests that th /
community acceptance of drug delivery through th.
existing governmental health infrastructure is highe
compared to that by other members of the community2
A novel drug delivery approach is being evaluate
in Pondicherry urban area. The partners in this approac
Z7
,44-----
May-June 2002
47
include different local governmental departments (social
Advocacy is also important for social mobilization of the'
welfare, health and family welfare, state unit of NFCH
community and other irnportant partners (such as
department of information and publicity), central,
politicians, community leaders, medical practitioners and
government departments (All India Radio, DoordarshanJ*,’
■media). Research on this aspect (including development
students (NSS) and other local volunteers (mahila
of IEC: information, education and communication
sangam, etc.), and pharmaceutical company (M/s.
Burroughs Wellcome has supplied DEC free for this
material) has already been initiated.
programme). The VCRC is coordinating the efforts, apart
Pilot Scale Intervention Programmes towards
Elimination of Filariasis in India
from undertaking the programme evaluation. This is an
example of site-specific strategy developed locally62.
Two important large-scale pilot intervention projects
Developing a distribution mechanism for DEC
medicated salt is also a challenging task. While in Karaikal
have been launched In India, the results of which will
decide the future design of the filariasis
elimination
urban area, the distribution was primarily through
programme. The first is the launching of National Filariasis
organized efforts of the health department in’ close
Day (NFD) by the Directorate of National Anti Malaria
collaboration with salt providers (merchants and vendors)
Programme (for administrative reasons, NFCP forms an
and with the able administrative support54, in Kanyakumari
integral part of the NAMR as all vector-borne diseases
district, the state government is implementing the same
are addressed under a single Directorate) in 1996. The
through the existing public distribution system (PDS).
second is a multicentric study on operational feasibility
However, several operational issues relating to
and impact of co-administration of albendazole and DEC
-manufacture, distribution and community acceptance
in controlling lymphatic filariasis launched by the ICMR.
of the DEC medicated salt need to be addressed.
There is an urgent need for the preparation of
advocacy material for intervention programmes. Findings
The NFD experience
Even before India became a signatory to the WHA
of advocacy research will be useful for sensitization of
resolution on filariasis elimination, the NAMP launched
policy makers and planners to allocate required funds,
a pilot project of mass drug administration covering
programme managers to develop sound intervention
approximately 40 million population in 13 highly endemic
designs, implementation process and mobilize partners.
districts in 7 states in India (Table II). The drug distribution
Table II. Epidemiological situation of filariasis in 13 districts selected for mass annual single dose of DEC
as a pilot project under NFD.
late
Andhra Pradesh
District
Total
population
(Milliion)
Year
mf rate
(%)
Diseae
rate(%)
Average
endemicity
(%)______
East Godavari
Srikakulam
4.54
2.32
1983
1956
16.70
13.90
8:90
4.10
25.60
18.00
Bihar
Darbhanga
Siwan
2.17
2.51
1958
1982
14.50
2.29
16.30
4.87
30.80
7.16
Kerala
Alappuzha
Kozhikode
2.62
2.76
1975
1960
13.40
9.28
8.20
5.66
21.60
14.94
Orissa
Puri
Khurda
1.29
1.63
1993
1958
10.60
4..51
NA
5.00 ‘
10.60
8.96 ,
Tamil Nadu
South Arcot #
North’ Arcot $
2.15
1.32
1958
1958
12.90
9.63
7.60
6.20
20.50
15.60
Uttar Pradesh
Gorakhpur
Varanasi
3.06
4.86
1962
1958
6.65
10.80
11.84
10.10
18.49
21.00
West Bengal
Puruliya
2.22
NA
NA
NA
NA
NA: Not Available;
# Currently named as Cuddaiore;
$ Currently named as Thiruvannamalai
ii
48
ICMR Bulletin
was to be carried out by observance of National Filaria
Day. The DEC tablets in.the dose of 6mg/kg body weight
were to be distributed according to age (Table III) either
by door to door visit or through drug delivery booths on
a single day. The entire population of the district excluding
pregnant women and infants formed the target population
for the drug distribution. Vector control measures and
selective chemotherapy were to be continued in the urban
areas where the NFCP units were located within these
13 districts. The NAME was to provide the drugs and
money for the IEC component. The coverage of population
was to be recorded in the family registers. The states
had to prepare macro- and micro-plans, train the health
personnel involved, provide additional resources,
implement the programme and send report to the NAME
The local programme implementation, and monitoring
and evaluation are to be carried out jointly oy the research
institutes under the ICMR or the National Institute of
Commicabie Diseases (NICD), Delhi and the state
programme managers.
Table 111. Age groups, DEC tablet strength and number of
tablets adopted for mass drug distribution in Tamil
Nadu (upto 2001)
Age
(years)
DEC
(dose in mg)
No. of tablets
(50 mg)
1
Nil
Nil
1-2
50
1
3-4
100
2
5-8
150
3
9-11
200
4
12-14
250
5
>14
300
6
Pregnant women excluded
The programme was launched in August 1996, in
only South Arcot (Cuddalore) district of Tamil Nadu. In
othei districts the programme was initiated during
1997-98. The reported coverage of drug distribution in
these districts was found to range from 43.8 to 95.0%
while consumption was between 12 to 89% in different
sites03. A mid-term programme assessment was carried
out by the NAME in January 2000. Inadequate coverage
in drug distribution and consumption were found to be
the major limitations of the pilot project. It was found
that supervised consumption was not adhered to. Single
day distribution was not found practical. Although the
first day coverage was higher, at least 4-5 additional day
were required for mopping up. The constraints include
inadequate manpower, lack of incentives (particularly i
comparison to other community programmes such a
pulse polio vaccination), poor community awareness an
acceptance, inadequate funds for IEC, mobility
supervision and training. The financial commitment an
support to the programme was not uniform in differer
states and consequently affected the resource allocatio
and priority settings. The review committee recommende
for the continuation of the pilot project for the five round
in each of these 13 districts and to ensure supervise
consumption. The committee further reconQ’ jnde
proper monitoring, supervision, timely reviev
development of site-specific IEC and social mobiiizatio
methods and mechanisms, pre-and post-assessmer
surveys, provision for adequate funds, orientation (
medical and paramedical personnel, and dthe
distributors. Reducing the number of tablets fc
consumption by increasing the strength could b
important for overcoming the constraints.
Health being a state subject, the Tamil Nadu Eubl'
Health Department launched the NFD programme o
its own in 10 additional endemic revenue districts (othc
than South and North Arcot districts already covered t
NAME) of the state covering 15 health unit districts (HUD;
from 1997 (Table IV). Mass annual drug administratic
using DEC alone was carried out between 1997 an
2000 in all the 15 HUDs. In 2001, while albendazole (4C
mg for all the individuals equal to or above 2 CSrs <
age) was distributed along with DEC in 9 of these HUD; 4
DEC alone was distributed in the remaining 6 HUD;
Considering the difficulties in community acceptance <
the age specific drug schedule as implemented unde
the NAME project (an adult has to take 6 tablets <
DEC of 50mg strength), the Tamil -Nadu has revised tf1
drug schedule using 3 age classes by distributing DE
tablets of 100mg strength (1 tablet for 2-5 years, 2 tablefor5-r to 14 years and 3 tablets for >14 years age grouf
for the subsequent rounds.
Operational feasibility and impact of co-administraiic
of albendazole and DEC
Evaluation of NFD programme has shown th;
improving the community compliance in DE
consumption is the major challenge. Hypothesizing th.
it could be improved if the community perceives its benef
co-administration of albendazole with DEC became
—•
1
May-June 2002
49
Table IV. Coverage for annual single dose of DEC/DEC + albendazole in additional districts of Tamil Nadu.
Revenue
district
Kanchipuram
Health unit
district
Total
population
(million)
Population covered (%) In 5 years
1997
1998
1999
2001 @
2000
DEC
Albendazole
Kanchipuram
1.07
94.0
ND
97.0
97.0
96.6
96.4
Saidapet
1.39
92.0
ND
95.3
96.6
94.0
94.0
Thiruvallur
1.30
94.0
ND
95.2
94.0
97.0
94.9
Poonamalie
1.43
93.0
ND
96.5
95.2
93.5
92.9
Vellore
1.67
96.0
ND
94.4
93.31
96.0
96.0
Thirupathur
1.65
95.0
ND
95.3
96.2
97.6
97.3
Nagapattinum
Nagapattinum
2.39
96.0
ND
94.7
94.2
96.0
94.5
Thanjavur
Thanjavur
2.13
96.0
ND
85.4
84.6
87.4
86.9
Thiruvarur
Thiruvarur
1.22
96.0
ND
92.5
94.1
97.2
97.2
Thirucnirapalli
Thiruchirapalli
4.11
95.0
ND
88.0
89.0
99.1
•NA
Villupuram
Villupuram
1.45
88.0
ND
90.2
90.7
93.4
NA
Kalakurichi
1.30
91.0
ND
91.7
94.0
95.0
NA
Aranthangi
0.6
97.0
ND
96.9
96.7
95.1
NA
Pudukottai
1.32
94.0
ND
94.8
95.5
93.7
NA
Kanyakumari
T.6
90.0
ND
91.5
96.2
95.9
NA
Thiruvallur
V
re
Pudukottai
Kanyakumari
ND = Not done
NA = Not applicable
@ In 2001 albendazole was distributed along with DEC in 9 HUDs and remaining 6 HUDs received DEC alone
Source: District Public Health Authorities.
potential proposition by which community compliance
can be enhanced through perceived benefit of
deworming. In view of this, the ICMR has initiated a study
to compare the operational feasibility and impact of co
administration of DEC and albendazole with that of DEC
alone at district level. This multicentric study which covers
9 districts for DEC + albendazole and 4 for DEC alone
(Table V) is being carried out in the states of Tamil Nadu,
Orissa and Kerala. The parameters for process evaluation
include (i) reported and assessed coverage of drug
distribution; (ii) assessed coverage of drug consumption;
(iii) safety in terms of adverse side reaction experience
report; (iv) perceived benefits - in terms of experience
of expulsion of intestinal parasite; and (v) the cost. The
impact is assessed in terms of (i) microfilaraemia
prevalence and intensity; (ii) antigeneamia prevalence
(ICT card test); (iii) transmission parameters (vector
infection, infectivity and intensity); (iv) prevalence and
intensity of geohelminths; and (v) prevalence of disease.
The first round of drug distribution was implemented in
March 2001 in Tamil Nadu and Kerala. The results show
that the reported coverage of distribution ranged between
87-100% in Tamil Nadu and 81-86% in Kerala. The
assessed coverage of distribution as per the ICMR study
was significantly higher in rural areas (65 to 73%) of Tamil
Nadu compared to urban areas (40 to 45%). In.Kerala
these figures were 72 to 82% in rural areas and 67 to
85% in urban areas respectively.
Analysis of data from Tamil Nadu shows a significant
positive correlation between drug coverage by distribution
and consumption. The gap between population covered
and total population is wider than the gap between
coverage and compliance (drug consumption on
50
ICMR Bulletin
Table V.
Population, endemicity level and coverage of drug distribution in districts included to compare the
impact of co-administration of DEC and albendazole with that of DEC alone
Centre
Institution
Bhubaneswar RMRC
State
District
Drug
Population
(in millions)
Endemicity
rate (%)
Reported coverage
(%) in 2001
DEC
Alb-
Orissk
Puri
Balesore
Ganjam
DEC
DEC +Alb
DEC +Alb
1.57
1.80
2.90
10.6
4.5
24.9
ND
ND
ND
NA
NA
NA
Chennai
TRC
Tamil
Nadu
Trichy
Kanchipuram
Vellore
Thiruvallur
DEC
DEC +Alb
DEC +Alb
DEC +Alb
2.44
2.72
3.33
2.73
2.7
19.3
15.7
19.2
96.64
96.59
96.90
97.09
NA
96.45
93.80 .
94.21 i'r?
Pondicherry
VCRC
Tamil
Nadu
. Thiruvannamalai DEC
Thanjavui
DEC +Alb
Thiruvarur
DEC +Alb
Nagapattinam
DEC +Alb
•2.192.14
1.18
1.54
15.6
15.9
15.9
15.9
92.13
87.36
97.67
100
NA
86.87
95.15
97.97
Delhi
NICD
Kerala
Kozhikode
Alappuzha
DEC
DEC +Alb
2.80
2.20
7.1
21.3
85.90
80.80
NA
84.49
Alb: Albendazole;
NA = Not applicable
ND = Not done;
distribution). Therefore there is a scope to increase
improved by training and manpower development. In
coverage (Fig.1a&b). Performance of providers can be
Kerala the gap between coverage and consumption is
Operational
>
>
>
Thiruvannamalai (DEC alone)
>
At Provider level
Strengthening training
Organizing skill
Optimize distributors target population ratio
Improve logistics/Timings/No.of. visits
Improve supervision
Incentives for distributors
Realistic schedule
Drug availability
Not received
33.50%
Consumers Compliance
Received and
concumed
54.76%
•V
._)
Tanjavur (DEC+aJbendazole)
Received and
consumed
42_J2%
Not received
38.75%
Receh -u -r ' j
— consumed ■
11.73%
>
Improve social mobilization through
o Advocacy
o Sensitization
■
People
■
People opininon leader
■
Press/Media
■
Politician
■
Private practioners
o Appropriate IEC
o IPC during enumeration
Social mobilization
.Received and not —
.V
consumed
\ 18.93%
Fig. 1a. Recommendations for programme improvement based on the assessed coverage and compliance during
the first round of MDA in Tamil Nadu (2001)
May-June 2002
51
Operational
At Provider-level
Kozhikode (DEC)
Not received
24.81%
Received and
consumed ;
34-37% :
> Strengthening training
> Organizing skill
> Optimize distributors target population ratio
> improve logistics /Timmgs/No.of. visits
> Improve supervision
> Incentives for distributors
>
Realistic schedule
Drug availability
Alappuzha (DEC+Albendazole)
Not received
22.25%
Received and
consumed
L 43.13%
Consumers Compliance
Received and not -O
coMumed
40,82%
Fig. 1b.
>
Improve social mobilization through
o
Advocacy
o
Sensitization
■
People
■
People opininon leader
■
Press/Media
■
Politician
•
Private practioners
o
Appropriate EEC
o
IPC during enumeration
Recommendations for proramme improvement based
the first round of MDA in Kerala (2001)
wider and therefore efforts are necessary to improve the
consumption. This can be achieved by health education
and IEC. Being out of station and forgetfulness were
the reasons cited for non-receipt or non-consumption
of drugs in the districts of Tamil Nadu. In Kerala, the
reasons cited for not consuming the drugs were the fear
j)f side reactions and the feeling that drugs were not
.jssary for the individuals.
The drugs (either alone or in combination) were found
safe to administer. The perceived adverse reaction
reported in Tamil Nadu was 7% with DEC alone and 12%
with DEC+ albendazole. Whereas, in Kerala the reported
adverse reaction was less than one per cent of those
who consumed the drug(s).
Based on the results of process evaluation, certain
changes have been made for improving the drug
distribution. This include involvement of volunteers (one
volunteer for every 50 houses) to offer achievable target
and thereby good coverage of distribution, supervised
drug administration to ensure compliance, reducing the
number of tablets and treatment class for community
acceptance and coverage and limiting drug distribution
to one day only to overcome community resistance.
\\
Received and not
\\
Y—
consumed \
34.62% \
—___________ _
on the assessed coverage and compliance during
Conclusions
India has shown a political commitment for filariasis
elimination by becoming a signatory to the WHA
resolution. However, the prospects of elimination will
depend on converting the commitment to practical action
in the field. These include the articulation of a policy
statement, preparation of a blue print of national, regiona
and local plan of action, social mobilization, generation
of necessary funds, effective implementation through a
partnership approach, monitoring and evaluation and
to progress dynamically by taking evidence based
decisions with timely review.
While implementing the recommended control
strategy, research in certain areas is also essential to
address issues related to monitoring and evaluation,
morbidity management and enhance elimination process.
This include development of stage specific diagnostics,
information on disease pathogenesis particularly
lymphoedema and hydrocele, strain variation in relation
to response to drugs and clinical manifestations, disease
burden estimation, monitoring and evaluation strategies application and validation of models for incorporation in
national control programmes, sampling strategies,
52
ICMR Bulletin
modification and incorporation of other interventions such
as vector control and medicated salt along with MDA,
optimization of MDA implementation process, modeling
of disease dynamics and progression, developing and
validating advocacy and social mobilization measures,
cost-effectiveness of interventions, defining operational
criteria of elimination, setting up of morbidity management
centers, rapid mapping and delimitation of areas, policy
issues at national and state level, training and man power
development, partnership issues - international, regional,
national, state, district and local, documentation, utilization
(j>f knowledge gained through other control/elimination
programmes, methods for dissemination of information
including research findings, etc.
References
1.
Pani. S.P. and Dhanda, V. Natural history and dynamics of
progression of clinical manifestation of filariasis. In: Tropical Disease:
Molecular Biology and Control Strategies. (First edition). Ed. Sushil
Kumar et al. Publication and Information Directorate, Council of
Scientific and Industrial Research. New Delhi, pl, 1994.
2.
World Health Organization. Lymphatic filariasis: The disease, and
its control. Fifth Report of the WHO Expert Committee on Filariasis.
WHO Tech Rep Ser 821: 1, 1992.
3
Pam, S.P. Yuvaraj, J.. Vanamail, P., Dhanda, V., Michael, E.. Grenfell.
B.T and Bundy, D.A.P. Episodic adenolymphangitis and
lymphoedema in patients with bancroftian filariasis. Trans R Soc
Trop Med Hyg 89: 72,1995.
4.
Ramaiah. K.D., Vijaya Kumar, K.N., Ramu, K.. Pani. S.P. and Das.
P.K. Functional impairment caused by lymphatic filariasis in rural
areas of South India. Trop Med Int Health 2: 832, 1997.
5.
Pani, S.P. and Lail, R. Clinical features, pathogenesis and
management of lymphatic filariasis. ICMR Bull 28: 41, 1998.
6.
Das, P.K. and Pani, S.P. Towards elimination of lymphatic filariasis
in India: Problems, challenges, opportunities and new initiatives.
J Int Med Sci Acad 13: 18, 2000.
12.
World Health Assembly. Elimination of lymphatic filariasis as a publi
health problem. A 50.29, 1997.
13.
Michael, E., Bundy, D.A.P. and Grenfell. B.T. Re-assessing the glob;
prevalence and distribution of lymphatic filariasis. Parasitology 111
409, 1996.
14.
Sabesan, S., Palaniyandi, M. and Das, P.K. Mapping of lymphat:
filariasis. Ann Trop Med Parasitol 94: 591, 2000.
15.
Das, P.K., Manoharan. A., Ramaiah, K.D., Balraman, K. and Dhand;
V. Cost-analysis of blood-surveys for the detection of microfilar
carriers in rural areas. Nat Med J India 8: 143, 1995.
16.
Ramu, K., Ramaiah, K.D., Guyatt, H. and Evans, D. Impact c
lymphatic filariasis on the productivity of male weavers in a soul
Indian village. Trans R Soc Trop Med Hyg 90: 669, 1996.
17.
Ramaiah, K.D., Ramu, K., Vijaya Kumar, K.N. and*» } /art, h
Epidemiology of acute filarial episodes caused by wucherer
bancrofti infection in two rural villages in Tamil Nadu, south Indi
Trans R Soc Trop Med Hyg 90: 639, 1996.
18.
Ramaiah, K.D., Ramu, K., Guyatt, H„ Vijaya Kumar, K.N. and Par
S.P. Direct and indirect costs of the acute form of lymphatic filarias
to households in rural areas of-Tamil Nadu, south India. Trop Me
Int Health 3: 108, 1998.
19.
Ramaiah, K.D., Guyatt, H„ Ramu. K., Vanamail, R, Pani, S.P. ar
Das. P.K. Treatment costs and loss of work time to individuals wi
chronic lymphatic filariasis in rural communities in south India. Trc
Med Int Health 4: 19, 1999.
20.
Ramaiah. K.D.. Das, P.K., Michael. E. and Guyatt, H. The Econom
burden of lymphatic filariasis in India. Parasitol Today 16:251,200
21.
Ramaiah. K.D. and Vijaya Kumar, K.N. Effect of lymphatic filarias
on school children. Acta Trop 76: 197, 2000.
22.
Suresh, S., Kumaraswami, V., Suresh, I., Rajesh, K., Suguna, C
Vijayasekaran, V., Ruckmani, A. and Rajamanickam, M.«
Ultrasonographic diagnosis of subclimcal filariasis. J Ultrasoui
Med 16: 45, 1997.
23.
Pani. S. P., Balakrishnan, N., Srividya. A., Bundy, D.A.P. aritJurenk
B.T. Clinical epidemiology of bancroftian filariasis: Effect of at
and gender. Trans R Soc Trop Med Hyg 85: 260, 1991.
24.
Gyapong, J.O., Omane-Badu, K. and Webber, R.H. Evaluation
the filter paper blood collection method for detecting Og4
circulating antigen in bancroftian filariasis. Trans R Soc Trop M<
Hyg 92: 407, 1998.
Sasa, M. Human Filariasis: A Global Survey of Epidemiology and
Control, University of Tokyo Press, Tokyo, p336, 1976.
8.
Das, P.K. and Pani, S.P. Filariasis in India: Epidemiology and control
In: Helminthology in India Ed. M.L.Sood. International Book
Distributors, Dehra Dun, 2002 (in press).
25.
Pani, S.P. and Srividya , A. Clinical manifestations of bancrofti.
filariasis, with special reference to lymphoedema grading: Indi
J Med Res 102: 114, 1995.
9.
Sabesan, S., Pradeep Kumar, N., Krishnamoorthy, K. and Pantcker,
K.N. Seasonal abundance and biting behaviour of Mansonia
annulifera, Mansonia uniformis and Mansonia Indiana and their relative
role in the transmission of Malayan filariasis in Shertallai (Kerala
’State). Indian J Med Res 93: 253, 1992.
26.
Vijayalakshmi, N., Sambasivarao, R., Anand Paul Kumar, M.
Yuvaraj, J. and Pani, S.P. Role of aerobic bacteria in t!
aetiopathogenesis of acute adenolymphangitis (ADL) in filar
lymphoedema. Prog Lymphol 17: 163, 2000.
27.
10.
Tewari, S.C., Hiriyan, J. and Reuben, R. Epidemiology of subperiodic
Wuchereria bancrofti infection in Nicobar islands, India. Trans R
Soc Trop Med Hyg 89: 163, 1995.
25 Years of Research. Silver Jubilee Publication, Vector Cont 4
Research Centre, Pondicherry, p. 95, 2000.
28.
Elango, A., Paily, K.R, Pani, S.P., Yuvaraj, J. and Anand Paul Kum
M.P. Histopathology and immunopathology of skin of different grab
of lymphoedema (W. bancrofti) in south India. Prog lymphol ;
162, 2000. .
11. World Health Organization. Lymphatic filariasis: Reasons for hope.
WHOJCTDIFIL/97.4 ,p.1, 1997
May-June 2002
29. Weil, G.J., Lammie, RJ. and Weiss, N.'The ICT filariasis test A
rapid-format antigen test for diagnosis of bancroftian filariasis.
Parasitol Today 13: 401, 1997.
44.
Norman, R.A., Chan, M.S:, Srividya, A., Pani, S.R, Ramaiah,
K.D.,Vanamail, R, Michael, E, Das, P.K. and Bundy, D.A.P. EPIFIU
The development of an age-structured model for describing the
transmission and control of lymphatic filariasis. Epidemiol Infect
124: 529, 2000.
45.
Kurmaraswami, V., Ottesen, EA., Vijayasekharan, V., Umadevi. S.,
Swaminathan, M., Aziz, M.A., Sharma, G.R., Prabhakar, R. and
Tripathy, S.P. Ivermectin for the treatment of Wuchereria bancrofti
filariasis: Efficacy and side reactions. J Am Med Assoc 259: 3150,
1988.
46.
Shenoy, R.K., Sandhya, K:, Suma, T.K. and Kumarasami, V. A
preliminary study of filariasis related acute adenolymphangrtis with
special reference to precipitation factor and treatment modalities.
Southeast Asian J Trop Med Public Health 26: 301, 1995.
47.
Reddy, G.S., Venkatesvarlou, N., Das, P.K., Vanamail, R, Vijayan
S. K. and Pani, S.P. Tolerability and efficacy of single dose
diethylcarbamazine (DEC) or ivermectin in the clearance of
Wuchereria bancrofti microfilaraemia at Pondicherry, south Ir dia.
Trop Med Int Health 5: 779, 2000.
48.
Pani, S.R, Subramaniyam R. G., Das, L.K., Vanamail, R, Hoti, S.L.,
Ramesh, J. and Das, P.K. Tolerability and efficacy of single dose
of albendazole or diethylcarbamazine (DEC) or co-administration
of albendazole with DEC in the clearance of Wuchereria bancrofti
microfilaria earners in Pondicherry, south India: Hospital based
study. Filaria J 1:1,2002
49.
Subramaniyam, R. G., Pani, S.P. and Das, P.K. Ivermectin: A new
wonder drug for lymphatic filariasis, Clin Pharmacol Therapeut 18:
29. 1997.
50.
Das, P.K, Sivagnaname, N. and Amalraj, D. A comparative study
of a new insecticide impregnated fabric trap for monitoring adutt
mosquito populations resting indoors. Bull Entomol Res 87: 397,
1997.
Das, P.K, Ramaiah, K.D., Vanamail, R, Pani, S.R. Yuvaraj, J.,
Balaraman, K. and Bundy, D.A.P. Placebo controlled community
trial of four cycles of single dose diethylcarbamazine or ivermectin
against Wuchereria bancrofti infection and transmission in India.
Trans R Soc Trop Med Hyg 95: 336, 2001.
51.
Srividya, A.. Lail, R., Ramaiah, K.D., Ramu, K., Hoti, S.L., Pani,
S.P. and Das, P.K. Development of rapid assessment procedures
for the delimitation of lymphatic filariasis endemic areas. Trop Med
Int Health 5:64, 2000.
Ramaiah, K.D., Vanamail, R, Pani, S.P. and Das, P.K. The effect of
six rounds of single dose mass treatment wrth DEC and ivermectin
on Wuchereria bancrofti infection and its implications for lymphatic
filariasis elimination. Trop Med Int Health, 7:767, 2002.
52.
Balakrishnan, N., Ramaiah, K.D. and Pani, S.P. Efficacy of biannual
administration of DEC in the control of bancroftian filariasis. J
Commun Dis 24: 87, 1992.
53.
Panicker, K.N., Krishnamoorthy, K., Sabesan, S., Prathiba, J. and
Abidha. Comparison of effects of mass annual and semiannual
single dose therapy with DEC for the control of Malayan filariasis.
Southeast Asian J Trop Med Public Health 22: 402, 1991.
54.
Subramaniyam, R. G. and Venkatesvarlou, N. Mass administration
of DEC medicated salt for filariasis control in the endemic population
of Karaikal, south India: Implementation and impact assessment.
Bull World Health Organ 74: 85, 1996.
55.
Appavoo, N.C., Pani S.P. and Das, RK. The Science and Art of
Lymphatic Filariasis Elimination in India: Hope for the Next Millennium.
Department of Public Hearth and Preventive Medicine, Government • of Tamil Nadu and Vector Control Research Centre, Pondicherry,
p.1, 1999.
56.
Rajagopaian, P. K. and Das, P.K. What ails mosquito control
programmes in India. Bull Sci 4: 14, 1988;
30.
Pani, S. P., Hoti, S.L., Elango, A.,Yuvarajf J., Lail, R. and Ramaiah
K.D. Evaluation of the ICT whole blood antigen card test to detect
infection due to nocturnally periodic Wucherena bancrofti in south
India. Trap Med Int Health 5: 359, 2000.
31.
World Heatth Organization. Collaborative global programme to
eliminate lymphatic filariasis. Programme background and overview
towards initiating a national programme to eliminate lymphatic
filariasis. WHO/CEE/FIL, p.1, 1999.
32.
Lakshmi, A. A statistical approach to monitor ongoing intervention
for control of lymphatic filariasis. J Commun Dis 32: 10, 2000.
33.
Hoti, S. L, Vasuki, V., Patra, K.R, Harrths, V.R., Ravi, G. and Sushma,
S. Laboratory evaluation of Ssp I PCR assay for the detection of
Wuchereria bancrofti infection in Culex qumquefasciatus. Indian J
Med Res 114: 59, 2001.
/
34.
Hoti, St L., Vasuki, V.,Lizotte, M.W., Patra, K.P., Ravi, G., Vanamail,
R, Manonmani, A.M., Sabesan, S.. Krishnamoorthy, K. and Williams,
S. A. Detection of Brugta malayi in laboratory and wild-caught
Mansonoides mosquitoes (Diptera: Culicidae) using Hha I PCR
assay. Bull Entomol Res'91: 87, 2001.
35... Hoti, S.L., Patra, K.R, Vasuki, V., Lizottee, M.W., Harrths, V.R., Sushma,
S., Gunasekaran, K., Ramaiah, K.D., Vanamail. R, Mariappan, T.
and Williams, S.A. Evaluation of a PCR assay in the detection of
Wuchereria bancrofti infection in the field collected Culex
quinquefasciatus in the transmission studies of lymphatic filariasis.
J Appl Entomol, 2002 (In press).
36. Vasuki, V, Patra, K.P. and Hoti, S.L. A rapid and simplified method
of DNA extraction for the detection of Brugia malayi infection in
mosquitoes by PCR assay. Acta Trop 79: 245, 2001
37.
39.
G.J. The LYMFASIM stimulation programme for modeling lymphatic
filariasis and its control. Methods Inf Med 37: 97, 1998.
Srividya, A., Palaniyandi, M., Michael, E., Pani S.P. and Das, P.K.
A geostatistical analysis of the geographical distribution of lymphatic
filariasis prevalence in southern India. Am J Trop Med Hyg, 2002
(In Press).
40.
World Health Organisation. Research on rapid geographical
assessment of bancroftian filariasis. TDRfTDF/COMDT/SS 2:1,1998.
41.
Vanamail, R, Subramanian, S„ Das, P.K., Pani, S.P. and Rajagopaian,
P.K. Estimation of fecundic life span of Wuchereria bancrofti from
a longitudinal study of human infection in an endemic area of
Pondicherry (south India). Indian J Mad Res 91: 293, 1990.
42.
Chan, M.S., Srividya, A., Norman, R.A., Pani, S.P., Ramaiah, K.D.,
Vanamail, P., Michael, E., Das, P.K. and Bundy, D.A.P. EPIF1L A
Dyanamic model of infection and diseases in lymphatic filariasis.
Am J Trop Med Hyg 59: 606, 1998.
43.
Plaisier, A.R, Subramanian, S., Das, RK., Souza, W., Lapa, T., Furtado,
A.F.F., Vander Ploeg, C.RB.,Habbema, J.D.E. and Van Oortmarssen,
ICMR Bulletin
57.
Subramanian, S., Pani, S.P., Das, P.K. and Rajagopalan, P.K.
Bancroftian filariasis in Pondicherry, south India: II. Epidemiological
evaluation of the effect of vector control. Epidemiol Infect 102:693,
1989.
exposure of sub-lethal dose of Bacillus sphaencus as larvae. Act
Trop 74: 43, 2000. . '
61. Annual Report, Vector Control Research Centre, Pondicherry. p2c
2000.
58.
Rajagopalan, P. K.. Das, P. K., Pani, S.P., Mariappan, T., Rajavel,
A.R., Ramaiah, K.D., Amalraj, D., Paily, K.P., Balakrishnan, N.,
Sadanandane, C., Vanamail, P., Subramanian, S., Srinivasan, R.,
Arunachalam, N., Reddy, C.M.R..Reddy C.B.S. and Somacnary,
N. Evaluation of integrated vector control measures on filariasis
transmission in Pondicherry. Indian J Med Res 97: 434, 1988.
59.
Das, P. K., Manoharan, A., Subramanian, S., Ramaiah, K.D, Pani,
S.P., Rajavel , A.R. and Rajagopalan, P.K. Bancroftian filariasis in
Pondicnerry, south India - Epidemiological impact of recovery of
the vector population. Epidemiol Infect 108: 483. 1992.
60.
Gunasekaran. K.. Padmanaban, V. and Baiaraman, K. Development
of Wucherena bancrofti in Culex quinquefasciatus that survived the
62. Annual Report, Vector Control Research Centre, Pondicherry, pl £
1998.
63.
Ramaiah, K.D., Das. P.K., Appavoo,-N.C., Ramu, K., Augustin, D.J
Vijayakumar, K.N. and Chandrakala, A.V. A programme to eliminatf
lymphatic filariasis in Tamil Nadu, India: Compliance with annue
single dose DEC mass treatment and some related operatione
aspects. Trop Med Int Health 5: 842, 2000.
This article has been contributed by Dr. P.K. Das, /Rector
Dr. S.P Pani, Deputy Director (SG) and Dr. K.Krishn? ’orthy
Asst. Director, Vector Control Research Centre, Pondicherry
ICMR NEWS
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A
REVISED STRATEGY
FOR THE CONTROL OF
LYMPHATIC FILARIASIS IN INDIA
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NATIONAL INSTITUTE OF COMMUNICABLE DISEASES
and
NATIONAL MALARIA ERADICATION PROGRAMME
(Directorate General of Health Services)
Ministry of Health & Family Welfare, Govt, of India
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REVISED STRATEGY
FOR THE CONTROL OF
LYMPHATIC FILARIASIS IN INDIA
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Report and Recommendations of the
WHO Sponsored Workshop
New Delhi, 4 and 5 January 1996
NATIONAL INSTITUTE OF COMMUNICABLE DISEASES
and
NATIONAL MALARIA ERADICATION PROGRAMME
(Directorate General of Health Services)
Ministry of Health & Family Welfare, Govt, of India
oooob^
Compiled and edited by :
Gautam Biswas *
Deputy Director
V.K. Raina •
Assistant Director
C. Krishna Rao •*
Consultant
* Division ofHelminthology
National Institute of Communicable Diseases
22, Sham Nath Marg, Delhi -110 054
” National Malaria Eradication Programme
22, Sham Nath Marg, Delhi -110 054
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...............
CONTENTS
Page No.
Foreword
1
Executive Summary
IJSRARY
%
3
N.
Proceedings of the Workshop
5
Inaugural Session
5
Filariasis Problem: Global Scenario
7
Recent Advances in Filariasis Control
8
Operational Research in Filariasis
9
Filariasis Problem in India and the Control Strategy
10
Review of Ivermectin Field Trials in India and its prospects
in the National Programme
11
Proposed strategy for Control of Filariasis
13
Communication Strategy for Revised Filariasis Control
14
State’s Proposed Plan for Revised Strategy
Andhra Pradesh
15
Bihar
15
Kerala
16
Orissa
16
Tamil Nadu
16
Uttar Pradesh
17
West Bengal
17
Group Discussions
Group - I: Single dose DEC Mass Therapy & Case Management
18
Group - II: IEC and Development of Proformae for Monitoring
20
Recommendations of the Workshop
23
Appendices
1:
List of Participants
27
2:
Programme of Workshop
30
3:
Document on Revised Strategy for Control of Filariasis in India
32
OOOOB^
I
1
: 'Twft xfrn"
Dr. K.K. DATTA
Director
Telegrarp : "COMDIS" Delhi
Direct: 2913148
2521449
2521524
2521272
2521326
2521344
2521060
Fax : 00-91-11-2922677
a
7TT2T HI4.
D.O. No______________
GOVT. OF INDIA
NATIONAL INSTITUTE OF COMMUNICABLE DISEASES
(Directorate General of Health Services)
22, SHAM NATH MARG, DELHI-110054
FOREWORD
Lymphatic Filariasis continues to be a major vector borne public health
problem in India, with the country contributing to 38% of the global bancroftian
and 20% global brugian filariasis problem. It is estimated that India now has 20
million people suffering from chronic filariasis and 27 million micro-filaria
carriers. A population of 412 million is exposed to therisk_of_filariasis in India.
Though the National Filaria Control Programme (NFCP).primarily based on antilarval measures and selective chemo-therapy in urban areas is in operation over
four decades no significant reduction in filariasis had been achieved.
However, global research in the control of filariasis have now made
available operationally feasible and cost effective technologies for the effective
control of lymphatic filariasis and the disease has now been recognised amongst
the six potentially eradicable diseases by the “Intern ational Task Force on
Disease Eradication”. This is only possible if the necessary political will and
resources for the Filaria Control Programme are available. The National Institute
of Communicable Diseases in collaboration
with the National Malaria
Eradication Programme organised this workshop for tensing the National Filaria
Control Programme in light of the modem technologies and recommended the
administration of a single annual dose mass chemo-therapy through observance
of a National Filaria Day along with better management of patients of lymphatic
filariasis.
I hope that the Government will consider the recommendations of the
experts and make necessary resources , available for observance of the National
Filaria Day which will help in reducing the human suffering caused by this
disease.
We are grateful to be World Health Organisation for their financial and
technical support and to the Indian Council of Medical Research and State
Governments who made their experts available for this Workshop
(K.K. DATTA1______-
1
REVISED STRATEGY FOR THE CONTROL OF
LYMPHATIC FILARIASIS IN INDIA
EXECUTIVE SUMMARY
I
A two day WHO sponsored workshop to formulate guidelines for a revised strategy for the
control of lymphatic filariasis in India was organised on 4th and 5th January 1996 at the National
Institute of Communicable Diseases (NICD), Delhi jointly by NICD and the Directorate of National
Malaria Eradication Programme (NMEP). A total number of 52 experts from WHO, Central and State
organisations participated in the workshop. Special topics pertaining to ‘Filariasis’ were deliberated
by the national and international experts. The representatives from seven endemic States presented
the proposed plan of activities for the revised strategy.
The new strategy is recommended to be implemented starting from 1996 in view of the success
achieved by four endemic countries namely Japan, Taiwan, South Korea and Solomon Islandsjn
the elimination of filariasis. Single dose Diethylcarbamazine (DEC) massjherapy was found tobe
equally effective compared to the 12 dav “standard” therapy in clearingmicrofilana from blood. The
single dose regimen has the advantage of lesser side effects, better public compliance, decreased
delivery cost as the cost of detection of each case is avoided and is feasible to implement through
the existing Primary Health Care system. The hew strategy will comprise of the following four
components?
1)
Single dose DEC mass therapy at a dose of 6 mg/kg body weight once a year x.
2)
Management of acute and chronic filariasis through referral services at selective centres,
3)
IEC for inculcating individual and community based protective and preventive
measures for filaria control and
4)
Continuation of anti-vector measures in all NFCP towns as an adjunct to single dose DEC
mass therapy and the microfilaria carriers detected in filaria clinics
The revised strategy is proposed to be taken up in 13 endemic districts covenng a population
of 40.91 million in the first year which will be extended to 412 million endemic population (303
million rural and 109 million urban) in all the 18 endemic States/UTs by 1998. The 13 en<Jemic
districts identified for initiation of the revised_strategy in 1996 are East Godavari and Snkakulam in
Andhra Pradesh; Darbhanga and Siwan in Bihar; Alappuzha and Kozhikode in Kerala; Kh^d^and
PurTinOrissa; North Arcot and South Arcot in Tamil NaduFGorakhpurandyaranasi in Uttar Pradesh;
and Purulia in West Bengal.
It is proposed to observe a ‘National Filaria Day’ on 5thAugus£ every year for successful
implementation of single dose DEC mass therapy. A high profile social mobilisation through IEC
programme is to be implemented through mass media, print media, inter-personal communication,
etc., to generate community acceptability.
It is recommended that the Government of India procure DEC and supply to the States as per
the calendar of activities spelt out in the revised strategy document. Under the Central share of
3
T*
expenditure, the following components are to be borne during the first year of the revised strategy
(i) Cost of DEC tablets: Rs. 1.75 crores (ii) IEC: Rs. 2.05 crores @ Rs. 5 lakhs per million population
and (iii) Petrol, Oil & Lubricants (POL): Rs. 0.26 crores @ Rs. 2 lakhs per district. Besides these three
components, Govt, of India may also take up training of medical professionals for proper
management of acute and chronic manifestations including the latest surgical methods at selected
medical institutions actively involving the Indian Council of Medical Research in collaboration with
WHO and other bilateral agencies..
The State governments may bear under their share, the expenditure on: (i) Operational Cost
(ii) Cost of drugs (other than DEC) likez antibiotic, anti-pyretics and anti-fungal agents for case
management (iii) 15% share of IEC, (iv)" Cost of transportation (excluding POL expenditure).
The revised Strategy will be periodically monitored and reviewed through a network of
institutions identified in each State. Independent appraisal of the progress of the revised strategy
is also proposed. It was unanimously recommended by the participants to entrust the implemen
tation of the revised strategy to the National Institute of Communicable Diseases in view of its past
experience in the successful implementation of the Small-pox Eradication Programme and the
National Guinea Worm Eradication Programme. The proceedings and recommendations of the
workshop are detailed in the document. The revised strategy’ for the control of filariasis in India is
given in Appendix - 3-
4
i
1
I
PROCEEDINGS OF THE WORKSHOP
A two day workshop to formulate the revised strategy for the control of lymphatic filariasis in
India was organised on 4tli and 5th January 1996 jointly by the National Institute of Communicable
Diseases (NICD), and the Directorate of National Malaria Eradication Programme (NMEP) with
financial assistance from the World Health Organisation. The workshop was attended by the experts
from \XTIO, Geneva, WHO-SEARO, New Delhi, representatives from seven endemic States, Indian
Council of Medical Research, Central Health Education Bureau, Indian Institute of Mass Commu
nication and Directorates of NICD & NMEP (Appendix-1).
National and International experts in the field of filariasis after highlighting the magnitude of
the global and Indian problem of lymphatic filariasis, deliberated on the recent advances made in
the area of control of lymphatic filariasis. Representatives of the state governments, who had earlier
been given a working document on the revised strategy for the control of filariasis, proposed their
plan of action for the revised strategy in the identified districts for the first year. The participants
then had in-depth workshop in two sub-groups to propose an action plan as per the terms of
reference. The group’s recommendations were discussed in length and a comprehensive plan for
the revised strategy has been prepared. The programme of the Workshop is given in Appendix-2.
INAUGURAL SESSION
Dr. K.K. Datta, Director, NICD while welcoming the distinguished participants, experts and
invitees, emphasised the urgent need to revise the strategy for the control of filariasis in India in
view of the newer control strategies which have yielded successful results in other countries.
However, before extending the revised strategy on a nation-wide basis he advocated that the new
strategy’ be implemented on a pilot basis in selected endemic districts in the initial year which could
then be extended to all other endemic districts in the country in a phased manner. He requested
the participants to fonnulate a pragmatic and cost-effective strategy suitable to Indian conditions
for eliminating the age old scourge inflicting the population in India.
*
Dr. Gautam Biswas, Deputy Director, NICD enumerated the objectives and methodology of
the workshop highlighting that the new strategy should encompass the three pronged attack on the
disease with single annual mass administration of DEC, case management to reduce morbidity and
community based prophylactic measures as an integral part of the entire control strategy.
Dr. R.S. Sharma, Director, National Malaria Eradication Programme in his address traced the
prevalence of filariasis in India to the famous Indian physician Susruta in 600 EC in his treatise
‘Susruta Samhita’. He said that filariasis being one of the important public health problems in India
second only to malaria, should be accorded due priority for its control. He remarked that the new
strategy could be implemented through the existing health care delivery infrastructure of the
country7. He said that integrated health care approach supplemented by the concerted efforts of NonGovernmental Organisations should be able to yield the desired results when the new strategy for
the control of filariasis would be implemented.
Dr. Prema Ramachandran. Adviser (Health), Planning Commission, Govt, of India mentioned
that the Planning Commission was well aware of the magnitude of lymphatic filariasis in India and
assured that the Commission would consider positively the funds for the revised strategy for the
control of filariasis.
5
Dr.V.S. Orlov, Senior Regional Adviser, (Mai & VBC) WHO-SEARO expressed that he was
encouraged to note that India would soon be revising the strategy for the control of filariasis, and
conveyed full support of the World Health Organisation in achieving the goals of Alma Ata
declaration.
Ms. Shailaja Chandra, Additional Secretary to the Govt, of India, Min. of Health & F.W. assured
that the Govt, of India was fully committed in alleviating the sufferings of the population in the vast
areas of India from the chronic manifestations of filaria disease. The Govt, of India would favourably
consider for sharing the expenditure with the States in the implementation of the revised strategy
for eliminating the filaria infection in the country.
Dr. N.K. Shah, TOO Representative to India, in his inaugural address higlighted that the
International Task Force for Disease Eradication has identified lymphatic filariasis as one of only
six infectious diseases considered eradicable or potentially eradicable. He said that the time has now
come for India to join the global programme to eliminate the disease and was optimistic that die
national efforts in India would be successful in achieving this goal. He added that the World Health
Organisation in collaboration widi UNDP, World Bank and endemic countries would be actively
participating in the global strategy for the control of lymphatic filariasis. He complimented the
organisers for the timely holding of this workshop. He wished the participants success in their
deliberations during the workshop in formulating the new strategy for the control of filariasis in
India.
Dr. B.P. Patnaik, Joint Director. NMEP, while proposing a vote of thanks complimented all the
States for their participation in the workshop. He thanked WHO for the financial assistance in
conducting the" workshop and expressed gratitude to Dr. N.K. Shah, Dr. V.S. Orlov, Ms. Shailja
Chandra, Dr. Prema Ramachandran and other dignitaries and representatives of States & Research
Organisations for attending the workshop. He thanked all the Officers, staff members and
consultants of NICD and NMEP for extending their full support in organising the workshop on a
successful note.
6
J'
Filariasis Problem: Global Scenario
Dr. C.P. Ramacbandran, WHO, Geneva
The estimates of the global prevalence of lymphatic filariasis in 1992 revealed that there were
about 72.8 million people with IF. bancrofti and 5.8 million people with B. malayi or B. timori
infections. Although these estimates have indicated the magnitude of the problem, the data could
not indicate the disease problem separately and hence the public health problem of these infections
could not be correctly projected. The information with regard to countries of Sub-Saharan Africa
was based on very old data. However, recently an attempt has been made for the detailed assessment
which ha$ revealed that about 106.2 million persons are now infected with IF. bancrofti and 12.9
million with B. malayiox B. timori. Thus a total of 119.1 million are now estimated to be harbouring
lymphatic filariasis infection world-wide. The overt physical disabilities from these infections affect
about 43 million (40 million with bancroftian filariasis and 3 million with Brugian or timorian
filariasis).
IF. bancrofti is prevalent in sex'en countries in the Americas, four countries in the Eastern
Mediterranean Region, eight countries each in south-east Asia, and the West-Pacific Regions and
about 38 countries lie in the endemic areas of Sub-Saharan .Africa while Brugian infection is prevalent
in eight Asian countries. India and Sub-Saharan countries contribute 38% and 34% of the global
disease burden respectively. The infection and disease burden are low and focal in ‘Latin-America’,
‘Caribbean’ and ‘Middle Eastern crescent’ countries. In respect of brugian infections, half of the
global problem is contributed by China (32%) and India (2096) and the rest by other South-east Asian
countries namely Indonesia. Thailand, Malaysia, Philippines, Vietnam.
The microfilaria and disease rates have been found increasing with age and the highest disease
and microfilaria rates are encountered in 45-60 + age group. Males show 20% more cases in
bancroftian filariasis and 25’ more cases in brugian filariasis as compared to females. Though
overall Chronic disease manifestations are more in males, lymphoedema cases are greater (about
18% more) among females. Similarly brugian filariasis cases are also higher amongst males as
compared to the same in females (Mf: Males 6.52 million and females 3.84 million cases and
Lymphoedema: Males 1.8 million and females 1 million cases).
The global burden of lymphatic filariasis was estimated to cause a loss of 8.50,000 Disability
Adjusted Life Years (DALYs). Further data are required to arrive at reliable values of DALYs.
*
Ms. Shailaja Chandra, Chairperson, highlighted the proportion of cases contributed by India
and advised that efforts should be made to reduce the disease burden in India.
1
7
Recent Advances in Filariasis Control
Dr. C.P. Ramacbandran, WHO, Geneva
Dr. Ramacbandran while mentioning that there was no single panacea available for the control
of a disease like filariasis, proposed that multiple methods were to be incorporated in the long term
control strategy. The success of a particular control strategy in one country may not be replicable
in other countries. The strategy requires needful modifications suitable to the socio-cultural aspects
of the community. Vector control is not to be used as a single option but as a potential adjunct to
anti-parasitic measures.
Besides diethylcarbamazine (DEC), ivennectin has been evaluated to be another important tool
for the control of bancroftian and brugian infections. Remarkable observations in the optimal use
of DEC and ivermectin alone or in combination have been made in recent times. This has opened
new vistas in launching the revised control strategies. The combination of two drugs i.e. DEC and
ivermectin appears to be significantly more effective than either drug alone.
Various drug regimens used for filariasis control were reviewed by the speaker such as single
dose DEC at weekly, monthly, six monthly and yearly intervals tried by many workers. Annual or
six monthly single doses were found to be advantageous taking into consideration the expenses
of drug delivery, drug compliance and efficacy in reducing microfilaria prevalence and density.
Where the use of DEC is contraindicated in areas having coexistence with Onchocerciasis or Loiasis,
ivermectin is the drug of choice.^DEC fortified salt at concentrations ranging from 0.1% to 0.6% gave
excellent results in reducing W. bancrofti and B. malayi microfilaraemia by 70% to 100% in 6-9
month studies. Adverse reactions caused by DEC and ivermectin were elaborately reviewed
Highlighting the advantage of DEC fortified regimen in preventing side effects of the drug.
yV
There is increased understandingof pathogenesis of lymphoedema and acute adenolymphangitis
(ADD which has enabled undertaking of morbidity control measures. Simple measures like foot
hygiene, foot care and the use of prophylactic use of antibiotics were found possessing profound
effect in the prevention of damaging episodes of ADL. Recent studies revealed that many of the socalled ‘asymptomatic’ microfilaria carriers showed marked abnormal dilatation of lymphatics and
abnormal lymph flow, low grade renal damage, which could be detected by lymphoscintigraphy
technique. | Vector control measures through the use of biocides, polystyrene beads, insecticide
impregnated bed-nets, synthetic pyrethroids and integrated vector management serve as suppl’ementary methods to chemo-therapeutic measures, j New tools for diagnosis, epidemiologicaT
monitoring, assessment and evaluation were also reviewed. The recently available new diagnostic
tools to detect circulating filarial antigen, DNA probes, rapid assessment techniques, predictive
mathematical modelling, psycho-social and socio-economic issues related to control programmes
were elaborately discussed by the speaker.
8
I
...
Operational Research in Filariasis
Dr. P.K. Das, Senior Deputy Director, Vector Control § Research Centre, Pondicherry
In view of the limited financial resources made available to the National Filaria Control
Programme, Dr. P.K. Das advocated the determination of the best course of control strategy that
would yield optimum results in the containment of the problem. Accordingly intervention measures
should be directed against the most vulnerable link in disease transmission chain. The best type of
intervention measures should be selected to stop the spread of infection. He reviewed the vector
control measures from 1981 to 1992. The relative advantage of the methods is dependent upon
important variables. He highlighted the following four operational issues: (i) Mass DEC therapy with
blood smear examination, (ii) Mass DEC therapy without blood smear examination, (Hi) Selective
treatment of microfilaria carriers after screening the population in the night blood survey and dv)
Survey of a section of population in the age group of 15 to 25 years and treatment of microfilaria
carriers and immediate contacts.
Chemotherapy has two approaches: (a) Selective Chemotherapy and (b) Mass Chemotherapy.
The latter approach (i.e. mass chemotherapy) can be implemented either by administration of tablets
to the community as per the standard age-wise dosage schedules or through DEC medicated salt
regimen. Among the two options of mass drug administration, DEC medicated salt is better because
of least side effects of.the.drug and community compliance. Immunological responses in filariasis
were elaborated by the speaker highlighting the role of immunological tolerance and concomitant
immunity. Immuno-tolerance is maintained in the individual by continuous exposure to the
infective larvae. He discussed in detail about the percentage reduction in the median microfilaria
density, intermittent control methods, pulse treatment, critical house- hold levels, filariometric
indices and the relative cost of different control strategies.
i
The optimisation of control measures should be adopted balancing the three important
components of the control strategy which are: (a) transmission intervention measures to reduce
niarHmpsc]u.itQ..conta.ct, (b) cherno-therapeutic measures to reduce the reservoir of infection and
(c)palliative measures to reduce morbidity caused by acute episodes and chronic manifestations.
The speaker advocated that the treatment of 11 to 30 years age group would be very ideal. This age
group is the most vulnerable group encompassing maximum number of microfilaria carriers in the
community and as such the community- will be very receptive to such an approach in the selective
control strategy. The review of literature on operational research in India revealed that one single
strategy was not sufficient to control the disease and a multi-pronged approach should be adopted
to make an impact on the transmission of filariasis.
Dr. Orlov, Chairman of the session mentioned in his concluding remarks that the National
Filaria Control Programme has lost its momentum and a big country like India should not depend
upon one type of strategy- for the entire country. The community response may vary in different
geographical regions and motivation of community through IEC should be a prerequisite for
successful implementation_of the revised strategy. Periodic evahiatioq'should be undertaken on
inputs and outcomes. Stratified control strategy should be adopted suitable to coastal, southern and
northern areas endemic for bancroftian and brugian infections. He thanked the speakers for their
lucid presentations.
9
«
Filariasis Problem in India
and the Current Control Strategy
Dr. /?.£. Shanna, Director, NMEP, Delhi
million people have disease manifestations. Bancroftian filariasis contributes 99.4 per cent of
tanasis problem in India Bniglail Filariasis transmitted by Mansonia mosquitoes is usually
confined to rura areas mostly in the west coast of Kerala and a few pockets in six other States. About
-o million people are living in the endemic areas of B. malayi. Both the infections in the mainland
ndia exhibit nocturnal periodicity. Diurnal sub-periodic fonn of W. bancrofti infection possibly
'‘'^mtted bx day biting AedesCFmlaya) nmez/sgroup of mosquitoes is prevalent in Nicoba^ Group
Islands inhabited by about 10.000 population in four islands.. The first pilot project in the world
for rite control of bancroftian filariasis was taken up in Orissa from 1949 to 1954 using three control
methods separately These were: (i)five day mass DEC therapy (ii) indoor residuafspray against
a u tv ectors in rural and (m) anti-larval measures in urban areas. The five year pilot study revealed
a reduction of about 30% in the transmission by each method. The National Filaria Control
Programme was launched in 1955 with the objectives: ®to delimit the problem (ii) to undertake
nXnn f C°ntro1 Prog“le ln endemic areas and (iii) to train the professional and ancillary
personnel lequired for the programme.
The initial control strategies were mass DEC therapy at a dose of 4ing/kg body weight per day
fix e consecutive days, three rounds of indoor dieldrin spray in rural areas and weekly anti-larval
mass DEC th
“ areaS Jh.e drawbacks of
control strategy surfaced in the initial years. The
.
EC therapy was withdrawn due to poor coverage on account of side effects of the drug and
dte indoor residual spray was withdrawn due to precipitation of resistance in bancroftian vector
On account of titese problems, the programme was totally withdrawn from the rural areas hence
only anti-laival measures continued at weekly interval in urban areas. Following the recommen
dations of Second ICMR Assessment Committee, selective DEC therapy to microfilaria carriers at
dose of 6 mg per kg body weight per day for 12 days was introduced to supplement the anti-larval
measures in IxFCP towns.
At present there are 206 NFCP Control Units in urban areas with 198 Filaria Clinics and 27 Survey
thatP™5™6 C°yers onl>'11% of the
population in the country. It was obsetved
hat 8*/o of he towns, where control measures had been in operation for more than five years
showed marked reduction in Mf rate and 69% of the towns showed reduction in disease rate The
piogrimme was assessed periodically since its inception by independent experts under the aegis
of Indian Council of Medical Research and the Assessment Teams made many recommendations
tor modification of the control strategy from time to time.
10
i
1 ,,
Remew of ivermectin field trials in India
and its prospects in the National Programme
Dr. Kumarasu-ami, Assistant Director, Tuberculosis Research Centre, Madras
I
™™S'C
” “On“iOn ShO“’d “ “'P“b,e *»« <>f
of ire„S
h ennectin is the drug of choice against Onchocerciasis. It is a mixture of two microcvclic
lactones derived from the fermentation of actinomy<
/cetes. Streptomyccs avermitilis. The efficacv of
the drug was <discovered
”
and developed in the laboratories of Merck Sharp and Dohm.
Tile hospital based clinical field trials were carried out in India initially in Madras and
, ‘™anetShwaf :’8a,nst " ■ bancrofti infection and in Alleppey against B. malavi infection. The
o parative efficacy and tolerability of single and split doses of ivermectin and DEC were studied
he microfilaria clearance and associated side effects were monitored in double blind studies.
In the first clinical trial in Madras 40 mf carriers with U'C bancrofti infection divided into four
equal groups were separately treated with ivermectin at doses of 25,50.100 and 200pg/kg body
weight. The drug was found effective in all the four groups in ’clearing
the
circulating^
within-J5
’
‘
to 12 days. After three months the mf in most jpatients (89
— to 92%)
— reappeared at 10 to 19% and after
six months at 14 to 329m of the pre-treatment levels'
“
'
In the second trial in .Madras ivermectin was given at a single oral dose of 20pg/kg body weight
to the first group of 13 mf carriers and the second group of 13 mf carriers ^vere given a single oral
d°S,e °f ,’0^'8/^8 b°dy We‘sht’ whlle a third 8rouP of 14 mf carriers were given DEC at a daify dose
of 3 mg/kg body weight from day 2 to day 13. All the 26 patients in ivermectin groups were free
rom microfilaria, while 3 out of 14 in DEC group continued to show microfilaraemia.
The level of mf at two months and six months after treatment was 11.2% and J 8 3% in the first
group of ivermectin, 6.5T and 19.5% in the second group of ivermectin and 1.2% and 6 0% in DEC
group respectively as compared to pre-treatment levels. The reappearance rate was found higher
in ivermectin groups as compared to DEC group.
In Bhubaneshwar trial 60 mf carriers with W. bancrofti infection were divided into four equal
groups and ivermectin was administered as a single oral dose at four dosage levels of 20ug 50u«
lOOpg and OOpg per kg body weight. Microfilaria from blood was cleared in all patients with all
dosages within 1 to 14days. In most patients the microfilaria reappeared by 3 months and 6 months
and the levels averaged to 12.2% to 44% of the pre-treatment values in the four study groups.
In Alleppey trial 60 mf carriers with B. malayi infection divided into four equal groups were
given sing e oral dose of ivermectin. The dosages were was 20pg, 50pg, 100pg and Mlpg per ka
body weight. After six months, 32 patients received repeat treatment with ivermectin at the same
dose given initially. Reduction in circulating microfilaria was observed from 12 hours after initial
dose up to 30 days and thereafter the mf started increasing. After 6 months the mf lex-el reached
20 to ,0 per cent of pre-treatment levels. The two higher dose groups showed faster and greater
clearance as compared to the two lower dosage groups.
11
The side effects in all the treated patients generally consisted of fever, headache cough
weakness, myalgia, lethargy, etc. The side effects were quantitatively and qualitatively similar in
ivermectin and DEC groups. The side effects were more among patients with higher mf counts. The
side effects subsided within 24 to 72 hours after simple medication.
The studies with ivermectin in other countries revealed that a single oral dose of400ug/kg body
weight yielded definitely superior microfilaricidal activity. The single yearly or even two yearly
doses of ivermectin appear equally effective as similar dosing with DEC. Ivermectin field trials are
in progress m Tamil Nadu under the aegis of CRME, Madurai and VCRC Pondicherry. When
ivermectin is registered for large scale use in the control of lymphatic filariasis, it will serve as an
additional tool in the mass treatment regimens in the national programmes of the endemic countries.
Dr. S. Pattanayak in his concluding remarks as chairperson of the technical session commended
the interaction of the participants with the speakers and was veiy optimistic that the new control
strategy would yield the desired results at a shorter interval with the dedicated team of workers in
the country.
12
"T
Proposed Strategy for the Control of Filariasis
Dr. I^.S. Sharma, Director, NMEP, Delhi
Dr. R.S. Shanna outlined the following four components of revised control stnteav me- i
dose mass DEC therapy at a dose of 6 mg/kg body weight once a year CH Man
r 8
and chronic filariasis through referral services at selective centres (iii) IEC for inculcffingTndMduaD
community based protective and preventive measures for filaria control and (ivreontinuation^f
■ ntmectourjeasures in aHtheNFCP towns as^complimentaiy to anti-parasitic m^sur^T^hhf
^ers detected pi filaria, clinics and elsewhere will r^e we sl^Xd^e of 6 mX body
f-yr—pv-j ay -°r 1~ d‘!-\dHe enumerated the advantages of single dose DEC mass therapy as
follo^srW It appears to be as effective as the 12 day therapy as a public health measure Gi) h has
costs GvIRdiT therebyfaCllltatI”8 ^tter public compliance, (iii) It involves decreased delivery
costs (n ) It does not require complex management infrastructure (v) It can be integrated into the
comlynnrPr,ma?h ei
SySte?
deIiVei?' ComPliance’ (vi) Single dose mass therapy in
bination with other techniques has already eliminated lymphatic filariasis from Japan, Taiwan
ith Korea and Solomon Islands and markedly reduced the transmission in China and (vii) DEC
mass therapy is much safer in India in the absence of onchocerciasis and Loiasis infections.
He listed the following points for management of acute and chronic manifestations in the
revised strategy; G) Adequate referral centres for filaria case management to be developed in the
se ected centres initially which will have to be extended to other areas, (ii) Treatment of
adenolymphangitis (ADD with the antibiotics to be augmented since majority of acute episodes
appear to be of bacterial aetiology, (iii) Rigorous local hygiene with or without local antibiotic and
anti-fungal agents to be promoted to prevent ADE so as to permit the reversal of lymphoedema
iv) Early treatment with standard 12 day DEC therapy of mf carriers to be adopted to prevent further
ymphattc damage and renal failure, (v) Community health education to be intensified emphasising
the importance of lorai_hygiene_to_t,he affected limbs and to organise self-help support groups
trough\GOs and (vi) Project proposals tqbe taken up for imparling training to medical profession
on_the htest surgical technK|ues_ir:i filariasis in selected medical institutions thromOrfhe Indian
Councilof Medical Research in collaboration with the World Health Organisation and other bilateral
ii
I
•
I
He reiterated the proposal of observing the National Filaria Day (NFD) on Sth August every
year for five years from 1966 to 2000 AD since Sth August falls on school working days during the
five consecutive years thereby enabling to integrate the single day mass therapy xvith midday meal
programme of school going children. NFD could be taken up in selected districts in the endemic
belts in 1996 which could be extended to the entire endemic districts in the subsequent two years.
le average per capita expenditure of single dose DEC comes to 28 paise which will prove to be
cost-effective in achieving the goal of the revised strategy.
I
I
>
/
13
I
Communication Strategy for Revised Filariasis CONTROL
Dr. S.K Dharan, Director, Central Health Education Bureau, New Delhi
Dr. Dharan emphasised the importance of communication development for successful
implementation of revised strategy for the control of filariasis. She said that community education
was an integral part for the success of any mass based health programme. She asserted that individual
and community '"protective and preventive measures need to be propagated within the socio
economic environment to generate a demand for the envisaged services from the revised strategy
for the control of filariasis. The communication methodology shall be oriented in convincing the
community that the revised strategy will be highly beneficial to the community and the new
generation will be totally freed from the ugly manifestations of filariasis. The communication
modules shall be simple and effective in conveying the message. Preferably the message shall be
pictorially depicted which could be easily understood by semiliterate also and the written script shall
be in local language so as to reach the maximum persons of target group. The involvement of
opinion leaders as well as non-formal leaders will serve the objective in disseminating the message
to the community' for seeking their full co-operation and active participation in the revised strategy.
The mass media methods like TV. Radio, Video Quickies, Video on Wheels, Cable TV, and the print
media like posters, folders, hand bills, etc. shall be judiciously utilised through the help of mass
media experts to relay the message to every nook and corner of the vast endemic belts. The
preparation for the National Filaria Day shall be planned in advance taking advantage of the
experience gained in the observation of national days for other health programmes like National
Immunisation Dav. She assured that the Central Health Education Bureau would extend all the
needful help in developing the mass communication material for successful implementation of the
National Filaria Day.
I
14
..
STATE’S PROPOSED PLAN FOR THE
REVISED STRATEGY
ANDHRA PRADESH
East Godavari and Srikakulam districts are proposed to be taken up in the first year of the
revised strategy for control of filariasis. The population as per 1995 estimate is 4.91 million in East
Godavari District and 2.49 million in Srikakulam district. There are 60 PEICs, 553 Sub-centres and
1411 villages in East Godavari district and 54 PHCs, 291 Sub-centres and 3813 villages in Srikakulam
district respectively. The endemicity rate during 1995 was 2.9% and 5.0% in East Godavari and
Srikakulam districts respectively.
Health Infrastructure: The total sanctioned strength of health personnel in East Godavari and
Srikakulam districts is 2729 and 773, while the vacant posts are 321 and 197 respectively. Efforts are
being made to fill the vacant posts on priority in view of the Revised Strategy.
In East Godavari district 42 vehicles are road-worthy while 27 vehicles arc in working condition
in Srikakulam district. The list of organisations for intra and inter-sectoral co-ordination is given in
the report of the State.
The requirement of funds for NFD is given below:
Item of Expenditure
Cost
1.
Cost of 44.4 million tablets
Rs. 20.72 lakhs
2.
POL
Rs. 19.84 lakhs
3.
Biscuits
Rs. 37.00 lakhs
4.
IEC material
Rs. 5.00 lakhs
Total
Rs. 82.56 lakhs
The calendar of activities, Reporting System. Nodal Officers at different levels and PHC-wise
population are furnished in the detailed report prepared by the State.
BIHAR
Two Districts namely Darbhanga and Siwan are proposed by the State for revised control
strategy and the population of the two districts is 2.51 million and 2.17 million respectively. There
are 13 blocks in Darbhanga. 15 blocks in Siwan and the filaria vector density was 109 and 132 per
10 man hours respectively. The infection rate was 9-5 % in Siwan and 0.9% in Darbhanga. The State
representative identified the shortage of staff due to vacancy and the acute shortage of vehicles as
major problems. Only three vehicles are in working condition out of 34 vehicles. At present there
are no NGOs to co-ordinate NFD in the two districts.
15
KERALA
Two districts namely Alappuzha (Alleppey) and Kozhikode (Calicut) with a population of 2.76
million and 2.11 million respectively are proposed for the revised strategy. The endemicity rate
during 1994 was 2.1% in the former district while the same in the latter district was 0.21%. However,
the endemicity rate in Kozhikode during 1995 (up to October) was 1.66%. There are 87 medical
institutions, 69 villages and 356 sub-centres in Alappuzha district while in Kozhikode 129 Medical
Institutions, 87 villages and 369 Sub-centres are present. The requirement of IEC material and names
of nodal officers are given in the report of the State.
The states requirement of funds for POL is Rs. 2.0 lakhs and for IEC for NFD is Rs. 12.0 lakhs
apart from the requirement of DEC tablets.
ORISSA
* ■' Two districts namely Khurda and Puri are selected for the revised strategy. The population in
Khurda District is 1.63 million while the same is 1.41 million in Puri District. The mf\md disease
rates in Khurda district during 1995 were 7.67% and 15-3% while the same in Puri district were 9.8%
and 1.8% respectively. The number of important NGOs working in Puri and Khurda districts are 8
and 12 respectively. The names of NGOs are furnished in the state report.
The requirement of material and funds for obsen ing NED is as follows:
Items of expenditure
Requirement
1.
DEC tablets
11 million tablets
2.
POL funds
Rs. 1.25 lakhs
3-
IEC material
Rs. 1.05 lakhs
Health Infrastructure: In Khurda district, there are 7 Govt. Hospitals, 17 Govt, dispensaries,
2 CHCs, 2 UGPHCs, 7PHCs, 21 new & additional PHCs and 186 Sub-centres. There are 11 BEEs, 34
LHVs, 186 HW (F), 192 HW(M), 1091 VHGs, 799 TBAs, 283 Anganwadi Workers and 13 Anganwadi
Supervisors.
In Puri District, there are 11 Govt, hospitals, 4 Govt, dispensaries, 4 CHCs. 2 UGPHCs, 6 PHCs,
21 new & additional PHCs, and 262 Sub-centres. There are 12 BEEs, 45 LHVs, 58 MPHs, 179 HW
(M), 261 HW (F), 984 VHGs, 1003 TBAs, 84 Anganwadi Workers and 3 Anganwadi Supervisors.
Block-wise distribution of medical institutions is furnished in the report.
TAMIL NADU
Two districts namely North Arcot and South Arcot with a population of 5.23 million and 4.83
million respectively are proposed for the revised strategy. In North Arcot district there are 2021
villages, 9 Municipalities, 38 Hospitals, 141 Primary' Health Centres, 872 Health Sub-centres, 1751
field public health functionaries and 6 voluntary agencies. In South Arcot district there are 2389
16
<
villages, 7 Municipalities, 12 hospitals, 133 Primary Health Centres, 876 Health Sub-centres, 1708
field public health functionaries and 74 voluntary agencies. The.endemicity rate in 1995 was 0.42%
in urban areas, 2.3% in rural areas of North Arcot district and 0.66% in urban areas and 0.58% in rural
areas of South Arcot District. The district-wise health manpower, list of NGOs, requirement of IEC,
details of Nodal Officers and proformae for monitoring of NED and the details of expenditure are
given in detail in the state report. The budget requirement of Rs. 32.68 lakhs for IEC is projected
' for the revised strategy.
UTTAR PRADESH
Two districts namely Varanasi with a population of 5-3 million and Gorakhpur with a
population of 3-3- million are proposed for the revised strategy. The endemicity rate as per survey
team reports was 9-0% in Varanasi District and 16.12% in Gorakhpur District. The State representative
furnished full details of the existing NFCP.
WEST BENGAL
Purulia district with a population of 2.22 million spread in 20 developmental blocks, 2456
villages and 3-8 lakhs households is proposed for the revised strategy. The district has 2.01 million
rural population and 0.21 million urban population. There are 72 PHCs and 385 Sub-centres. The
State representative projected the total cost of revised strategy in 9 districts in West Bengal.
Strengthening of referral centres for filaria case management will be augmented through World Bank
assistance soon. This project has strong training and Health Management Information System
(HMIS) components which will be utilised to train doctors in diagnosis and treatment of filaria
patients appropriately at the local level and surgical treatment will be provided at district level. The
revised strategy could therefore complement and consolidate investments made in the World Bank
aided Project by providing basic infrastructure.
Before formation of the groups, Dr. Jaishri Jethwaney, Professor of Indian Institute of Mass
Communication, was invited to apprise the participants on IEC. She gave the relevant methods to
be obsewed for the successful implementation of the revised strategy for the control of filariasis.
Dr. Paul Kandaswamy, Joint Director, Directorate of Public Health and Preventive Medicine,
Tamil Nadu apprised the participants about the successful implementation of DEC medicated salt
trial in Tamil Nadu.
f Cr
-
J
17
GROUP DISCUSSIONS AND
RECOMMENDATIONS
Group 1
Single day DEC mass therapy and case management:
STRENGTHENING OF REFERRAL SYSTEM.
1.
Target population and area to be covered
The revised strategy will be implemented in the identified 13 districts of seven States. The
approximate population to be covered will be 4.1 crores (41 million) in the first year and by 1998
the entire 412 million endemic population will be brought under the revised strategy.
7
Phasing of the Strategy
i)
ii)
Planning Phase
a)
Training of personnel involved in the revised strategy
b)
Arrangements of funds for the DEC, POL and IEC material
c)
Arrangements of logistics
Preparatory Phase
Broad calendar of activities as given in the draft document is agreed.
iii)
3.
Implementation Phase
a)
Broad strategy defined in the document is agreed upon. (The representa
tives of Andhra Pradesh feel that in their districts on account of heavy rains
during the month of August, NED should be observed in the month of
October/Noyember. (However, the change of months for NED is not
recommended by the group)
b)
Single day drug therapy will be for first two years followed by a medicated
salt for another three years. Thus the programme will go on for a total period
of five years. Where medicated salt is not available, the annual single day
therapy will continue. The community should be educated to get the drug
after meals. The cases will be treated with the standard recommended
regimen for foot hygiene & antibiotics for which the field personnel will
be given adequate training.
Infrastructure through which it is to be implemented
At the Central level Directorates of NICD and NMEP will be the nodal agencies. They will be
responsible for procurement of drug and developing strategy for IEC. They will arrange necessary
funds for the same. At the State level State Programme Officer (Filaria) will act as nodal agency.
18
i
49
Chief Medical Officer in the identified district will look after the programme for the district. MO,
in-charge of the PHCs through its staff will take part in actual implementation of NED. In urban areas,
Corporation/Local Bodies and FW Centres will look after the programme. Maximum participation
of NGOs will be ensured.
4.
!
Procurement, Distribution and Delivery System of DEC
As envisaged in the revised strategy, Director NMEP will procure the DEC tablets, which will
be directly supplied to CMOs who will distribute them to Primary Health Centres. The drugs will
be stored at Sub-centres for NED.
For supply of DEC medicated salt it is proposed that the major supply of DEC medicated salt
shall be procured from the manufacturing agencies.
5.
Requirement of Resources in Terms of Finances, Trained manpower, drugs and
material
It should be worked out by the Directorates NICD & NMEP.
6.
Mobilisation of Resources through Restructuring of Already Available
Resources and through Additional Resources
It is proposed that DEC tablets powder and POL will be funded totally by the Centre and
expenditure for IEC activities will be carried out by the individual States on the sharing basis in the
ratio of 85:15 between Centre and States respectively.
Operational Guidelines
As laid down under item Nos., 6.1, 6.1.5, 6.1.6, 6.1.7, 6.1.8, 6.1.9, 6.2 and 6.3
of document of the revised strategy for control of filariasis, is broadly agreed to (vide Appendix 3).
8.
Monitoring and Evaluation System
Concurrent and terminal evaluations will be done by a committee of independent experts.
Broad outlines of the evaluation as specified under items 7.1, 7.2 and 7.3 of the document of revised
strategy will be followed (vide Appendix-3).
*
J
19
It
Group 2
Iec And Development Of Proformae For
Monitoring And Assessment Of Revised Strategy
For Control Of Felariasis In India
The group deliberated and eventually reached a consensus that instead of naming it ‘National
Filaria Day’, we should change the nomenclature to 'Filaria Day’ as during the current year the
programme of mass chemotherapy on August 5, 1996, is restricted only to 13 districts in the country
(However, after deliberations the Group agreed to retain ‘National Filaria Day’ in view of extension
of the revised strategy to all endemic districts by 1998)
Objectives of the IEC Programme:
To create awareness among the target segments (40.91 million people) about the Filaria Day
and inducing them to take the DEC tablets.
Target population to be reached:
Among the 40.91 million population in 13 districts, everyone is to be reached. But .in order to
reach out to different segments through appropriate media, the target population is divided into
three major segments:
i.
School/College students and drop-outs. (Age: 5 years - 20 years)
2.
Industrial workers/Agriculture workers (20 years +)
3.
Women (20 years +).
In order to know the demographics and psychographics of the target public, secondary data
analysis will be necessary for choosing the appropriate media and knowing their communication
habits.
Other targeted segments to receive this message are:
1.
Medical Community (Doctors, Paramedical staff, Health workers, Anganwadi workers,
etc.)
2.
Opinion makers (Local MPs/MLAs, bureaucrats, school teachers, panchayat members,
industrial sector officers, Mahila Mandal Chiefs, etc.)
3.
General population (Youth, School/College going/school drop-outs, Industrial work
ers and women).
While it is a matter of detail to workout the specific communication messages to suit the level
of comprehension of the above mentioned target audience, an attempt has been made to give below
the information required to be included for two target segments viz. the general public and the
medical fraternity.
20
i
Message treatment for general public
Message input:
•
In order to prevent filaria, do not forget to take the DEC tablets.
•
Remember August 5 is the Filaria Day.
•
Take your free-dose of medicine from health worker, Primary Health Centre, Filaria
Clinic or Filaria Control Unit or other designated outlets.
Additional Input:
A few may get fever, headache, nausea or feel uneasiness; it is possible you are carrying the
filaria parasite. Do not panic. It is an indication that the medicine is having its impact. If the symptoms
persist for more than three days, consult the doctor.
The above mentioned message would be suitably adapted to suit the required media in which
it is intended and the target segments for which it is used. It is recommended to have these messages
in the local language of the district.
Message Statement for the Medical Fraternity:
Remember August 5. is the Filaria Day. The following schedule is recommended.
Age group
Dose of DEC
18 years and above
300mg
(three tablets of 100 mg each or six tablets of 50 mg each).
12 to 17 years
225 mg
(21/4 tablets of 100 mg each or 41 - tablets of 50 mg each).
6 to 11 years
150 mg
(11/2 tablets of 100 mg each or 3 tablets of 50 mg each).
2 to 5 years
"5 mg
(3/4 tablet of lOOmg or 11/2 tablets of 50 mg each).
1 year
30mg
(1/3 tablet of 100 mg or 2/3 tablets of 50 mg)._________
Note: Infants need not be given DEC in view of long pre-patent period of filaria infection.
Where to say? (Use of media vehicles):
As the message dissemination is restricted only to 13 districts of the country covering a
population segment of 40.91 million, use of mass media at national level is ruled out. While it is
a matter of detail to work out the appropriate media to suit its reach and accessibility to the target
audience, following means of media are recommended:
n
1.
Local News Papers
2.
Programmes in Local Radio Stations/Regional TV Programmes
3.
4.
Posters/Pamphlets/Direct-mailers/Cable Network
Inter-personal communication including folk media, local hats, melas, etc.
5.
Video-vans and Outdoor publicity (wall slogans, etc.)
The Ministry of Information and Broadcasting has a wide network throughout the length and
breadth of the country with their mass media officers posted at district level and their services can
be utilised for sensitising the media. The message can be made to reach every nook and corner
through their field publicity units. Every district also has State District Information Officer who is
trained in mass-media handling. His services can also be fruitfully utilised in dissemination of
information about the Filaria Day.
21
i
J
I
Phasing of the Strategy/Time-table:
a. Planning Phase:
b. Preparatory Phase:
c. Implementation Phase
(Launching of awareness campaign):
Infrastructure through which to be implemented:
January-March, 1996
April-July, 1996
July 5 to August 5,1996.
Existing and as indicated above.
Problem for procurement and distribution of delivery system:
Requirement of resources:
P-dtingtSX^“ ^StSior08.1^ eX1Stin8 —P—
past experience of the Tamil Nadu in the Pulse Poho Tmn
POpulatlon is w°^ed out, based on
total expenditure would workout to 40 91 x 4 = Rs 1^4 nnnT, Pr°8ramnle ’ ^5). Hence the
lakhs and sixty four thousand only) T^he expend^re is w vT (
°ne CrOre sixtV
would include existing medicallffictre JnToJer hZhh
ioetd iesders, p^te pu.d.ioners,
“1°*’
™n-Power required
WO'k^
Phamaeeuiicals.NCOsSn^c'ubmdTtonTcLte’cOT'"^??0^"™8'”"'"01'™5^0"’
PnanC'xl concessions like tax^elieO and['slsna fromSiniemationaP<sgoncirsleGOVem'nen[CanOPer
Operational Guidelines:
During the preparatory phase of April-July, 1996 the folioTh_ n. . .
,
'Wln8 actlvities need to be taken up:
quantum of drug required.
to draw a list of the Centres, the personnel and the
2.
XTiST’
■«*
me Bodies and „te I„sd„fo„a| Bodies neel "beS w'00' P'“'°P’'S' C"P°‘
3.
4.
Convening of Inter-departmental meetings for support and networking.
- rrangement of Administrative support (Pooline of vphioi
responsibilities, etc.).
PP
8 f ehldes, manpower, fixing of
Monitoring and Evaluation S•ystem:
It should be three pronged viz.
a.
b.
A mid-term appraisal of the IEC Programme.
c.
A media impact study at the end of the programme.
After presentation ofgroup recommendations th.
tor the revised strategy for control of filariasis. ’ ie entire house made tire salient recommendations
22
i
recommendations of the
national workshop on revised
STRATEGY FOR THE CONTROL OF
LYMPHATIC FILARIASIS IN INDIA
various
infeedon evai, 27millic!„
diS’’ib"“” °f
^riasis in
a c”Z,”d'™ "dld»> exposed ro rhe risk of
and rural areas affeedng an age and gender groups in 18
"h”
~dX2xtobVSXedT™.
fc
by the “
K b^' *
5
° 'noSquito 8enera viz- Cu/ex and Mansonia in a wide
diversity of habitats;
bTO'inS are “""y '”Sed in d'ra'
a8S4'2
tosuffiden. wa.er sene .es
, .1 .»ndl.io„S as seen by
drainage and accepdng .be „al rd. n'lXT™ he 01,”^ ""’S'™"1 ”d l”“
environments in filariasis endemic Conneries;'
''
' non-healrh senior io improve urban
C°""r"in88l°tal b“"'“
ImpaXonteaSa’™
personnel and d.e
“
~
new
and have identified improved ntedJsTv^^^^
Acknowledging that an international task force for disease
eradication identifies this grossly
neglected disease as potentiallv eradicableI
The Workshop:
1.
“ Zr “ "d COntr°' Ofl!rap,“fc "“---Id be a„„„e .be
23
2.
URGES the State health authorities:
(i)
to take advantage of recent advances in the understanding of lymphatic filariasis
and the new opportunities for its control;
CH)
to strengthen national prevention and control of lymphatic filariasis mechanisms
ensuring inter-sectoral collaboration regarding the monitoring and evaluation of
all control measures;
CHi)
to strengthen local programmes, in particular at the urban level, to implement
simple, affordable, acceptable and sustainable control technologies including
urban planning, environmental sanitation and vector control;
Civ)
to strengthen training, research, diagnostic, laboratory and disease management
capabilities in order to improve clinical, epidemiological and control activities
directed at lymphatic filariasis; '
(v>
to involve all relevant sectors and mobilise affected communities, enlisting their
active participation and those of non-governmental agencies (NGOs) for the
control of the disease;
(vii) to link wherever possible and desirable the control of lymphatic filariasis with the
control of other vector-bome diseases to environmental management.
Observing that the current National Filaria Control Programme (NFCP) in operation for the last
four decades could not achieve the desired results due to a variety of reasons both operational and
financial;
3. RECOMMENDS
1.
Thw initiation of a revised NFCP strategy on a pilot scale covering highly endemic states
and districts from 1996 and the revised strategy be extended to all the endemic areas
in the country in phases by 1998.
2.
The revised strategy will be an additional input on the existing NFCP strategy to make
it technically more precise, and cost-effective so as to achieve the desired results.
3.
.And endorses, in principle, the revised strategy for control of filariasis in India circulated
by the Directorate of National Malaria Eradication Programme (NMEP) and National
Institute of Communicable Diseases (NICD).
4.
The revised strategy covers the entire population, both in rural and urban areas as the
problem of filariasis is equally high in rural areas and the current programme does not
have any component to cover rural areas. The present available technology is equally
effective both in the rural and urban areas and is affordable, feasible, sustainable and
cost-effective.
5.
The revised strategy be primarily focused around observing one day as National Filaria
Day on which entire target population to be covered will be provided with single dose
of Diethylcarbamazine citrate 6 mg/kg body weight. This will be observed once a year
for a period of 2-3 years to bring down infection rate to an appreciably low level so that
transmission will be reduced and lymphatic filariasis ceases to be a major public health
problem.
6.
Thai this effort be continued through coupling with DEC medicated salt for another 35 years based on the opinion of International Experts that the disease is amenable to
elimination.
24
i
After detailed deliberations on the endemicity, the current status of the programme and
the available infrastructure, that the following highly endemic states/districts could be
taken up with the revised NFCP on a pilot basis from 1996.
States
Districts
1.
Andhra Pradesh
1. East Godavari
2. Srikakulam
4.91
2.49
2.
Bihar
3. Darbhanga
4. Siwan
2.51
2.17
3.
Kerala
5. Alappuzha(Alleppey)
6. Kozhikode(Calicut)
2.11
2.76
4.
Orissa
7. Khurda
8. Puri
1.63
1.41
5.
Tamil Nadu
9. North Arcot
10. South Arcot
5.23
4.87
6.
Uttar Pradesh
11. Gorakhpur
12. Varanasi
3-30
5.30
7.
West Bengal
13- Purulia
2.22
Total
8.
9.
10.
11.
12.
Population
(in million)
40.91
To make the National Filaria Day successful, people’s co-operation and participation
is highly essential. To achieve the same, high profile IEC programme tailor made for
the target population involving mass media, print media, inter-personal communica
tion, health education, community participation, etc. needs to be implemented. The
expenditure on IEC may be shared between the Centre and States in the ratio of 85:15.
For the successful implementation of the National Filaria Day the anti-parasitic drugs
need to be procured and distributed through all the health care delivery points through
appropriate logistic support and the Group recommends that the drugs are to be
procured by Government of India and given to the States. The expenditure on POL is
also to be met by Govt, of India. Distribution of drugs through the entire health care
delivery^ network and administration of drugs should be the responsibility of the State
governments.
The revised strategy be periodically monitored and reviewed through the network of
institutions of NICD and its branches, Regional Offices of Health N F.W., ICMR
institutions like RMRC, Bhubaneshwar, VCRC, Pondicherry and the concerned State
Health authorities.
The revised strategy include a component for management of acute and chronic
filariasis involving the existing filaria clinics, the existing medical college hospitals,
district hospitals, training of physicians, paramedical staff, etc. in proper case manage
ment. For proper management of morbidity the drugs will be provided by the states and
the training for morbidity control will be provided by the national programme
management. The management of acute filariasis including microfilaria carriers will
be given the prescribed full standard treatment as per the guidelines including
antibiotics.
The existing NFCP units will continue to function as it is today for vector control
activities. These vector control activities are also supplemented with malaria control
activities under the urban malaiM scheme. In the rural, areas no new filaria vector
control measures are recommended.
25
13.
Personal prophylactic measures through use of impregnated bed-nets being considered
under NMEP to strengthen the filaria vector control.
14.
The Group also recommends establishment of an inter-sectoral co-operation mecha
nism particularly in the urban areas and project areas which create mosquitogenic
situations and, therefore, the Municipal Bye-laws should be appropriately implement
ed. Project authorities and all the related ministries should contribute in generating
resources in anti-vector measures.
15.
In the light of the fact that the first ever pilot project in the world for the control of
filariasis was undertaken by the erstwhile Malaria Institute of India (presently the
National Institute of Communicable Diseases) and the launching and subsequent
monitoring of NFCP by NICD for 23 years (1955-1978), the participants strongly
recommend that the programme management need to be entrusted to NICD for
successful implementation of the revised strategy. The Directorate of NMEP, which is
fully preoccupied with the implementation of accelerated malaria action programme to
contain the fulminating malaria epidemics which claimed many lives recently, may be
freed from the burden of management of filaria control. The main reason for transfer
of NFCP in 1978 from NICD to NMEP was the principal control methodology (anti-larval
measures) being similar in towns covered under Urban ^Malaria Scheme and NFCP. Now
the main thrust in the revised strategy being the single dose mass therapy rather than
vector control. NICD which is already bestowed with expertise in achieving successful
eradication of smallpox, bringing guinea worm disease on the verge of eradication and
containing quickly the spread of plague epidemic, it would be appropriate to entrust
the national task of filaria control to NICD for achieving the time-bound goal of the new
strategy.
16.
There should be provision for independent appraisal of the progress of the revised
filaria control programme.
The draft document on revised strategy circulated to all the participants ten days prior to
the workshop was approved in principle by the participants unanimously. The final
document on the Revised Strategy after incorporating various suggestions made by the
participants is given in Appendix-3.
26
i
APPENDICES
Appendix 1
LIST OF PARTICIPANTS
Representatives of State Governments:
TAMIL NADU
ANDHRA PRADESH
1.
Dr. N.C. Appavoo
Additional Director of Public Health
and Preventive Medicine (Malaria)
259, Anna Salai
Madras - 600 006
2.
Dr. Paul Kandaswamy
Joint Director of Public Health
and Preventive Medicine
Institute of Vector Control and Zoonoses
Hosur, Dharmapuri District
Dr. Mudrika Prasad
Asstt. Director, Filaria
Swastha Bhawan
Department of Health
Sultanganj, Patna.
3.
Dr. Prince Prabhakaran
Reader, Stanley Medical College
Madras - 600 001
Mr. S.A. Humayun
Entomologist
Dept, of Health
Swastha Bhawan
Sultanganj, Patna.
1.
Mr. S. Ramaswamy
Special Secretary. Health Sen-ices
Govt, of U.P., Lucknow.
2.
Dr. M.C. Tripathi
Director General of Medical Health Sen-ices
Directorate of Medical & Health Sen-ices
Swastha Bhawan, Lucknow,
3-
Dr. H.C. Vaish
Additional Director (Malaria, Filaria &
Other Communicable Diseases)
Jawahar Bhavan. 4th Floor, Lucknow,
4.
Dr. R.K. Chatterjee
Deputy Director
Division of Parasitology, CDRI, Chattar Manzil
Lucknow
5.
Dr. (Mrs.) Paramjit Kaur
Prof, of Epidemiology
Department of PSM
Institute of Medical Sciences
BHU, Varanasi
1.
Dr. V. Syamalamba
Additional Director (Malaria & Filaria)
Directorate of Health Sen ices
Sultan Bazar, Hyderabad
2.
Mr. T. Gopal Singh
Dy. Director (Malaria & Filaria)
Directorate of Health Sen ices
Sultan Bazar. Hyderabad.
BIHAR
1.
->
UTTAR PRADESH
KERALA
1.
2.
Mr. Gopala Krishna Pillai
Secretary to Govt, of Kerala
Department of Health
Thiruvananthapuram
Mrs. Elsie Abraham
Assistant Director (Filaria)
Directorate of Health Sen-ices
Th i ru v a n a n t h a pu ra m
ORISSA
1.
Dr. S. M. Hassan
Joint Director of Health Sendees (Mai. & Filaria)
Heads of Department Building
Bhubaneshwar - 751 001
27
6.
Dr. Ramesh Chandra
State Entomologist
Jawahar Bhawan
4th Floor,Lucknow,
7.
Mr. V.K. Raina
Assistant Director
8.
Dr. V.K. Saxena
Assistant Director
9.
Dr. C.N. Syed Mohd. Koya
Joint Director
RFTRC, Calicut
WEST BENGAL
1.
2.
3.
4.
5.
Dr. R.C. Das
Joint Director (PH & CD)
Directorate of Health Services
‘Writers' Building
Calcutta - 700 001
10. Dr. R.N. Rai
Joint Director,
RFTRC, Varanasi
Dr. Ashok Kumar Saha
Asstt. Director of Health Sen ices (Filaria)
20, Chandney Chowk Street
Calcutta - 700 072
11. Dr. S.K. Patnaik
Deputy Director
RFTRC, Rajahmundry
Mr. B.K. Saha
Deputy Secretary
Dept, of Health & Family Welfare
Govt, of West Bengal
Calcutta.
National Malaria Eradication Programme
22, Sham Nath Marg, Delhi-110054
Dr. S.P. Mukhopadhyay
Fonner Dean & Director
All India Institute of Public Health
and Hygiene
AD-322, Sector-I, Salt Lake
Calcutta - 700 064.
Mr. R.K. Chakravertty
Former Dy. Asstr. Director, NICD
12C, Gopal Ch. Mukherjee Road
Calcutta - 700 002.
National Institute of Communicable Diseases
22, Sham Nath Marg, Delhi-110054
1.
Dr. K.K. Datta
Director
2.
Dr. D.C. Jain
Joint Director
3.
Dr. M. Jamaluddin
Joint Director
4.
Dr. S.J. Rahman
Deputy Director
5.
6.
1.
Dr. R.S. Sharma
Director
2.
Dr. B.P. Patnaik
Joint Director
3.
Dr. H. Biswas
Deputy Director
4.
Dr. R.S. Sharma
Asstt. Director
5.
Mr. C. Krishna Rao
Consultant
6.
Mr. R.M. Sundaram
Deputy Director
Dr. S. Pattanayak
Former Director,
Central Health Education Bureau
3 Kotla Road, New Delhi-110002
Dr. (Ms.) S.V. Dharan
Director,
New Delhi
Indian Institute of Mass Communication,
New Delhi
Dr. Gautam Biswas
Deputy Director
Dr. Jaishri Jethwaney
Professor,
Dr. S.S. Saha
Chief Medical Officer
28
"J
Indian Council of Medical Research
Headquarters and Regional Organisation
1.
Dr. (Ms.) Rashmi Arora
Assistant Director, Division of ECD
ICMR, New Delhi - 110 029.
2.
Dr. P. K. Das
Deputy Director (Senior Grade)
Vector Control Research Centre
Indira Nagar, Pondicherry7
3.
4.
Planning Commission, Govt, of India,
New Delhi
Dr. Prema Ramachandran
Adviser (Health)
World Health Organisation Headquarters and
Regional Office
Dr. A.P. Dash
Asstt. Director,
Dept, of Parasitology’ & Medical Entomology
Regional Medical Research Centre
Bhubaneshwar
Orissa.
Dr. V. Kumaraswami
Deputy Director, Tuberculosis
Research Centre, Spur Tank Road
Chetput, Madras - 600 031
Tamil Nadu.
1.
Dr. C.P. Ramachandran
Chief Filaria Control (CTD.FIL)
Division of Control of Tropical Diseases
Geneva.
2.
Dr. N.K. Shah
WR to India
Nirman Bhawan
New Delhi
3.
Dr. V.S. Orlov
Senior Regional Adviser (Mai and VBC)
SEARO, New Delhi
4.
Dr. P.R. Arbani
Regional Adviser (Malaria)
SEARO, New Delhi
5.
Dr. A.K.M. Kafiluddin
Consultant
Ministry’ of Health & FW, Govt, of India,
New Delhi
Ms. Shailaja Chandra
Additional Secretary' (Health)
I
29
i fi
y
Appendix 2
PROGRAMME
4th January, 1996
Time
Activity
09.00-10.00
Registration of participants
10.00-10.45
Inauguration
Lecture Hall
Welcome and opening remarks
Objectives
Dr. K. K. Datta, Director, NICD
Dr. Gautam Biswas,
Deputy Director, NICD
Addresses by
Dr. R. S. Sharma, Director. NMEP
Dr. Prema Ramachandran. Adviser
(Healtli), Planning Commission
Dr. V.S. Orlov Sr., Regional Adviser
(MAL& VBC),WHO, SEARO
Ms. Shailaja Chandra, Additional Secretary
to the Govt, of India, MOH&FW
Dr. N. K. Shah,
WHO Representative to India
Dr. B. P. Patnaik, Jt. Director, NMEP
Inaugural Address
10.45 -11.00
Vote of Thanks
Tea
TECHNICAL SESSION -1
Chairperson:
Ms. Shailaja Chandra
Rapporteurs:
Dr. Gautam Biswas
Mr. V.K. Raina
11.00-11.30
Filariasis Problem : Global scenario
Dr. C.P. Ramachandran, WHO, Geneva
11.30-12.00
Regional scenario of filariasis
TECHNICAL SESSION - H
Dr. V.S. Orlov, SEARO WHO, New Delhi
Chairperson:
Dr. V.S. Orlov
Rapporteurs.
Mr. C. Krishna Rao
Dr. H. Biswas
12.00-12.30
Recent advances in filariasis control
Dr. C. P. Ramachandran, WHO, Geneva
12.30-13-00
Operational Research in Filariasis
Lunch
Dr. P.K. Das, Senior, Dy. Director, V.C.R.C
13.00-14.00
TECHNICAL SESSION - III
14.00-14.30
14.30-15-00
Chairperson:
Dr. S. Pattanayak
Rapporteur:
Dr. S.S. Saha
Filariasis problem in India
Dr. R.S. Sharma, Director, NMEP
and current control strategy’
Review of ivermectin field trials in India
Dr. V. Kumaraswami, Dy. Director
and its prospects in the national programme TB Research Centre, Madras
30
TECHNICAL SESSION - IV
Chairperson: Dr. K. K. Datta
Rapporteurs:
Dr. C.N.S. Md. Koya
Dr. R. N. Rai
15.00-15.30
Proposed strategy for control of filariasis
Dr. R.S. Sharma, Director NMEP
15.30-16.00
Communication strategy for
revised filariasis control
Dr. S.V. Dharan. Director, CHEB
TECHNICAL SESSION - V
Chairperson: Dr. S.P. Mukhopadhyay
Rapporteurs:
16.00-16.40
Dr. S.K. Patnaik
Mr. C. Krishna Rao
Proposed state plan of activities
for revised strategy’ - Andhra Pradesh
- Bihar
- West Bengal
- Orissa
TECHNIC AL SESSION - XT
16.40-17.20
Chairperson:
Dr. M.C. Tripathi
Rapporteurs:
Dr. D.C. Jain
Dr. V.K. Saxena
Proposed state plan of activities
for revised strategy - Maharashtra
- Uttar Pradesh
- Kerala
- Tamil Nadu
5th January, 1996
10.00-10.30
TECHNICAL SESSION -VII
Formation of groups for workshop and
discussion of their terms of reference
10.30-13.00
13.00-14.00
GROUP DISCUSSIONS
Group -1 : Single day DEC mass therapy and
case management: and strengthening
of referral system
Group - II IEC and Development of proformae
for Monitoring and Assessment
of Revised Strategy
Lunch
14.00-15.30
Group Discussions continued
15.30-16.30
Presentation of group recommendations
(.30 minutes for each group)
Chairperson: Mr. Gopala Krishna Pillai
Rapporteur:
16.30-17.00
Dr. G. Biswas
Workshop Recommendations
31
Biochemistry Seminar room
Seminar room 1
Appendix - 5
Revised Strategy for Control of Filariasis in India
1.
Historical Background
Filariasis has been the major vector-bome public health problem in India next only to
malaria. The disease was recorded in India as early as sixth century B.C. by the famous
Hindu physician Susruta. In Seventh Century AD, Madhavakara described the signs &
symptoms of the disease which hold good even today. In 1709 Clarke called
elephantiasis of legs in Cochin as ‘Malabar legs’.
2.
Species of Infection
In mainland India, Wuchereria bancrofti transmitted by the ubiquitous vector, Culex
quinquefasciatus, has been the most predominant infection contributing 99.4% of the problem in
the country. The infection is prevalent both in urban and rural areas. B. malayi infection is mainly
restricted to rural areas due to peculiar breeding habits of the vector associated with floating
vegetation. Mansonia (Mansonioides) annulifera is the principal vector while
uniformis is
the secondary vector. The role of M.(M) Indiana in transmission is very limited due to its prevalence
in small numbers.
Both W. bancrofti and B. malayi infections in mainland India exhibit nocturnal periodicity of
microfilaraemia.
In 1974-75 diurnal sub-periodic IF. bancrofti infection was discovered among aborigines
inhabiting the Nicobar Group of Andaman N Nicobar Islands. Acdcs (Finlaya) niveus group of
mosquitoes are suspected to be the vectors for this infection.
3.
Trend and present endemicity of the problem
3.1.
The problem of nocturnally periodic bancroftian filariasis from 1953 onwards is given
in Table 1.
Table-1 Problem of W. bancrofti Infection at Different Points of Time (in million)
Year
Population exposed to the risk of infection
Rural
Urban
Total
1953
Microfilaria
carriers
Filaria
disease cases
25.00
1962
40.16
34.08
64.24
5.30
4.40
1970
84.91
51.39
136.30
11.30
8.00
1977
174.08
62.05
236.13
18.31
14.44
1981
221.92
82.18
304.00
21.74
15.84
1985
251.80
90.56
342.36
23.70
17.56
1989
275.36
98.94
374.30
25.00
19.00
1994
302.87
108.78
411.65
26.92
20.40
32
I
Though the disease has been prevalent since antiquity, no organised survey or estimate had
been made to delimit the problem in the country7. Megaw and Gupta (1927) were the first to publish
filaria map of India based on night blood surveys conducted in different parts of the country. Jaswant
Singh and Raghavan highlighted the problem in 1953 and prepared an endemicity map based on
replies received to a questionnaire circulated to different States. The estimates made in 1962, 70 and
76 revealed the problem to be much higher than what had been estimated earlier. In 1981 the
delimitation surveys throughout the country7 showed about 304 million people living in endemic
areas. The latest surveys in 1994 indicate that 411.7 million people are exposed to the risk of
bancroftian infection and of them 108.8 million live in urban and 302.9 million in rural areas. About
26.9 million people are estimated to be harbouring microfilaria (mf) and about 20.4 million suffer
from chronic filaria disease manifestations.
Thus it is discernible from Table-I that the problem increased manifold during the last three
decades. The increase is mainly due to i). extension of delimitation surveys in hitherto un-surveyed
districts, ii). natural growth of population in the endemic areas and iii). spread of infection to new
areas previously known to be non-endemic.
State-wise distribution of population at risk, no. of nif. carriers and no. of persons with chronic
disease manifestations during 1994 is given in Table-2.
Table-2: State-wise estimated population exposed to the risk of filariasis and esti
mated number of mf carriers and filaria cases as on 31.12.1994
(figures in millions)
Population at Risk_____No. of Mf.
Carriers
Rural
Urban
No. of
Disease Cases
SI.
No
Name of the State/
Union Territory7
Total
1.
Andhra Pradesh
52.42
39.68
12.74
3.90
1.45
2.
Assam
10.18
9.14
1.04
0.38
0.09
3.
Bihar
62.70
54.68
8.02
4.25
5.83
4.
Goa
1.21
0.71
0.50
0.01
0
5.
Gujarat
17.93
10.80
7.13
1.08
0.14
6.
Karnataka
11.56
8.83
2.73
0.74
0.08
7.
Kerala
30.76
22.99
7.77
2.44
2.40
8.
Madhya Pradesh
23.39
18.98
4.41
0.55
0.08
9.
Maharashtra
18.19
3-26
14.93
0.17
10.
Orissa
26.52
23.51
3.01
0.93
2.34
11.
Tamil Nadu
38.13
25.56
12.57
2.40
1.27
12.
Uttar Pradesh
97.76
82.81
14.95
6.88
7.37
13.
West Bengal
19.70
1.23
18.47
0.96
0.03
14.
Pondicherry
0.74
0.36
0.38
0.03
0.01
15.
A N N Islands
0.21
0.17
0.04
0.01
0
16.
Daman & Diu
0.07
0.07
0
0
17.
Lakshadweep
0.05
0
0.04
0.01
0.01
0
18.
Dadra & Nagar Haveli
0.13
0.12
0.01
0.01
0
411.65
302.87
108.78
26.92
20.40
Total
33
1.48
It is seen from Table-2 that the State of Bihar has shown highest endemicity of over 17%
followed by Uttar Pradesh, Kerala and Orissa. Andhra Pradesh and Tamil Nadu have about 10%
endemicity. Goa showed the lowest endemicity of less than 1% followed by Lakshadweep (1 8%)
Madhya Pradesh (above 3%) and Assam (about 5%). The latter two States have pockets showing
high endemicity. Of the 20.4 million disease cases prevalent in the country, Uttar Pradesh and Bihar
country1^ COntnbUte 13’2 million cases which constitute nearly two thirds of the total cases in the
Northern districts of Kerala, Tamil Nadu, Andhra Pradesh, coastal districts of Orissa and eastern
e delimited in many districts in Maharashtra and a few districts in Karnataka, Tamil Nadu, Madhya
radesh, Orissa, Uttar Pradesh, Bihar, West Bengal and Assam.
The present estimates reveal that bancroftian filariasis is endemic in 13 States and five Union
HTn anTct
i f\WeS'i’m States/UTs namelV Jammu & Kashmir, Himachal Pradesh, Punjab
n ana Chandigarh, Rajasthan and Delhi and North Eastern States like Sikkim. Arunachal Pradesh’
SM“‘pur ”d Tripl’rJ "e k“°",o be free
3.2.
B. malayi nocturnal periodic infection
The infection is prevalent in the States of Kerala, Tamil Nadu, Andhra Pradesh, Orissa Madhya
desh, Assam and West Bengal. The single largest tract of this infection is along the west coJst
of Kerala comprising the districts of Trichur, Ernakulam, Alleppey, Quilon and Thiruvananthapuram
st etching over to an area of 1800 Sq. Kms The infection in the other six states is confined to a few
of foT °
,Undertaken recently in Kerala and « five villages revealed either diminution
oci or complete elimination of the parasite as well as the vector in many villages which were
no™ to be endemic for B. malayi infection three decades back. The declining trend of this
infection is due to 1). filling of Mansonia breeding places for real estate, 2). removaf of host plants
for lotus and fish culture 3). replacement of Pistiastratiotesby Salvinia auriculata, a less hospitable
host plant for the principal vector 4). use of residual insecticide spray under NMEP which has
marked y reduced B. malayi vectors and 5). increased use of microfilaricidal drugs as well as
of dNea r°P Y ‘C meaSUreS dUC tO better health education of general public about the causation
nif JXTind ^rliOknhPe?Ple 3re eXP°Sed tO tHe fiSk °f Biiii earners and 1.2? Lakhs chronic cases.
about two Lakhs
Nocturnal sub-periodic B. malayi infection prevalent in some South East Asian countries has
been found to be absent in India.
3.3.
W. bancrofti diurnal sub-periodic infection
in.f-fDfUrinA 1 r58 1116 ?atiOnal InStitUte Of Colllmi'nicaltle Diseases (formerly known as Malaria
emic foi this infection. Since the survey being very limited, it has not been possible to know
34
' I
... .....
the trend of this infection. Epidemiological evidence indicates the possibility of Aedes (Finlaya)
mveus group of mosquitoes playing the vector role. The surveys show that this infection is limited
to a few islands and the total population of these endemic islands is about 2000.
In India, both IF. bancrofti and B. malayi are know to be anthroponotic. Extensive blood
surveys of domesticated animals did not reveal the existence of zoonotic reservoir.
Control of Filariasis in India under NFCP
4.
The first pilot project for the control of bancroftian filariasis was undertaken in a group of
villages in Orissa from 19-19 to 1954 through the conventional methods namely (i). mass drug therapy
with diethylcarbamazine (DEC), (ii). recurrent anti-larval measures and (iii). residual insecticide
spray as anti-adult measures. The pilot study revealed that each of the above methods had its own
drawback but a multiple project using all the three methods concurrently was considered
appropriate for the control of filariasis.
The National Filaria Control Programme (NFCP) was launched in 1955 for the control of
bancroftian filariasis with the objectives: (a) to undertake delimitation surveys in known endemic
areas (b) to undertake large scale control measures in selected areas and (c) to train personnel
required to man the programme.
The control activities included anti-parasitic measures by instituting DEC therapy to total
population at a dose of 4 mg per kg body weight per day for 5 consecutive days and anti-mosquito
measures with 3 rounds of indoor-dieldrin spray in rural areas and anti-larval measures using
mosquito larvicidal oil or BHC in urban areas. The results of the control measures executed from
1955 to 1960 were assessed by the ICMR Assessment Committee. The major recommendations were:
1)
Reorganisation of control units on the basis of population
2)
Recurrent anti-larval measures
3)
Establishment of new control units
4)
Prevention of filariogenic condition in town extension and new township and
5)
Adequate provision for disposal of sewage and sullage.
The 2nd Assessment Committee of ICMR was appointed in 1970 to assess the progress made
by NFCP till that time and the salient recommendations were as follows:-
1)
Selective microfilaria carrier therapy as a compliment to anti-larval measures.
2)
Delimitation of the problem in un-surveyed districts
3)
Regionalisation of control measures in contiguous areas
The NFCP was evaluated by ICMR Assessment Committee in 1982 and 1995 which made many
recommendations for incorporation in the programme.
The DEC dosage adopted in the programme is 6 mg per kg body weight per day for 12 days.
Besides MLO as larvicide organophosphorus larvicides namely fenthion and temephos have also
been introduced in the programme in 1975.
35
Population protected under the National Filaria Control Programme
and the set-up as on 31.12.1995
SI.
No
State/UT
State/UT
1.
2.
Andhra Pradesh
Assam
Bihar
Goa
Gujarat
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Tamil Nadu
Uttar Pradesh
West Bengal
Pondicherry
A & N Islands
Daman & Diu
Lakshadweep
Dadra & Nagar Haveli
34.
5.
6.
7.
8.
9..
10.
11.
12.
1314.
15.
16.
17.
18.
Population
Protected
(in millions)
Filaria
Control
Units
Survey
Units
Filaria
Clinic
5.35
0.28
7.46
0.33
3-47
0.64
3-95
0.65
5-79
2.25
8.38
6.51
1.36
0.48
0.05
0.03
0.01
29
1
35
4
9
6
16
9
16
15
21
29
10
2
1
2
2
1
2
0
0
4
0
38
6
7
19
9
8
Total
46.99
* Source: National Malaria Eradication Programme
5.
1
1
2
3
6
2
1
2
4
0
1
0
0
206
27
10
15
42
34
3
0
1
2
0
198
DEC-Medicated Salt Trials in India
Based on the encouraging results obtained in pilot trials in Uttar Pradesh and Andhra Pradesh,
the distribution of 0.1% DEC medicated salt to general public for one year was implemented in
Lakshadweep comprising a population of 25,000 during 19/6-77 which reduced microfilaria rate
by 80% and circulating microfilaria by about 90%. The DEC medicated salt project with 0.2%
concentration was concluded at Karaikal, Pondicherry which gave significant reduction in
microfilaria. DEC pilot project was taken up during 1989 in selected villages of Kalakuchi Health
District of Tamil Nadu. The results of DEC-medicated salt trials conducted in India are given in
Table-3Table -3 DEC-Medicated Salt Trials in India
SI.
No.
1.
2.
34.
5.
6.
Study
Popu
lation.
Year
Parbatpur (U.P)
204
Nelaturu (A.P)
2489
Mandapeta (A.P)
24094
Darogakhera (U.P)
340
Lakshadweep
26000
Karaikal (Pondicherry) 13000.0
Hill Settlements (Kerala) 1380
1968
1969
1971
1972-73
1976-79
Place
1980-84
1981
months Dose of
of salt DEC in salt
distri
bution
2
11
3
3
27
46
12
0.1%
0.1%
0.1%
0.3%
0.1%0.15%
0.15%0.2%
0.4%
°/o age Reduction in
Mf rate
Circu
lating Mf
61.0
86.0
34.4
57.2
80.0
98.0
100.0
94
99.3
69.0
92.4
90.0
99.5
100.0
36
T*
fir
6.
Revised control strategy
Fortunately, safe and cost-effective filariasis control methods have become available now.
Instead of 12 day cumbersome drug regime with DEC, it is very encouraging to note that a single
day treatment once a year has been found equally effective in reducing the transmission. The
adoption of new strategies has eliminated lymphatic filariasis in countries like Japan, Taiwan, South
Korea and Solomon Islands and markedly reduced filaria infection in China.
The new strategy is envisaged to encompass a four pronged attack on the disease. These are:
•
A single day mass DEC treatment at a dose of 6 mg per kg body weight once a year.
•
Management of acute and chronic filariasis episodes to reduce the morbidity and also
remedy the massive swellings through referral services in selective centres.
•
Information, Education and Communication (IEC) to inculcate individual/community
based protective and preventive habits as an integral part of filaria control strategy7.
•
Continuation of existing control measures in NFCP towns to supplement single dose
annual treatment with DEC.
The details of each methods are as follows:-
6.1
Annual single day mass chemo-therapy with Diethylcarbamazine (DEC)
6.1.1. Age-wise dose schedule
The single day mass DEC treatment will be as per the existing dose i.e. 6 rng/kg body weight.
Since it is not feasible to weigh every individual in the field to calculate the exact amount of drug
to be administered, it is convenient to adjust the dose schedule as per different age groups and this
method is also followed in the programme.
Single dose of DEC
Age group
Adult 18 years & above
300 mg
12 to 17 years
225 mg
6 to 11 years
150 mg
2 to 5 years
75 mg
1 year______________ 30 nag_____ ____________________
As the pre-patent period of filarial infection is very long, infants are not included. Chronic cases
especially illnesses among old people like heart problem, etc. are also to be excluded from the mass
drug regimen.
6.1.2. National Filaria Day (NED)
In the light of impetus accorded to some of the successful mass programmes launched through
observation of national day throughout the country, it is in the right earnest that a National Filaria
Day throughout India is proposed to be observed to achieve the national goal. The day shall coincide
with working days of school going children who constitute as the prime group to be protected from
the infection. The month of August will be appropriate period, seasonally advantageous in the
beginning of academic year, and the inaugural day could be launched on 5th August, 1996 which
37
f
falls on the first working day of the week. The NFD is proposed to be observed for five years which
falls on the following week days:-
5th August, 1996
Sth August, 1997
Sth August, 1998
Sth August, 1999
Sth August, 2000
Monday
Tuesday
Wednesday
Thursday
Saturday
6.1.3. Area and population to be covered
It is proposed to take up the new mass drug therapy initially in 13 highly endemic districts @
two districts each in six States namely Andhra Pradesh, Bihar, Kerala, Orissa, Tamil Nadu and Uttar
Pradesh and one district in West Bengal. The names of selected districts and population are as
follows:
Name of the state
Name of the district
Population as per 1995 estimate
(millions)
1. Andhra Pradesh
1.
2.
East Godavari
Srikakulam
4.91
2.49
2. Bihar
3.
4.
Darbhanga
Siwan
2.51
2.17
3- Kerala
5.
6.
Alappuzha (Calicut)
Kozhikode (Alleppey)
2.11
2.76
4. Orissa
7.
8.
Khurda
Puri
1.63
1.41
5- Tamil Nadu
9. North Arcot
10. South Arcot
5.23
4.87
6. Uttar Pradesh
11. Gorakhpur
12. Varanasi
3-30
5.30
7. West Bengal
13. Purulia
2.22
13 districts
40.91
Total
Thus the total population to be covered in the first year in the 13 endemic districts will be 40.91
million.
During the second year, (i.e. Sth August, 1997), the NFD will be extended to 40 more districts
covering all the 18 endemic States and UTs in addition to the 13 districts to be covered in the first
year.
During the third year, the NFD will be extended to all the endemic districts in addition to S3
districts already brought under the ambit of mass drug therapy in the initial two years (i.e. 1996 and
1997).
The single day treatment once yearly for 2 to 3 years will continue throughout the filaria
endemic districts (both urban and rural areas) in the country.
The efforts will continue for another 3 to 5 years by implementing DEC medicated salt regimen
to achieve the national goal in the elimination of the disease from the country.
38
•J
4-
I
i
6.1.4. Nodal organisations to be involved in the first year of NFD
National Level
National Institute of Communicable Diseases and National Malaria Eradication Programme
State level
1.
Andhra Pradesh
i) . The Directorate of Health Services, Andhra Pradesh
ii) . The Regional Filaria Training and Research Centre, NICD,
Rajahmundry
i
iii) . The ROH & FW., Hyderabad
i
2.
Bihar
i).
Directorate of Health Services
ii). ROH & FW, Patna
iii). RMRI/NICD Patna
7
3.
Kerala
i).
The Directorate of Health Services
ii).
RFTRC'NICD Calicut
iii). ROH & FW, Thiruvananthapuram
4.
Orissa
i).
The Directorate of Health Services, Orissa
ii).
RMRC - Bhubaneshwar
iii). ROH & FW, Bhubaneshwar
5.
Tamil Nadu
i).
The Directorate of Public Health & Preventive Medicine.
ii). Vector Control Research Centre, ICMR. Pondicherry
iii). ROH & FW, Madras
6.
Uttar Pradesh
i).
The Directorate of Health Services
ii). RFTRC. NICD, Varanasi
iii). ROH & FW, Lucknow
7.
West Bengal
i). . Director of Health Services
ii).
ROH & FW, Calcutta
iii). All Indian Institute of Hygiene & Public Health / School
of Tropical Medicine, Calcutta.
After mutual consultations involving all the concerned organisations and the officials of
Directorate of NICD and NMEP, the Nodal Officers will be identified at National, Regional, State,
District and peripheral levels who will be responsible for successful implementation, monitoring
and assessment of NFD and other related activities.
6.1.5. Financial aspects for mass drug therapy
The requirement of DEC to cover 40.91 million population in the initial year will be 163.6 million
tablets of 50 mg each. An additional component of 50 per cent more tablets will have to be provided
39
-
to each state to meet the pipeline stocks and other exigencies. Thus about 250 million tablets will
be required for the first year. The left over balance of tablets after die first year of NED could be
used in the successive years since the shelf life of DEC is five years. After the first year exercise, the
requirement of drug for the second year could be worked out more precisely with marginal buffer
stocks in addition to actual requirement.
The cost of DEC at the current rates is Rs.70/- per 1000 tablets of 50 mg each and the total cost
of 250 million tablets will be Rs. 1.75 crores.
It has been recommended by the group that the Govt, of India bear the total expenditure of
the drug & POL and 85% of IEC while the states shall meet other inputs. The normal activities of
NFCP on pattern of sharing of expenditure between State and Centre will continue as in the past.
The total expenditure to be borne by GOI in the first year for the implementation of the New
strategy’ is as follows
Estimated Expenditure (Rs.)
1.
DEC
1.75 crores
2.
POL @ Rs.2.0 Lakhs per district
0.26 Crore
3-
IEC @ Rs.5.0 Lakhs per one million population
2.05 Crore
TOTAL
4.06 crores
6.1.6. Population coverage
It shall be ensured that at least 80 per cent of the target population is covered in the NED with
maximum coverage of 15 years and above age group who carry highest burden of infection.
6.1.7. Modus Operand! in NED
The nodal organisation will have to prepare detailed calendar of activities for successful
implementation of NED. Voluntary Organisations (NGOs), Missionaries, Medical Colleges, Research
organisations in Bio-Medical Sciences, Rural Development Departments, Panchayat Raj, AIR/TV as
detailed under IEC, etc. will be fully involved right from the initial stage of the programme.
6.1.8. Broad calendar of activities
L
January 4’ & 5, 1996: The workshop brought out the details of activities to be
undertaken by different organisations involved in the new strategy including the
tentative financial support.
IL
February-March, 1996: enquiries will be made from the Drug manufacturers whether
they would be able to supply 250 million tablets of DEC of 50 mg each at a short notice
in May, 1996 and the approximate price of the drug in bulk supply.
iii.
Feb-Mar., 1996: Additional funds in the budget for NED are to be provided by Govt,
of India.
iv.
April, 1996: BE Sanction by Govt, of India for NED. the drug manufacturers will be
requested to send quotations for supply of drug & placement of order.
v.
May, 1996: The manufacturers will have to supply the drug to the consignee CMOs.
40
i
vi.
June, 1996: The CMO will distribute the drug to PHC and PHCs will make the drug
available in all the village panchayats through sub-centres.
vii.
August, 1996: NFD will be observed in all the target villages and drug compliance
report will be prepared by MO-PHCs and submit to CMO who in turn will submit the
consolidated report to State Health Directorate with copies endorsed to ROH & FW and
the Directorate, of NMEP/NICD.
6.1.9 Precautions to be observed for DEC therapy
i).
It shall be ensured that the drug is swallowed by the community members in the
presence of the identified drug administrator who could be a Panchayat Member/Local
practitioner/School Teacher/Social Worker/DDC-FTD/MPW/Anganwadi Worker, etc.
ii).
For school going children the drug should be administered during midday meal.
The drug should never be left with the community members for their consumption at
a later stage lest the compliance should suffer.
iii).
The communin’ should be forewarned and prepared through IEC that the drug could
likely to cause some mild side effects especially among the infected persons and these
side affects are transitory which will subside in a couple of days and there shall not be
any room for panicky by the community on account of side effects.
6.2.
Case management
Control of filaria morbidity is the second weapon in the new strategy. Recent advances made
in unravelling the pathogenesis of lymphatic filariasis exacerbating sub-clinical pathology have
opened up new methods in specific management of manifestation like adenolymphangitis (ADD
and other associated disorders. Most of the cases with genital manifestations among males which
constitute more than one fourth of bancroftian manifestations in the country could be remedied
through surgical methods. Referral centres in District Hospitals, CHCs and even in PHCs, Medical
Colleges, etc. will have to be developed to give relief or remission to filarial cases. Medical colleges
with financial assistance from State/ICMR/UGC could organise re-orientation surgical training to
Medical Officers to meet the growing needs of filaria patients. The inputs for case management shall
be met within the sanctioned budget of respective organisations. WHO or International Organisations
will be approached for special equipment and expertise in the recent advances made in this direction
The Govt, of India may arrange necessary’ inputs for training of medical professionals through ICMR.
Initially the adequate referral centres may be created in the 13 target districts which will be
extended to other districts in the second and third phases.
The State Health Authorities may draw a plan of action for accelerating cases management
methodology.
6.3.
Information, Education and Communication (IEC) strategy for NFD
6.3.1. Introduction
Health Education is a part of the success of any Health Programme. Information Education and
Communication (IEC) plays an important role in bringing down the disease to a low level. In terms
of Filaria, Health Education serves two purposes i). to inculcate individual/community protective
& preventive habits as a part of Filaria control within the given socio-economic & environmental
context and ii). to generate a demand for appropriate services from the health delivery system.
41
In the changing circumstances of epidemiology of diseases, and the environmental, a broad
strategy for Health Education activity is given below:
6.3.2. General Objective
To create awareness among the members of the community about the causes, prevention,
treatment and management of microfilaria carriers and disease manifestations leading to the
reduction in morbidity.
6.3.3. Specific objectives
i).
To create awareness on the reduction in the frequency of the contact between man and
mosquito.
ii).
to create awareness among the masses regarding methods which bring about reduction
in the parasite load in the community.
iii).
to create awareness on the methods which can bring about reduction in the
mosquitogenic conditions leading to the lowering of the mosquito density in the area.
The following strategy is suggested:
6.3.4. Strategy
i).
Provider - Faculty of Regional Family Welfare Training Centres and State Health
Education Bureaux.
ii).
Receiver- School children, Housewives, Mahila Mandals, Villagers, Small factory
workers & different members of community.
The involvement of community opinion and non formal leaders will be of paramount
importance in spread of awareness on filaria in community and in obtaining their co-operation in
implementation and acceptance of control activities.
6.3.5. Mix Media
i).
Mass Media: Through electronic media like T.V, Radio, Video quickies. Video on wheel
& cables.
ii).
Print Media - Posters, folders handbills, charts, flip charts, flip booklets, stickers, book
markers for school children, postal prints etc.
iii).
Other media - Through Exhibition, Folk dance Puppet show, Drama, Bhaian Kirtan
Prabhat Pheri, etc.
6.3.6. Responsibilities
i).
Centre level
Press release
Release of filaria literature
Holding of Seminars
Panel discussions of AIR & TV
42
J
ii).
State level
The same activities mentioned above will be carried out at State level.
hi).
Peripheral level
Posters completion, essay competition
Organisation of exhibition at school level
Hoarding and banners at Melas (Carnivals)
Clay models depicting filaria vector, life cycle, ant-larval treatment etc.
Organisation of camps of opinion leaders
Meetings with Mahila Samitis and Youth Clubs
Youth clubs may organise street plays or puppet shows.
Observation of National Filaria Day on 5th August, every' year throughout the
endemic parts in the country7 for creating awareness among masses and seeking community
participation.
6.4.
Monitoring and Evaluation
6.4.1. Monitoring The nodal organisations in each state shall monitor continuously on time
schedules the efficiency of different implementing agencies at the grassroots level so
as to institute immediate remedial measures.
6.4.2. Assessment The implementation of NFD and other components envisaged in the new
strategy in respect of coverage and reduction in microfilaria rate and microfilaria load
in the community will be assessed every year by the identified agencies.
6.4.3. Evaluation The successful implementation of the new strategy, planning & implemen
tation, cost-effective ratio of the new strategy as against the conventional method of
implementation will be evaluated by7 independent experts not directly associated with
the new strategy.
The appropriate proforma and frequency’ of generation of data and submission of reports will
be developed in January - February, 1996 by Experts identified by the Directorate, of NICD and
NMEP in mutual consultation with other organisation.
43
l
C -
WHO/FIU98.194
Distr.: Limited
English only
Report from Informal Consultation
on Albendazole Research
Findings in Lymphatic Filariasis
13’14 October 1998
' •
■
•
■
%
8-^ .
i
Filanasis Elimination Programme (CDS/F1L)
Division of Control of Tropical Diseases
Communicable Diseases
World Health Organization, Geneva, Switzerland
WHO/FIL/98.194
English only
This document is not issued to the general public, and all rights are reserved
by the World Health Organization (WHO). The document may not be
reviewed, abstracted, quoted, reproduced or translated, in part or in whole,
without the prior written permission of WHO. No part of this document may
be stored in a retrieval system or transmitted in any form or by any means electronic, mechanical or other - without the prior written permission of
WHO.
The views expressed in documents by named authors are solely the
responsibility of those authors.
I
WHO/FIL/98.194
Page 1
Executive Summary
Those medical researchers responsible for the clinical trials of albendazole carried out to
date in lymphatic filariasis came from Africa, Asia and the Americas to participate in this
meeting, along with SmithKline Beecham’s clinical developer of albendazole and members of
the WHO* secretariat who have extensive experience in the use of albendazole and other drugs
for filariasis and intestinal parasite infections. The meeting focussed on the safety and efficacy
of albendazole (alone and in combination with either ivermectin or DEC) primarily in lymphatic
filariasis. Conclusions and recommendations were formulated.
Safety of Albendazole and albendazole combinations
Numbers of individuals assessed:
During the past 20 years it is estimated that
albendazole has been given for intestinal helminth infections to 200-300 million people (mostly
children) living in filariasis-endemic areas. If only 1% of these had active filarial infections [more
likely to be 10-30%], still at least several million co-infected children would already have been
treated. Safety experience with the drug has been excellent, and no adverse reactions have
ever been attributed to concurrent filarial infections.
in the present studies (funded by WHO, SB, USAiD, CDC and DBL) 2 728 men, women
and children have been treated (-25% being microfilaraemic) under conditions of both clinical
and laboratory safety monitoring (668 with albendazole alone, 1 850 with albendazole-plusivermectin and 116 with albendazole-plus-DEC).
Another 1 110 .children with intestinal
parasites received the same regimens and were clinically monitored for safety. By the end of
1998 the total number monitored for safety will be almost 4 000. Drug dosages generally were:
albendazole 400 mg, ivermectin 200 mcg/kg and DEC 6 mg/kg, given alone (albendazole) or in
2-drug combinations, but higher dosages and longer durations were used in -100 patients.
Safety assessments: Clinically, single-dose albendazole, alone or co-administered, was
extremely well tolerated. Systemic reactions of fever, headache and myalgia in microfilaraemic
patients treated with albendazole were seen only when albendazole was co-administered with
one of the microfilaricidal drugs DEC or ivermectin (as these reactions are caused by host
responses to the dying microfilariae, and albendazole appears to be minimally or not
microfilaricidal).
Albendazole alone did not induce these systemic reactions and when co
administered did not increase their frequency or severity. Localized reactions (inflammatory
nodules indicative of death of adult filarial worms) were seen occasionally after single-dose
treatments and were generally well tolerated, but such reactions were frequent and severe in
the 15 men treated with high-dose (800 mg) albendazole daily for 3 weeks. Blood chemistry,
haematologic and renal indices were unaffected by albendazole (either alone or in
combination), except for mild, self-limited liver transaminase elevations regularly seen in 1020% of individuals treated with albendazole for any indication.
Efficacy of Albendazole in Lymphatic Filariasis
Numbers of individuals assessed:
Completed studies have provided data for
microfilaraemic patients treated with albendazole alone (n = 130), albendazole-plus-ivermectin
(n = 160) and albendazole-plus-DEC (n = 45). Studies currently underway will add data from
about 165, 1 070 and 211 patients to each of these three groups, respectively. Additionally,
data from treated patients whose infections are defined by circulating-antigen positivity in the
absence of microfilaraemia will shortly be available from -100-400 individuals on each of these
See overall List of abbreviations (p. 19)
i
WHO/FIL/98.194
Page 2
single-dose treatment regimens. Drug dosages were those described above; all received only
‘single-dose’ regimens except for the 15 receiving high-dose albendazole daily for 3 weeks.
Efficacy assessments:
Albendazole was not demonstrably microfilaricidal when
administered in single-dose regimens (though it does appear to reduce microfilaraemia by
inhibiting adult worms from shedding additional microfilariae into the circulation). Therefore,
assessment of anti-filarial effects of albendazole alone must be based on long-term
‘suppression’ of microfilaraemia (after the ‘natural’ clearance [death] of microfilariae over 6-12
months) and on decreasing levels of circulating antigen.
In repeated high doses, albendazole appears curative for W. bancrofti infections. As a
single dose it demonstrated a sterilizing effect on adult W. bancrofti (but not B. malayi) worms,
that was either statistically significant or showed the same trend in all studies. When
administered in combination with ivermectin or DEC it enhanced suppression of microfilaraemia
(probably because of the activity against adult worms) for both W. bancrofti and B. malayi
infections.
Overall Conclusions
1.
-Single-dose’ combinations of albendazole plus either ivermectin or DEC were found to
be equally safely administered to patients with lymphatic filariasis (and other individuals living in
endemic communities) as single doses of ivermectin or DEC alone.
2.
Single-dose’ 2-drug combinations of albendazole plus either ivermectin or DEC are
superior in efficacy to single drug treatment for decreasing microfilaraemia in lymphatic filariasis.
3.
Albendazole alone has a killing or sterilizing activity on lymphatic filarial adult worms.
4.
There appears to be no reason why large-scale programmes to interrupt transmission of
lymphatic filariasis should not be based on single-dose treatment regimens based on
albendazole plus either DEC or ivermectin.
Combination treatment for lymphatic filariasis creates programmatic opportunities for
5.
coordinated public health interventions.
WHO/FIL/98.194
Page 3
Report from Informal Consultation on Albendazole
Research Findings in Lymphatic Filariasis
13-14 October 1998, WHO, Geneva
Introduction
It
It is
is the
the introduction of dramatically effective treatment regimens to decrease
microfilaraemia that is most responsible for the recent designation of lymphatic filariasis as a
disease that can be eliminated and for the Resolution by the World Health Assembly to
eliminate lymphatic filariasis as a public health problem globally . The observation that single
dose ivermectin produced a rapid and sustained reduction of microfilaraemia in lymphatic
filariasis2 was followed by studies which showed that single-dose diethylcarbamazme (DEC)
was equally effective in the long-term2.
The microfilaricidal efficacy of combinations of
ivermectin and DEC proved to be greater than with either of the two drugs given alone . Most
recently, combinations of albendazole with ivermectin or DEC have been shown to be equally
effective as the combination of ivermectin with DEC in the long-term reduction o
microfilaraemia4. Albendazole has the additional benefit of its safe use in areas endemic for
onchocerciasis and loiasis and its ability to reduce prevalence and intensity of intestinal worm
infections5.
Purpose of the Consultation
The main purpose of the Informal Consultation was to examine critically all the data
available on studies, both published and unpublished, carried out on the safety tolerability and
efficacy of albendazole and its combinations with ivermectin or DEC in lymphatic fi ariasis. It
also looked at studies, both completed and ongoing, on the efficacy of albendazole
combinations in the treatment of intestinal nematode infections.
Those medical researchers responsible for the clinical trials of albendazole in lymphatic
filariasis came from Africa, Asia and the Americas to participate in this meeting along with
SmithKline Beecham’s clinical developer of albendazole and members of the WHO secretariat
who have extensive experience in the use of albendazole and other drugs for filariasis and
intestinal parasite infections (see Appendix 1). The meeting focussed on the safe y and efficacy
of albendazole (alone and in combination with either ivermectin or DEC) primarily in lymphatic
filariasis (see Appendix 2). Conclusions and recommendations were formulated (see below).
Research findings (see Table)
Macrofilaricidal activity of albendazole has been demonstrated against sub-periodic
Brugia malayi in the leaf monkey6 and against Brugia pahangi in jirds .
Details of studies carried out on the safety and efficacy of albendazole and its
combinations in lymphatic filariasis in humans are summarized in the Table_ In the first study,
the comparative efficacy of high doses of albendazole (400 mg bid for 21 days) and DEC
(6 mq/kq per day in divided doses given for the same period) was evaluated in asymptomatic
microfilaraemic men with bancroftian filariasis7.
Multiple high dose albendazole reduced
microfilaraemia less than DEC did but appeared to have greater macrofilaricidal activity, as
WHO/FIL/98.194
Page 4
11 of 15 patients treated with albendazole had “scrotal syndrome” with development of scrotal
nodules (indicative of adult worm death) in the second week of treatment. The “scrotal
syndrome” was self-limited in most cases, but 3 patients required some analgesic support and
rest. Patients with scrotal involvement also showed systemic effects such as fever, chills,
anorexia and nausea. Multiple high-dose albendazole was clearly unsuitable as a treatment
regimen for bancroftian filariasis, but given the macrofilaricidal activity and microfilaraemic
reductions seen with albendazole and given the remarkable microfilaricidal efficacy of other
single-dose regimens, it seemed logical to investigate the antifilarial activity of single-dose
albendazole, especially in combinations with either ivermectin or DEC.
The first of these studies was carried out in Sri Lanka in a ‘blinded’ trial in which the
safety, tolerability and filaricidal efficacy of single-dose albendazole 600 mg (alb 600) alone or in
combination with DEC 6 mg/kg (alb 600 / DEC 6) or ivermectin 400 mcg/kg (alb 600 / iver 400)
were compared with a single-dose combination of DEC 6 mg/kg and ivermectin 400 mcg/kg
(DEC 6 / iver 400). Prior to its commencement, however, a safety study was conducted on
10 ‘healthy’ amicrofilaraemic volunteers (unpublished). Five were given alb600 / DEC 6 and
5 alb600 / lver400. The drugs were well tolerated and none of the volunteers showed any
clinical adverse effects during the 4 week period following treatment. A comprehensive set of
laboratory safety tests was carried out pre-treatment and on days 7, 14 and 28 (where
necessary). Four patients (2 in each group) showed slight elevations of liver enzymes on day
14. The interpretation was complicated, however, by concurrent consumption of alcohol by the
volunteers; enzymes returned to normal levels by day 28. One patient who had pre-test
electrocardiographic evidence of a Grade II A-V block continued to be clinically normal and
showed no additional ECG changes after treatment. The albendazole combinations therefore
appeared to be safe.
In the study on asymptomatic microfilaraemic patients4 all 4 treatments, including alb 600
alone, significantly reduced mf counts, but alb 600 / iver 400 was the most effective regimen for
clearing mf from night blood; 9 of 13 subjects (69%) were amicrofilaraemic by membrane
filtration 15 months after treatment. Alb 600 / DEC 6 brought about a slow reduction of
microfilaraemia initially but at the ninth month and thereafter there was no significant difference
between the % pre-treatment mf levels in the alb 600 / iver 400, alb 600 / DEC 6 and DEC 6 /
iver 400 treatment groups. At 15 months post-treatment the mf/ml level expressed as a % of
the pre-treatment levels in these 3 combination regimens were below 1.5%. Filarial antigen
tests suggested that all 4 treatments had significant activity against adult l/V. bancrofti but
alb 600 / DEC 6 had the greatest activity according to this test, with antigen levels decreasing
by 77%. Early clinical assessments and laboratory safety screens were hospital-based. All
4 regimens were well tolerated and clinically safe. Systemic adverse effects such as fever (in
58% of the patients), headache (in 60%), myalgia (in 48%) and weakness (in 46%) were no
different from those seen in Sri Lankan patients in previous studies using ivermectin and DEC
for treatment of asymptomatic microfilaraemia. These adverse effects were transient, lasting no
more than 48 hours and, with one exception, required no intervention other than the
administration of paracetamol in a few cases. One patient treated with alb 600 / iver 400
developed wheezing with breathlessness about 36 hours after treatment. This was controlled
with a single-dose of hydrocortisone 100 mg IV. The systemic adverse effects appeared to be
correlated to the pre-treatment mf level and not to the individual treatment groups. Mild
elevation of liver enzymes were seen in 25-35% of patients in all 4 groups; levels returned to
within normal limits by day 14. Three patients in the alb 600 / DEC 6 group developed small
scrotal nodules by 48 hours following treatment. The nodules regressed spontaneously by 2 to
4 weeks.
WHO/FIL/98.194
Page 5
All 4 treatment regimens were thus well tolerated, clinically safe and resulted in
significant reduction of microfilaraemia. Both albendazole combinations were better than
albendazole alone. It was possible to determine the mf levels in 34 of the 50 patients at 30
months post-treatment; the mean mf levels in all 4 groups were unchanged from to those
observed at 15 months (unpublished).
In a similar ongoing study in Sri Lanka using standard doses of albendazole (400 mg),
ivermectin (200 mcg/kg) and DEC (6 mg/kg), 47 male asymptomatic microfilaraemic patients
were randomly allocated to one of 3 treatment regimens; namely, albendazole 400mg with
ivermectin 200 mcg/kg, albendazole 400 mg with DEC 6 mg/kg, and albendazole 600 mg/kg
with ivermectin 400 mcg/kg (for comparison). A follow-up of 21 months after treatment has
shown clinical and laboratory safety and microfilaricidal efficacy to be very similar to that
observed in the previous study with higher doses of albendazole and ivermectin (manuscript in
preparation).
A randomised placebo-controlled comparison of ivermectin and albendazole alone and in
combination with W. bancrofti microfilaraemia was carried out in Haitian children . One hundred
and thirteen microfilaraemic children (mean age 7.8 years) were randomly assigned to one of
the 4 single-dose treatments; namely, placebo, ivermectin 200-400 mcg/kg, albendazole 400
mg or albendazole 400 mg with ivermectin 200-400 mcg/kg. Follow-up blood examinations for
microfilariae were carried out 4 months after treatment. The post-treatment mf concentrations
did not differ significantly between placebo and albendazole treatment (4 months likely being
too early to detect any microfilaricidal [or microfilaraemia-reducing] effect in the albendazole
treated group); however, there were significant differences between the placebo and both the
ivermectin and the albendazole / ivermectin combination. The reduction in mf concentration
was significantly greater for children who received the combination than for those who received
ivermectin alone. Adverse reactions following treatment were generally mild and well tolerated
but fever, headache, myalgia and cough were reported significantly more frequently among
children who received ivermectin alone or albendazole / ivermectin combination compared to
the other two groups. However, no significant differences were found in the frequency or
severity of symptoms between children who were treated with ivermectin alone and those who
received ivermectin with albendazole. The results thus showed that for children with W.
bancrofti microfilaraemia, combined treatment with albendazole and ivermectin was more
effective than ivermectin alone with no measurable increase in severity of adverse reactions.
In a study of Brugia malayi patients in India, 48 asymptomatic microfilaraemic adults and
children of both sexes were randomly allocated to receive one of the following 3 treatments^
ivermectin 200 mcg/kg with DEC 6 mg/kg, albendazole 400 mg with DEC 6 mg/kg, and
albendazole 400 mg with ivermectin 200 mcg/kg. All patients were hospitalized for drug
administration and initial safety assessments. The systemic adverse effects such as fever,
headache and myalgia and laboratory screens were similar to those observed in previous
studies with brugian filariasis. Local inflammatory reactions were not observed. At the end ot
the first year microfilarial densities showed greater than 98% reductions from pre-treatment in
the DEC/ivermectin and the DEC/albendazole treatment groups. With ivermectin / albendazole
the reduction was 90%. This study is now in its second year.
In a double-blind, placebo-controlled trial in a W. bancrofti endemic community in Ghana
involving 1 246 (340 being mf positive) men, women and children over 6 years of age (pregnant
women were excluded), 4 treatment regimens were used:
albendazole 400 mg alone,
ivermectin 150 mcg/kg alone, a combination of the two, and placebo. Both the ivermectin alone
and the albendazole / ivermectin treatment groups showed profound statistically significant
WHO/FIL/98.194
Page 6
reductions of microfilaraemia up to 12 months after treatment, with the reduction being
significantly greater for the combined therapy only at 3 months. Albendazole alone resulted in a
progressive decline in microfilarial density but which still had not reached statistical significance
by 12 months. Mild adverse effects (fever, myalgia) occurred beginning at 18 hours and
disappeared by 3 to 4 days without intervention.
In Tanzania an ongoing two-period crossover, double-blind, placebo-controlled trial has
examined the safety and efficacy of a combination of albendazole and ivermectin treatment in
20 patients with dual infections of bancroftian filariasis and onchocerciasis and 25 patients with
bancroftian filariasis alone. Twenty males between the ages of 15 and 55 years showing W.
bancrofti mf counts of >100 mf/ml blood and >5 0. volvulus mf/skin snip without chronic
manifestations associated with bancroftian filariasis or onchocerciasis were admitted to hospital
for 14 days. They received albendazole 400 mg with ivermectin 150 mcg/kg or placebo and
observed for 7 days. On day 8 a crossover of treatment regimens was effected and all patients
are being followed up. The results of clinical and laboratory safety assessments on the first
10 patients were similar to those seen in other studies. The trial is still ongoing and the code
jmains intact. Ninety per cent of the treated individuals were amicrofilaraemic at 30 days post
treatment. A similarly designed study is also underway with 25 individuals having bancroftian
fiiariasis alone.
In Sri Lanka a field study involving 200 asymptomatic W. bancrofti microfilaraemic adults
and children of both sexes has commenced. These patients have been randomly allocated to
receive one of 4 treatment regimens, albendazole 400 mg alone, DEC 6 mg/kg alone,
albendazole 400 mg / DEC 6 mg/kg and albendazole 400 mg / ivermectin 200 mcg/kg
combinations. The safety and microfilaricida! efficacy of these regimens are being monitored.
So far more than a hundred patients have been treated with no significant adverse effects.
In Papua New Guinea, studies to examine the efficacy of DEC 6 mg/kg alone and DEC
6 mq/kq in combination with ivermectin 400 mcg/kg in interruption of W. bancrofti infections are
now in their fifth year. After two annual treatments villages where DEC / ivermectin was given
showed a greater reduction in mf prevalence and intensity (-90-98% reduction) than those
where DEC alone was given (-80-90% reduction); with respect to transmission, the ATP in
tillages where DEC / ivermectin was used had reductions of -80-95% and those where DEC
alone was used showed a -70-80% decrease after 3 cycles of annual treatment. The safety
and efficacy of albendazole, DEC and combinations of these drugs with ivermectin will now be
studied in previously untreated villages.
Two studies have compared the efficacy of albendazole and its combinations with
ivermectin or DEC against intestinal nematode infections. In a randomised placebo-controlled
study in Haiti involving 853 children (mean age 7 years) of both sexes the anthelmintic'efficacy
and nutritional benefits of treatment with albendazole 400 mg alone, ivermectin 200-400 mcg/kg
alone, a combination of albendazole / ivermectin, and placebo were compared .
The
combination treatment reduced the prevalence of Tnchuns infections significantly-more th
either drug alone. Only combination therapy resulted in nutritional benefits not found with erther
drug alone. The second study9 of 176 children between the agesi of 4 and 14 years of both
sexes compared the efficacy of albendazole 400 mg alone, albendazole 400 mg with DEC 6
mg/kg, and albendazole 400 mg with ivermectin 200 mcg/kg against Trichun5
infections. Fifty-five children with Trichuris infection showed a cure rate of 79.3/o, 3 weeks
after treatment with albendazole / ivermectin combination which was significantly greater than
that seen with the other two treatments. Thus, these two studies carried out concurrently in
WHO/FFL/r 3.194
Page 7
Haiti and Sri Lanka have shown similarly enhanced efficacy against Trichuris infection with the
albendazole / ivermectin combination treatment.
Three further studies in Ecuador, Gabon and the Philippines are underway to evaluate
the comparative efficacy of single administrations of albendazole 400 mg, ivermectin 200
mcg/kg, DEC 6 mg/kg and their combinations against intestinal nematodes.
Safety of albendazole and albendazole combinations
Numbers of individuals assessed: During the past 20 years it is estimated that
albendazole has been given for intestinal helminth infections to 200-300 million people (mostly
children) living in filariasis-endemic areas. If only 1% of these had active filarial infections [more
likely to be 10-30%], still at least several million co-infected children would already have been
treated. Safety experience with the drug has been excellent, and no adverse reactions have
ever been attributed to concurrent filarial infections.
In the present studies (funded by WHO, SB, USAID, CDC and DBL) 2 728 men, women
and children have been treated (-25% being microfilaraemic) under conditions of both clinical
and laboratory safety monitoring (668 with albendazole alone, 1 950 with albendazole-plusivermectin and 116 with albendazole-pIus-DEC). Another 1 110 children with intestinal
parasites received the same regimens and were clinically monitored for safety. By the end of
1998 the total number monitored for safety will be almost 4 000. Drug dosages generally were,
albendazole 400mg, ivermectin 200 mcg/kg and DEC 6 mg/kg, given alone (albendazole) or in
2-drug combinations, but higher dosages and longer durations were used in -100 patients (see
Table).
Safety assessments: Clinically, single-dose albendazole, alone or co-administered, was
extremely well tolerated. Systemic reactions of fever, headache and myalgia in microfilaraemic
patients treated with albendazole were seen only when albendazole was co-administered with
one of the microfilaricidal drugs DEC or ivermectin (as these reactions are caused by hos
responses to the dying microfilariae, and albendazole appears to be minimally or no
microfilaricidal).
Albendazole alone did not induce these systemic reactions and when co
administered did not increase their frequency or severity. Localized reactions (inflammatory
nodules indicative of death of adult filarial worms) were seen occasionally after single-dose
treatments and were generally well tolerated, but such reactions were frequent and severe in
the 15 men treated with high-dose (800 mg) albendazole daily for 3 weeks Blood chemistry,
haematologic and renal indices were unaffected by albendazole (either alone or in
combination), except for mild, self-limited liver transaminase elevations regularly seen in 1020% of individuals treated with albendazole for any indication.
Efficacy of Albendazole in Lymphatic Filariasis
Numbers of individuals assessed:
Completed studies have provided data for
microfilaraemic patients treated with albendazole alone (n - 130), albendazole + '^6
(n = 160) and albendazole + DEC (n = 45). Studies currently underway will addIda a from about
165 1 070 and 211 patients to each of these three groups, respectively. Additionally, data
from treated patients whose infections are defined by circulating-antigen positivity in
absence of microfilaraemia will shortly be available from -100-400 individuals on each of these
single-dose treatment regimens. Drug dosages were as described above all received o y
'single-dose’ regimens except for the 15 receiving high-dose albendazole daily for 3 weeks (see
Table).
WHO/FIL/98.194
Page 8
Efficacy assessments:
Albendazole was not demonstrably microfilaricidal when
administered in single-dose regimens, though it does appear to reduce microfilaraemia by
inhibiting adult worms from shedding additional microfilariae into the circulation. Therefore,
assessment of anti-filarial effects of albendazole alone must be based on long-term
‘suppression’ of microfilaraemia (after the 'natural' clearance [death] of microfilariae over 6-12
months) and on decreasing levels of circulating antigen.
Albendazole in repeated high doses appears curative for IV. bancrofti infections. As a
single dose it demonstrated a killing or sterilizing effect on adult IV. bancrofti (but not B. malayi)
worms, that was either statistically significant or showed the same trend in all studies. When
administered in combination with ivermectin or DEC it enhanced suppression of microfilaraemia
(probably because of the activity against adult worms) for both IV. bancrofti and B. malayi
infections
I
I
Overall Conclusions
‘Single-dose’ combinations of albendazole plus either ivermectin or DEC were found to
1.
equally
safely administered to patients with lymphatic filariasis (and other individuals living in
be
endemic communities) as single doses of ivermectin or DEC alone.
2
‘Single-dose’ 2-drug combinations of albendazole plus either ivermectin or DEC are
superior in efficacy to single drug treatment for decreasing microfilaraemia in lymphatic filariasis.
3.
Albendazole alone has a killing or sterilizing activity on lymphatic filarial adult worms.
There appears to be no reason why large-scale programmes to interrupt transmission of
4.
lymphatic filariasis should not be based' on single-dose treatment regimens using albendazole
plus either DEC or ivermectin.
Combination treatment for lymphatic filariasis creates programmatic opportunities for
o.
coordinated public health interventions.
«
L
r
I
1
WHO/FIL/98.194
Page 9
Recommendations
1.
The safety data accumulated during studies of albendazole in lymphatic filariasis should
be collected, reviewed and prepared in a form suitable for publication/registration.
2.
The numbers of patients treated with the albendazole-containing combinations in
lymphatic filariasis should be expanded in further studies.
3.
The first national programmes using these combinations to eliminate lymphatic filariasis
3
should undertake active safety monitoring during the first 4 weeks after treatment to expand the
safety evaluation data.
Pharmacokinetic data should be obtained on the albendazole-plus-ivermectin and
4.
albendazole-plus-DEC co-administration regimens.
Single-dose and multiple-dose regimens of albendazole should be studied to define the
safest macrofilaricidal regimen for curing infections in individuals.
6.
The effectiveness of albendazole-containing regimens in reversing the pathology induced
by the filariae should be investigated.
Research should be undertaken to develop markers to identify potential resistance of
7.
the filariae to all the anti-filarial drugs.
8.
Efforts to coordinate the activities of lymphatic filariasis elimination programmes with
other related public health activities should be enhanced.
Additional studies should be carried out, especially in Africa, on the comparative efficacy
of ivermectin alone and its combination with albendazole against bancroftian filariasis in
onchocerciasis and loiasis endemic areas.
9.
'0
The efficacy of albendazole combinations with ivermectin or DEC to interrupt
transmission of lymphatic filariasis should be investigated in large-scale trials.
WHO/FIL/98.194
Page 10
References
Ottesen, E.A. (1998) in Infectious Diseases and Public Health (Angelico, M. and Rocchi G. eds.),
1
pp. 58-64, Balaban Publishers, Tel Aviv.
2
Cao W et al. (1997). Ivermectin for the chemotherapy of bancroftian filariasis: a meta
analysis of the effect of single treatment, Trop Med Int Hlth 2: 393-403.
3
Moulia-Pelat, J.P. et al. (1995).
Combination ivermectin plus diethylcarbamazine, a new
effective tool for control of lymphatic filariasis. Trop. Med. Parasitol. 46, 9-12.
4
Ismail, M.M. et al. (1998) Efficacy of single dose combinations of albendazole,
ivermectin and diethylcarbamazine for the treatment of bancroftian filariasis. Trans. R. Soc.
Trop. Med. Hyg. 92, 94-97.
5
Beach, M.J. et al. (1998) Assessment of combined ivermectin and albendazole for treatment
of intestinal helminths and Wuchereria bancrofti in Haitian schoolchildren. Am. J. Trop. Med. Hyg.
(in press).
6
Mak. J.W., Sim, B.K.L., and Yen P.K.F. (1984) Filaricidal effect of albendazole against
subperiodic Brugia malayi infection in the leaf-monkey, Presbytis melalophos. Tropical Biomedicine
1. 121-123.
Jayakody, R.L.,
Silva, C.S.S.
and Weerasinghe,
of mo
bancroftian
7
Jayakody,
R.L, De
De Silva,
C.S.S. and
weerasmgne, W.M.T.
vv.ivi. i. (1993) Treatment
1
v.
. .....
filariasis with albendazole: evaluation of efficacy and adverse reactions. Tropical Biomedicine 10,
19-24.
8
Addiss, D.G. et al. (1997) Randomised placebo-controlled comparison of ivermectin and
albendazole alone and in combination for Wuchereria bancrofti microfilaraemia in Haitian children.
Lancet 350. 480-484.
9
Ismail, M.M. and Jayakody, R.L (1998) Efficacy of albendazole and its combinations with
ivermectin or diethylcarbamazine (DEC) in the treatment of Trichuris trichiura infections in Sri
Lanka. Trans. R. Soc. Trop. Med. Hyg. (in press).
10.
Denham DA et al. (1980). The anthelminthic effects of albendazole on Brugia pahangi. J.
helminthology, 54, 199-200.
WHO/FIL/98.194
Page 11
Research studies on the safety and efficacy of albendazole and its
Table:
combinations with ivermectin or DEC in lymphatic filariasis
**
Albendazole alone in lymphatic filariasis
No. of pts
Safety
assessment
Remarks
Investigator
Country
Type of study
Species
Dose
Jayakody
Sri Lanka
Multidose
Wb
400 Abid x21d
15
Published 7
Ismail
Sri Lanka
Single dose
Wb
600 A
12
Published 4
Addiss/Beach
Haiti
Single dose
Wb + Helm
400 A
219 (29 mf+)
Published 5 8
Shenoy
India
Single dose
Bm
400 A
3
Ms in preparation
Dunyo
Ghana
Single dose
Wb
400 A
369 (71 mf+)
Ms in preparation
Weerasooriya
Sri Lanka
Single dose
Wb
400 A
50
Beach
Haiti
Single dose
Wb
400 A
400
| Kazura
PNG
Single dose
Wb
400 A
75
★
See List of abbreviations (p. 19)
Clinical
Ongoing (for 6 months)
To start 11/98
Clinical
To start 12/98
WHO/F1L/98.194
Page 12
Combination of albendazole with ivermectin
Safety
assessment
No. of pts
Remarks
Investigator
Country
Type of study
Species
Dose
Ismail
Sri Lanka
Single dose
None
i normal
volunteers)
600 A/400 I
5
Sri Lanka
Single dose
Wb
600 A/400 I
13
Published 4
Ismail
Addiss/Beach
Haiti
Single dose
Wb + Helm
400 A/200 I
218 (24 mf+)
Published
Ismail
Sri Lanka
Single dose
Wb
600 A / 400 I,
400 A/200 I
Ismail
Sri Lanka
Single dose
Trichuris
India
Single dose
Bm
400 A/200 I
16
Ms in preparation
Shenoy
India
Repeat single dose
Bm
400 A/200 I
16
Ongoing (for 6 months)
Shenoy
Dunyo
Ghana
Single dose
Wb
400 A / 150 I
371 (75 mf+)
Dunyo
Ghana
Repeat single dose
14/b
400 A/150 I
1 184
Tanzania
Single dose
crossover
Wb + Ov
20
19
Ongoing (for 4 months)
Makunde
Tanzania
Single dose
crossover
Wb
25
20
Ongoing (for 4 months)
Makunde
Weerasooriya
Sri Lanka
Single dose
Wb
400 A/200 I
50
Clinical
Ongoing (for 6 months)
Espinel
Ecuador
Single dose
Helm
400 A
200
Clinical
Ongoing (for 3 months)
Belizario
Philippines
Single dose
Helm
400 A/200 I
200
Clinical
Ongoing (for 3 months)
Gabon
Single dose
Helm
400 A/200 I
200
Clinical
Ongoing (for 5 months)
Lenoble
Kazura
PNG
Single dose
Wb
400 A/200 I
75
Clinical
To start 12/98
+
5.8
Ongoing (x 21 months)
16 + 16
55
Unpublished
Clinical
In press 9
Ms in preparation
Clinical
Ongoing (for 2 months)
WHO/FIL/98.194
Page 13
Combination of albendazole with DEC
Safety
assessment
No. of pts
Investigator
Country
Type of study
Species
Dose
Ismail
Sri Lanka
Single dose
Normal
volunteers
600 A/6 D
5
600 A/6 D
13
Ismail
Sri Lanka
Single dose
Wb
Ismail
Sri Lanka
Single dose
Wb
600 A/6 D
16
400 A/6 D
47
Remarks
Unpublished
+
Published
4
Ongoing (for 21 months)
Clinical
i
In press
9
Ismail
Sri Lanka
Single dose
Trichuris
India
Single dose
Bm
400 A/ 6 D
16
Ms in preparation
Shenoy
India
Repeat single dose
Bm
400 A/6 D
16
Ongoing (for 6 months)
Shenoy
Sri Lanka
Single dose
Wb
400 A/6 D
50
Clinical
Ongoing (for 6 months)
Weerasooriya
Ecuador
Single dose
Helm
400 A / 6 D
200
Clinical
Ongoing (for 3 months)
Espinel
Philippines
Single dose
Helm
400 A/6 D
200
Clinical
Ongoing (for 3 months)
Belizario
Beach
Haiti
Single dose
Wb
400 AZ 6 D
400
PNG
Single dose
Wb
400 A/6 D
75
Kazura
To start 11/98
Clinical
| To start 12/98
WHO/FIL/98.194
Page 14
Appendix 1
Informal Consultation on Albendazole Research Findings
in Lymphatic Filariasis
13-14 October 1998, Room L 14, WHO, Geneva
Participants
Dr David G. Addiss, Division of Parasitic Diseases, Centers for Disease Control and Prevention (CDC),
Mailstop F-22, Bldg. 102, 4770 Buford Highway, N.E., Atlanta, GA 30341-3724, USA (Tel: 770-4887760, fax: 770-488-7761, E-mail: dga1@cdc.gov) CHAIRMAN
Dr Michael Beach, Division of Parasitic Diseases, Centers for Disease Control and Prevention (CDC),
Mailstop F-22, Bldg. 102, 4770 Buford Highway, N.E., Atlanta, GA 30341-3724, USA (Tel: 770-4887760. fax: 770-488-7761)
Dr Samuel K. Dunyo, c/o Danish Bilharziasis Laboratory, Jaegersborg Alle 1D, DK-2920 Charlottenlund,
Denmark (Tel: 45-77-32-77-32, fax: 45-77-32-77-33, E-mail:
sd@bilharziasis.dk)
Dr Mahroof M. Ismail, Dept, of Parasitology, Faculty of Medicine, University of Colombo, Kynsey Road,
Colombo 8, Sri Lanka (Tel: 941-698-449, fax: 941-699-284) RAPPORTEUR
Dr R.L. Jayakody. Department of Pharmacology, Faculty of Medicine, University of Colombo, Kynsey
Road, Colombo 8. Sri Lanka (Tel/Fax: 941-695-230, E-mail: phrm_cmb@slt.lk )
Dr James W. Kazura, Chief, Division of Geographic Medicine, School of Medicine, Department of
Geographic Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 441064963, USA (Tel: 216-368-4818, fax: 216-368-4825)
Dr Williams Makunde, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA (Tel:
'44-151-708-9393. fax: 44-151-708-8733)
Dr R.K. Shenoy, Former Professor and Head, Department of Medicine, T.D. Medical College Hospital,
Alleppey 688011, Kerala (Tel: 91-477-251-611, fax: 477-251-353).
SmithKline Beecham
Dr John Horton, Head of Therapeutics (Tropical Medicine), International Medical Department,
SmithKline Beecham International, SB House, Brentford. Middx TW8 9BD, United Kingdom
(Tel: 44-181-975-3638, fax: 44-181-975-3514, E-mail: john.horton@sb.com)
WHO Secretariat
Dr K. Behbehani. Director, Division of Control of Tropical Diseases (CTD), WHO, CH-1211 Geneva 27
(Tel: 41-22-791-826, fax: 41-22-791-4777, e-mail: behbehanik@who.ch)
DrT. Gyorkos, Short-term Professional, Schistosomiasis and Intestinal Parasites (CTD/SIP), Division of
Control of Tropical Diseases (CTD), WHO, CH-1211 Geneva 27 (Tel: 41-22-791-3820, fax: 41-22-7914869, e-mail: gycrkost@who.ch)
WHO/FIL/98.194
Page 15
Dr Marc Karam, Division of Control of Tropical Diseases (CTD), WHO, CH-1211 Geneva 27 (Tel: 41-22791-4389, fax: 41-22-791-4777, e-mail: karamm@who.ch)
Dr A. Montresor, Short-term Professional, Schistosomiasis and Intestinal Parasites (CTD/SIP), Division
of Control of Tropical Diseases (CTD), WHO, CH-1211 Geneva 27 (Tel: 41-22-791-2621, fax: 41-22791-4869, e-mail: montresora@who.ch)
Dr Y. Nose, Short-term Professional, Division of Control of Tropical Diseases (CTD), WHO, CH-1211
Geneva 27 (Tel: 41-22-791-3792. fax: 41-22-791-4777, e-mail: nosey@who.ch)
Dr Eric A. Ottesen, Acting Chief, Filariasis Control (CTD/FIL), Division of Control of Tropical Diseases,
WHO, CH-1211 Geneva 27 (Tel: 41-22-791-3225, fax: 41-22-791-4777, e-mail: ottesene@who.ch)
Dr Francesco Rio, Short-term Professional, Training Unit (CTD/TDT), Division of Control of Tropical
Diseases (CTD), WHO, CH-1211 Geneva 27 (Tel: 41-22-791-3833, fax: 41-22-791-4777, e-mail:
riof@who.ch)
u/i L. Savioli, Schistosomiasis and Intestinal Parasites (CTD/SIP), Division of Control of Tropical
Diseases (CTD), WHO, CH-1211 Geneva 27 (Tel: 41-22-791-2664, fax: 41-22-791-4869, e-mail:
saviolil@who.ch)
WHO/FIL/98.194
Page 16
List of abbreviations
A
albendazole (in Table)
Alb
albendazole
B. malayi
Brugia malayi
Bm
Brugia malayi
CDC
Centers for Disease Control and Prevention
D
diethylcarbamazine (in Table)
d
day
DBL
Danish Bilharziasis Laboratory
DEC
diethylcarbamazine
1
Ivermectin (in Table)
Iver
Ivermectin
mcg
microgram
mg
milligram
SB
SmithKline Beecham
USAID
United States Agency for International Development
W. bancrofti
Wuchereria bancrofti
Wb
Wuchereria bancrofti
WHC
World Health Organization
i
■
-■MJ
WHO/CDS/CPE/CEE/2000.05
ENGLISH ONLY
DISTR.: GENERAL
I
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I
Eliminate Filariasis:
Attack poverty
1
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The Global Alliance to Eliminate Lymphatic FilgHgsis
Proceedings ofthe First Meeting
^3
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Sgntiggo de Compostela, Spain
4-5 May 2000
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Report prepared by the
Department of Communicable Diseases Control,
Prevention and Eradication, World Health Organization
Geneva, 2000
S3
’
^°£al5^T0ELWatelymphatk;
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The World Health Organization would like to emr
and
With
’ SmithKline Mecham
, G°Ve,mment °f the United Kingdom
°em‘l
Ordering code: WHCVCDS/CPE/CEEZ2OOO.O5
Available in English only, with a two-page summary in French
Tnnted June 2000
Wspubta,™ is lv,ibble „„
Copies may also be requested from the:
World Health Organization
Lymphatic Hlariasis Elimination
Conn-ol, Prevention and Eradication
CH-1211 Geneva 27, Switzerland
Fax: 4122 7914777
Email: filariasis@who.int
Website: www.fllariasis.org
Text Adrea Mach
© World Health Organization 2000
i
‘'ifTr"'"'
« Tt“'“ J™® All rishB „
toi™" ’ T“
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concerning the legal status of any counny“on Xo
°f the Wor,d Heaith Organization
delimitation of its frontiers or boundaries^Dotted Itoes r7n F 3162 °f ltS authorities- or concerning the
■nay not yet be full agreement.
“ ',neS repreSent aPP™ximate border lines for which ±ere
i I
2
>
PROCEEDINGS OF FIRST MEETING. MAY 2000
Contents|
List of Acronyms
Message from the Director-General
Executive Summary
v
vi
VII
Mounting a massive effort against the diseases of poverty
Opening Ceremony
1
WHO Welcome Address
Address by His Excellency D. Fernando Riquelme Lidon, Spanish Secretary of State
Video Welcome: WHO Director-General Dr Gro Harlem Brundtland
Address by Mr Enrique Castellon Leal, Spanish Vice-Minister of Health
Address by Mr Manuel Fraga Iribarne, the President of the Galician Government
Address by the Government of the United Kingdom (DFID)
1
2
2
2
2
3
The Programme to Eliminate Lymphatic Filariasis
Lymphatic Filariasis: A Global Overview
Report from the Technical Advisory Group
Report from the Programme Review Group
Regional and Country Reports
African Region
Region of the Americas
Eastern Mediterranean Region
South-East Asia Region
Western Pacific Region
PrivBte Sector Partners: LF and the Case of a Gold Mine Manager in Papua New Guinea
Video Synopsis of SmithKline Beecham video
Working Groups' Discussions
5
5
9
10
11
11
12
14
15
16
19;
20
21
Working Group 1: Addressing Global Alliance Communications and
Information Needs
Working Group 2: Seeking Support (including funding)
Working Group 3: Defining the Role of Non-Governmental Development
Organizations (NGDOs) in National Programmes to Eliminate LF
Working Group 4: Meeting the Needs of Countries: How the Alliance
can best support more effective country action
Working Group 5: Identifying Critical Elements for Successful LF Programmes
Working Group 6: Maximizing Regional Coordination
The table of contents reflects the agreed-upon agenda of the Santiago meeting.
3
21
22
22
23
24
25
^^^CETOEUMIMTELY^TICFILAglA.^
Closing Statements
26
Smith Kline Beecham
Merck & Co., Inc.
The World Bank
Wo,KJ H.ai«,“XS
nsdo.)
Rapporteur’s Round-up
Meeting Chairperson
Annex: List of Participants
26
26
26
27
27
28
28
29
i
30
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4
?
proceedings of first meeting, MAY 2000
List of Acronyms
..
ADL
Acute adenolymphangitis
APOC/OCP
African Programme for Onchocerciasis Control/Onchoceciaisis Control Programme
CDC
US Centers for Disease Control and Prevention
CEE
Control, Eradication and Elimination
CFF
confirmed filariasis free
:c
Diethylcarbamazine (one of the drugs used against lymphatic filariasis)
DFID
Department for International Development, United Kingdom
DOH
Department of Health
HDI
Health and Development International
ICT
immunochromatographic test
IEC
information, education, communication
IMA
Interchurch Medical Association
LCS
.r.r- ■».
500OT0)
Stra‘e9y
eliminati°n Of ,ilariasiS (coun,ries Wl,h Populations greater than
■
LF
lymphatic filariasis
MDP
MML
Misima Mines Ltd.
MoH
(national) ministry of health
’
NFCP
National Filiarisis Control Programme
NGDO
Non-governmental development organization
I
.ELF
Pacific Countries Elimination of Lymphatic Filariasis
PHC
primary health care
PIS
500 0C0(i)land S'rate9y f°r e'imina'iOn 0' fi'ariaSiS (C°UntrieS Wi,h P°Polations less than
SB
SmithKline Beecham, pic. (the pharmaceutical
towards the elimination of lymphatic filariasis) company donating albendazole for use
SPC
Pacific Commission
TCC
Technical Coordination Committee
TDR
Tropical Disease Research
UN
United Nations
UNDP
United Nations Development Programme
UNFPA
United Nations Population Fund
UNICEF
United Nations Children's Fund
WHO
World Health Organization
5
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FLARIASIS
Message from the
Director-General
The world has committed to halving the number of people living in poverty by 2015. To succeed we must
strengthen our focus on how health actions can help reduce poverty. Bad health is an important’factor in
keepmg people locked in poverty. But health is, at the same time, part of the solution - a neJ and poUnXlly
powerful exit route out of poverty. The elimination of lymphatic filariasis is one good example.
Y
^^i a^ei^in thC G‘Obal Alliance-none can eliminate lymphatic filariasis on its own. When we met in
Ctetober 1999 in Geneva at WHO for the dedication of the onchocerciasis statue, many recalled the difficult
es experienced in setting up the onchocerciasis partnership. I am confident, however, that in the LF Global
that is the basis for a sound partnership. Together we will succeed.
The tasks ahead are clear: the programmes in the countries will be integrated with other disease control
Xd wi± iTn M,niS“leS °f Health' For example, the lymphatic filariasis elimination programme may be
joined with leprosy activities m some countries. It may be joined with intestinal parasite control in othen
And it may be joined with onchocerciasis activities in yet others. Millions of people will need medication to
Md^ffXSmiSS10n °f 1116 d'SeaSe; and mini°nS mOre'already infeC,ed'Wi" "eed help t0 a,leviate theirPain
comm USin8,°7- aCdVitieS °n the m°St eSSential and
most effective interventions, we can reach our
o“erty°
,ntemlptlng transmission- A‘
same time we will make a large and most immediate impact
In 1998 SmithKline Beecham agreed to donate its drug albendazole free-of-charge until the disease is eliminated
This islikely to be a donation of between 4-6 billion tablets over a 20-yejJeriod. MeS Co ™c aS
p edged to expand its Mect.zan® Donation Program for onchocerciasis to cover the treatment of lymphatic
filanasis m all areas where the two diseases occur together.
Some people have suggested that Industry-WHO partnerships such as these represent a conflict of interest
On ^ contrary, we believe such collaboration, which provides drugs for periods long enough to reach the
target, are an exemplary commitment to public health in the 21 st century.
There are several other contributors. The Arab Fund for Economic and Social Development was among the
first. The Governments of Belgium, Italy, Japan, the Netherlands, Spain, and the United Kingdomare now
generous supporters of the global programme. We are working to widen these partnerships further.
°f th6Se
and t0 a1'th£ equa"y important organizations that have committed their
eliminate lvmnh°. V?1*56’
‘0 eXPreSS my SinCere gratltude'The G1°bal Alliance has the will to
eliminate lymphatic fi ariasis and we all know the way. Let us focus on the highest priority actions for
elimination and we will surely make an impact on the lives of the poorest.
Dr Gro Harlem Brundtland
Director-General
World Health Organization
6
I
PROCEEDINGS OF FIRST MEETING, MAY 2000
Executive Summary
Green Light for the Global Alliance to
Eliminate Filariasis, Attack Poverty
I
By all accounts, the first meeting of the Global Alliance to Eliminate Lymphatic Filariasis convened in Santiago
de Compostela, Spain on 4-5 May 2000, was a success. It more than fulfilled its stated goals to review
progress in the 18 months since the previous Partners’ Meeting in October 1998, to strengthen the existing
Alliance, to seek creative ways to stimulate financial and other support in order to “reach the first 200 million
people at risk by the end of 2004.”
Overall, more than 25 presentations were made to some 70 participants at the meeting (see list of participants
in Annex). Following the welcoming ceremony and completion of organizational matters, a global overview
of the disease and its links to poverty was presented, followed by reports and recommendations from the first
meeting of the Technical Advisory Group on the Global Elimination of Lymphatic Filariasis (2-3 May 2000)
and the Programme Review Group.
In phase two of the meeting, regional and country presentations were made by 11 delegates, reviewing
progress and contributions made to LF elimination among people in affected areas through mapping, strategic
research and the development of new cost-effective interventions. The importance of interruption of
transmission and alleviation of suffering were repeatedly stressed, as was the need for mapping and programme
integration. It was recognized that no one agency could achieve success alone but that partnerships were
imperative, as were the development of advocacy and resource mobilization campaigns. This session concluded
with a ‘Targeting LF’ video produced by SmithKline Beecham.
Phase three featured interactive dialogue as participants divided into six working groups to discuss strategic
issues on themes ranging from 1) communication and information to 2) creative support and funding to 3) the
role of NGDOs to 4) effective country action to 5) critical elements for successful LF programmes to 6) maximizing
regional coordination. The final day was devoted to presentation and discussion of the informal
recommendations of each of the discussion groups.
The meeting concluded with closing statements by the major partners: SmithKline Beecham, Merck
&
Inc., the World Bank, the NGDO spokesperson, WHO, the meeting Rapporteur, and the chairperson.
Ti. _»pshot was that “an enormous amount of activity” had occurred in the short space of the last two years
to position the new Global Alliance favourably for success in reaching its goal of eliminating lymphatic
filariasis as a public health problem by the year 2020. Participants were agreed that this meeting, too, had been
a success and that the strengthening of partnerships between the public, private and non-profit sectors was
crucial to this endeavour. There were two press conferences and favourable media coverage, especially in
Spain.
At the conclusion of the meeting, the chairperson representing India announced that his country, with the
active support of WHO and SmithKline Beecham, would launch a major LF elimination campaign, starting
with a 40 million-person pilot programme. As one WHO participant put it, “This is a major breakthrough; it will
change the entire nature of our work.” Or, as the Rapporteur said in his closing remarks, ‘The most important
thing to communicate is that this campaign to eliminate lymphatic filariasis is a “first” - and that it is going to
succeed. In Santiago, the Global Alliance moved from being an idea with a name - to a concrete reality.”
7
I
GLOBAL ALLIANCE TO ELIMINATE LYfcFHATIC Ftt ARIASLS
Mounting a massive effort
against a
disease of poverty
Opening ceremony
The beginning of this two-day conference
featured statements by WHO and its Spanish
Government counterparts, highlights of which are
found below.
WHO Welcome Address
Dr Maria P Neira, WHO Director of the Department
of Control, Prevention and Eradication in the
cluster for Communicable Diseases, opened the
meeting by thanking the City of Santiago de
Compostela, the Province of Galicia, and the
Government of Spain for linking itself so
prominently with WHO’s worldwide effort to
eliminate lymphatic filariasis as a public health
problem.
Infectious diseases killed 14 million people each year,
she said, and exacerbated this personal trauma by
undermining national social and economic
development.
The graphic (below) presented by Dr Neira
illustrated the four main categories of communicable
disease in the world: the big killers like HIV/AIDS,
TB and malaria; the recurrent threats (e.g. yellow
fever, cholera, meningitis), the emerging and reemerging marauders (e.g. Ebola, hepatitis C); the
diseases targeted for elimination as public health
problems: polio, onchocerciasis (river blindness),
leprosy, guinea worm disease, Chagas’ disease,’
schistosomiasis — and lymphatic filariasis. It can
be done by 2020.
Infectious diseases: fatal, recurrent, (re-)emerglng and eradicable
.
..
'
'■........................................ ■.......... .
",................................................................................................ ”................. ■
’
.
Obstacles to Social and Economic Development
Fatal disease
To be eradicated
or eliminated
Emerging
diseases
..... rv M
Recurring
diseases
I
J
■
AIDS
Tuberculosis
Malaria
Measles
Diarrhoeal disease
Pneumonia
g rneumoma
L
_
Polio
Leprosy
Guinea worm
Filariasis
Onchoceciasis
Measles
Cha9^'disease
Rift Valley Fever
Creuxfeld Jacob’s
Disease (CJD)
Ebola
Nipah
Lassa Fever
West Nile Fever
Monkeypox
Plague
Cholera
Meningitis
Cho^
Yellow Fever
■
KSS
||||
___
Lymphatic filariasis, though not usually deadly, is c
with the
the right
right resources
resources and
and political
nXih^Lu
curable" with
will. P
d b
’ bolh ol pe0P,e
8
of ProSress. Yet it is a disease
disease that
that isis •effortlesslv
"effortlessly
t
PROCEED^GS OF FIRST MEETING, MAY 2000
said that the current focus on lymphatic filariasis
would reduce its “intolerable damage”.
Counter-intuitive though it might seem in this age
of unprecedented progress and high technology,
communicable diseases still accounted for 45% of
all deaths in least developed countries and 48% of
all premature deaths worldwide, she said, including
all of the social and economic losses that went with
them. In this day and age, this is unacceptable.
Together we must do something about it. Dr Neira
stressed.
Video Welcome: WHO DirectorGeneral Dr Gro Harlem Brundtland
An extract from the message from the DirectorGeneral is given on page vi.
Address by Mr Enrique Castellon
Leal, Spanish Vice-Minister of Health
Dr Neira described lymphatic filariasis (LF) as an
infectious disease transmitted by mosquitos. It
affected 120 million people in more than 80
countries, she said, thriving in impoverished urban
and rural communities in tropical developing
countries. The parasites (larvae and worms) lodged
in human lymphatic systems and, over the years,
caused permanent disability through swelling in
^productive organs and lower physical extremities.
Equally devastating were the psychological stigma
and adverse social consequences caused by this
debilitating and disfiguring disease.
Mr Castellon Leal cited LF’s heavy global disease
burden -120 million people in 80 countries, 700 000
of them in South America alone. He also referred to
the goal set to eliminate LF as a public health
problem by 2020 through stopping transmission
and reducing morbidity.
Address by Mr Manuel Fraga Iribarne,
the President of the Galician
Government
In declaring the meeting opened, Mr Fraga Iribarne
highlighted
health
“Clearly, we must mount
improvement as a primary
a massive effort against
objective of social and
"We must mount a massive errort
such diseases of poverty.
economic
development in
against the diseases ofpoverty.
Lymphatic filariasis is one
the 21“ century. Referring
of them. We can eliminate ! "Lymphatic filariasis is one ofthem
to Santiago’s history as a
it,” Dr Neira asserted. “To
place
of pilgrimage since
|
- and we can eliminate it."
do so, the paradigm must
the 12th century with a long
be broadened from
tradition of concerns
vaccines to drugs and other products. Collaboration
about illness and water-borne diseases affecting
must also be broadened to a wider range of
many pilgrims, he said that the scientific community
committed partners.”
must remain on the alert for re-emerging diseases.
He also focused on the “moral link”, bolstered by a
Today’s green light for the Global Alliance w'as very
decade of close cooperation, between the Spanish
important, she said. “We have the means, the
Government and PAHO. “Only one illness mechanics and the will. We must follow with action.
smallpox - has ever been eradicated in the whole
*-ormer American First Lady, Eleanor Roosevelt
history of health,” he said. “Now lymphatic filariasis
once said, ‘The future belongs to those who believe
is one of seven slated for elimination within the
in the beauty of their dreams.’ The ‘dream’ of this
coming decades.” He expressed the hope that this
Global Alliance is to eliminate lymphatic filariasis
Santiago-hosted meeting would prove useful in
once and for all from the earth. With ‘a little help
developing the Global Alliance to fight LF.
from our friends’, we will do it, too, in the short
space of only twenty years.”
Comments
Address by His Excellency
D. Fernando Riquelme Lidon,
Spanish Secretary of State and
Ambassador on Special Mission,
Dr Neira commented on the importance of financial
support by the Spanish Government and the highlevel political commitment to action against LF in
the Americas.
Ministry of External Affairs
Appointments
Ambassador Riquelme Lidon singled out the
importance of eradicating poverty which he called
an “aggression against human dignity” and both a
cause and consequence of ill health. He cited
Spain’s ongoing collaboration in the Americas and
Mr Javid A. Chowdhury, Secretary, Indian Ministry
of Health and Family Welfare, was elected
Chairperson of the meeting by consensus, and
Dr Bernhard Liese, Senior Adviser, Human
Development, African Region, the World Bank, was
appointed as meeting Rapporteur.
9
PROCEEDINGS OF FIRST MEETING. MAY 2000
much importance to building new partnerships, such
as the current one with the Lymphatic Filariasis
initiative.
from attempting to change the way we support
development. I know the LF initiative is wellequipped to do the same.”
Mr Mason said that DFID had reaffirmed its long
term support for this initiative in January with the
Liverpool School of Tropical Medicine LF Support
Centre formally coming into existence in April 2000.
Mr Mason concluded by saying that “We in the
UK are proud to be associated with the initiative. It
is concrete action to match the aspiration of
eliminating poverty. It builds on partnership and a
sharing of effort. It will rely on trust and
transparency. We hope to continue to play
whatever role the initiative asks of us to contribute
to the success of this great endeavour.”
■
The task is enormous, he said; in many ways, a
microcosm of the challenge DFID set itself in
redefining its approach to international
development. “We are learning more all the time
.... 't .. r.. . ... ;
. .....
Crttert,. The New Vision for Pevebpment
■
I
.....
• 3 true partnership, of different placers all with strengths harmonized to a
• common purpose;
. sWegie soundness, hS embwi„g » sod
'.eouindnenrs to lesso„-le3mlng and owneohip by national governed,
and
Tl
<
- ■■ ' r.
UL
7
+L
■
+l
■
■■■■ y--
•-
11
I
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
imposed by the few. ‘Tor the first time in living
memory, perhaps ever, there has materialized a
global consensus about the important things
we need to do.”
Address by the representative of the
Government of the United Kingdom's
Department for International Devel
opment: Eliminating World Poverty:
A Strategy for the 21st Century
• United Nations Reform: The UN, emerging from
a period of Cold War sterility, is reforming and
re-engineering itself as a far greater contributor
to international development than it was in the
past. The Development Assistance Framework
at country level means UN agencies work much
more closely together. Reforms at headquarters
level with results-based budgeting in UNICEF,
UNFPA and UNDP are making progress. The
trend is in the right direction.
The presenution delivered by Mr Phil Mason,
Deputy Head, Health and Population Division, of
the United Kingdom’s Department for International
Development (DFID), focused on the links between
poverty and ill health and strategies to eliminate
them in the new millennium.
A White Paper published by the British Government
in November 1997* re-defined Britain’s international
development approach with the overarching goal
of contributing to halving the number of people
living in poverty by 2015. No one underestimated
the challenge, Mr Mason said, quoting American
poet James Russell Lowell who wrote that “Not
failure, but low aim is the crime”.
• WHO Revitalization: Considering how many of
the Targets are health-related, the reforms
introduced by WHO Director-General,
Dr Gro Harlem Brundtland, are widely regarded
as re-energizing, empowering WHO to recapture
the lead in international health.
•
Performance
Measurement: To match its
aspirations, the international
Targets - a world free of
but low^im 15 the crime,
community has agreed on 21
,
abject poverty; a world in :
indicators to monitor global
which all children are
progress
which
will
... complement develop-ment
educated; where health care
removes the shadow of
targets set by national governments.
illness and disability; an environmentally
• Globalization: Increasing awareness of the
sustainable world in which each generation hands
disparities between rich and poor assail our
on to the next what is needed for living fulfilling
consciences daily. Rapid communication links
and productive lives.
mean that business happens very differently.
These International Development Targets Suddenly there is a shared interest in the health
“the bedrock of the UK’s international development
of people thousands of miles away. HTV/AIDS
strategy”- represent key aspirations in human
and tuberculosis serve as a stark reminder that
development: reducing child and maternal mortality,
the threat of transmission is now global.
making reproductive health care accessible for all,
• New Opportunities: Finally, Mr Mason said,
providing universal primary education; eliminating
there had never been a more fertile moment for
gender imbalances in education — all by 2015; and
directing new energy at the problem. Despite
implementing national strategies for sustainable
fluctuating official government development
development in all countries within the next five
assistance levels, big philanthropic foundations
years.
now offered vast new opportunities. “I was told
Mr Mason said he liked to think of these targets as
recently that the top six US Foundations now
“aiming for the stars...they may always be out of
out-spend the US Agency for International
reach, but like the maritime explorers of old, we can
Development. This is a window of opportunity
chart our course by them”. He also pointed to six
that behoves us all to respond,” he concluded.
reasons why these human development targets
“That is our vision...but we need more than lofty
were different - and feasible:
ideas. Enthusiasm is no substitute for capacity;
• Consensus: They are shared targets, endorsed
willingness no substitute for experience,”
by the big UN conferences of the 1990s, giving
Mr Mason said, explaining why DFID attached so
them the legitimacy of being owned by all, not
Britain allied itself firmly to
tits:
Eliminating Poverty: A Challenge for the 21st Century. DFID, United Kingdom. November 1997.
10
ii nun lllllll■mllllll■lllll nun in
1
i
I
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
The Programme to Eliminate
Lymphatic Filariasis
Briefly recapitulating where and how it all began.
Dr Ottesen said that the Partners’ Forum in October
1998 in Geneva had affirmed the overarching goals
of the programme as:
Lymphatic Filariasis:
A Global Overview2
Dr Eric Ottesen, Project Leader, Lymphatic
Filariasis Elimination (WHO), Department of
Control, Prevention and Eradication,
Communicable Diseases, WHO
• Interrupting transmission, primarily through
mass treatment of all endemic populations with
a single-dose, once-yearly, two-drug regimen albendazole with either Mectizan® (ivermectin)
or diethylcarbamazine (DEC) - for four to six
years or the secondary option of DEC-fortified
table/cooking salt for one year; and
Dr Ot.esen started his presentation with the
observation that, even though “the excitement is
really what happens on the ground - at the country
and community level,” it was vital to the worldwide
elimination of lymphatic filariasis to have the right
programme-supporting “building blocks” in place.
Therefore, his “global overview” would emphasize
the contributions of many to this effort of laying
“the appropriate building blocks for the
programme”.
• Controlling morbidity (i.e., alleviating suffering,
preventing disability, promoting rehabilitation)
through intensive local hygiene and education
for patients and healthcare workers.
New hope for people with Lymphoedema
Si
3
"•
J
4-’
'
-'9
■ is
2
For further details, see WHO’s Global Programme to Eliminate Lymphatic Filariasis: Programme Activities 1999.
12
■
PROCEEDINGS OF FIRST MEETING, MAY 2000
Recommendation: Upgrade this process to a
formal study; produce LF morbidity monitoring
indicators and use results as interpretation
models.
• Ensuring supplies of quality DEC Drugs:
Steps for manufacturing to ensure quality
products (e.g. new chromatography assay).
Recommendations: 1) Order DEC through WHO
to achieve economies of scale; 2) launch studies
on the development of chewable tablets to
preclude difficulties with inadequate or
contaminated water supplies; 3) appoint a small
group to study the use of standardized tablet
strengths/colours.
• Morbidity control: Development and
dissemination of the strategy.
Recommendations:].) Define disability
prevention and rehabilitation terminology in
terms of its components (e.g. management of
lymphoedema/elephantiasis, cure of hydrocele);
2) strengthen morbidity control through targeted
resource mobilization efforts, such as NGDO
inventory and training, documentation of needs,
etc.; 3) monitor follow-up activities through
development of regional LF collaborating
centers, support for hydrocelectomy and IEC to
advocate for morbidity control.
• LF as a childhood disease: Unrecognized and
under-reported in the past, studies now reveal
that LF disease starts in childhood and that
proper treatment can prevent it.
i
Dr Dadzie expressed the view that the next
20 years for LF would resemble the last
20 years for the onchocerciasis programme and that
it would be a similar success story. He stressed the
need to mobilize partners to fight this disabling
disease.
Report from the Programme Review
Group8
Dr Barnett Cline (USA), Professor Emeritus,
Tulane University School of Public Health and
Tropical Medicine, New Orleans, USA, began the
presentation by identifying the members of the
Programme Review Group: Dr P.K. Das (India),
Dr Jaime Z. Galvez Tan (Philippines), Dr Peter Kilima
(United Republic of Tanzania), Prof Isao Tada
(Japan), Dr J. Williams (New Zealand) and himself.
The Programme Review group was an independent
body with members were appointed for a three-year
term.
Dr Cline said that there had been four meetings to
date, initially focused on developing criteria for the
review and application process. The review criteria
were as follows:
Recommendations’. 1) Mobilize partners, such
as UNICEF, interested in disease/disability
prevention in children; ensure treatment and
support for children undergoing ADL attacks;
2) develop advocacy packages; 3) conduct
studies on effective macrofilaricidal treatment
with DEC and albendazole; investigate
effectiveness of various regimens on treating
and preventing the disease in children.
•
Summing up the reflections of the Technical
Advisory Group, Dr Dadzie highlighted the
importance of this programme to combat “the
world’s second largest cause of permanently
disabling disease”. He reminded his audience that
LF was assessed to be eradicable and that the
intervention tools were available. The Technical
Advisory Group members were satisfied, he
reported, that the programme was off to a good
start, had strong operational research components
and a sound plan for “learning through doing”.
• Ministerial commitment to the elimination of
lymphatic filariasis;
• Sufficient epidemiological and parasitological
data to begin operations, and provision to
expand that data progressively as needed to
support the requirements of a full national
On 5-6 May 2000 immediately following the First Meeting of the Global Alliance, an ad hoc meeting of the
Programme Review Group was held at which: 1) The Dominican Republic’s plan of action was reviewed and release
of 200 000 albendazole tablets for the first year approved; 2) The national LF plan of the Federal Islamic Republic
of Comoros was reviewed and their request for albendazole approved; 3) The plan resubmitted by Kiribati was
reviewed and conditionally approved for release of albendazole subject to completion of administrative formalities;
) The meeting received a new application from the Government of Bangladesh to initiate mass drug administration
as of January 2001; this would be reviewed in the next meeting in September 2000; 5) There was discussion of issues
around harmonization of the application form for requests for both albendazole and Mectizan® (ivermectin) by
countries in Africa where onchocerciasis co-exists with LF, with the objective of keeping the entire application
process as simple as possible for endemic countries; 6) A preliminary plan for Guyana was also discussed.
5
17
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
programme (a phased approach) generally
anticipated for larger countries);
Six additional countries’ applications had been
approved:
three
from
the
African
region
(Ghana,
Tanzania
and
Togo),
one
• Potential to integrate with other public health
from the Americas (Dominican
services/programmes;
Republic) and two from the
• Existence of a national
Western Pacific (Cook
coordination committee or
Our future isto devolve into
Islands and Vanuatu).
similar body;
Another six had almost
the regions - where the real
• Clear identification of
problem-solving takes place.. J completed the application
process: two from the African
resource requirements
teiisE
.
.
.
.
....
Region
(Zanzibar and the
needed to implement the
Comoros),
one from the
intervention programme;
Americas
(Haiti)
and
two
from
the
Western
Pacific
for applications requiring expansion of initial
(Fiji
and
Kiribati).
Applications
were
being
prepared
operations, the provision of evidence that:
by seven other countries: Bangladesh, India,
- the targets of the initial operations are being
Indonesia, Maldives, Myanmar, Sri Lanka and
met,
Thailand.
O'--
- -
- the epidemiological data are available to
justify the expansion,
• Technical capacity present already or a clear
statement of how such capacity will be created;
Three additional countries had almost completed
their plans of action: Brazil, China and Viet Nam.
Fourteen other countries had already expressed
interest in the programme: Benin, Burkina Faso, Cote
d’Ivoire, Guyana, Nepal, Malaysia, Papua New
Guinea, Solomon Islands, Sudan, Tuvalu, Uganda,
Wallis and Futuna, Yemen and Zambia.
• Guaranteed exemption from fees or counter-part
payments to cover customs duties, acceptance
and clearance; evidence of mechanisms in place
for appropriate drug handling and warehousing;
In response to a comment about the future of the
Programme Review Group, Dr Cline said,
“Our future is to ‘devolve’ into the regions - where
the real problem-solving takes place.”
• A plan for impact assessment on transmission
in a subset or sentinel group of the treated
population;
Regional and Country Reports
- the resources for that expansion are
adequate;
African Region
Dr J. B. Roungou presented the first regional status
report, saying that 39 of the 46 countries in the
African Region9 were LF endemic (see map,
page 12) and 420 million people were considered at
risk for LF. Monitoring and mapping was a top
priority for the region; a workshop had already been
held (Ouagadougou from 8-12 March) for
23 nationals from 7 countries; over 106 000 ICT
tests have been ordered by WHO.
• The capacity to adequately identify, manage,
report and monitor serious adverse experiences
’th the drugs being used.
The Programme Review Group could play “a key
role in the process of decentralization,” Dr Cline
said, emphasizing that problem-solving should
occur at the country and regional level.
Dr Jaime Z. Galvez Tan (Philippines), Professor,
Department of Family and Community Medicine,
University of the Philippines, then presented a
status report, saying that a total of 44 out of 80 LF
endemic countries were in various stages of
readiness for LF elimination. Eight countries had
already begun multi-drug administration: one in The
African Region (Nigeria); one in the Eastern
Mediterranean Region (Egypt); and five in the
Western Pacific region (American Samoa, French
Polynesia, Niue, Philippines, and Western Samoa).
Priority activities, according to Dr Roungou, centred
around mapping the distribution of the disease,
which he estimated would require about
USS 305 000 to cover mapping field expenses. Mass
treatment using the two-drug regimen would also
be needed to interrupt transmission. In addition,
both regional and national plans were needed as
only Ghana, Togo and Tanzania already had national
LF plans approved.
|
Of the 51 countries on/adjacent to the African continent, 46 belong to WHO’s African Region while three (i.e.,
Egypt, Sudan and Yemen) belong to the Eastern Mediterranean Region.
18
1
PROCEEDINGS OF FIRST MEETING, MAY 2000
Phases of the mapping of LF distribution
at the right place at the right time (that is, not
during the rainy season).”
The region’s partners included:
• The Carter Center which was supporting
activities in Nigeria;
• DFID which, through the Liverpool School of
Tropical Medicine LF Support Centre, had
funded the Ouagadougou workshop and
activities in Benin, Burkina Faso and Cote
d’Ivoire;
• HDI which was
funding activities in
Ghana and Togo;
2003
2002
2001
2000
I rje orcicj *
.
dowtion.
• Merck & Co, Inc.;
■
• SmithKline
Beecham;
• WHO; and
m uch Sore Is
required.
• The World Bank.
<
Looking forward, Dr Roungou said it would be
crucial to strengthen WHO’s Regional Office for
Africa and get partners involved. DFID had been
the main contributor to date. A major constraint
had been “delayed funding”.
In the open discussion period following the
presentation, the Director of the Mectizan®
Donation Program, Dr Stefanie Meredith, said that
a “sustainable long-term cash flow” would be
needed to truly eliminate filariasis. Dr Anne Haddix,
economist from Emory’s Support Center at the
Rollins School of Public Health, introduced a
funding study10. Comments were also made on the
vertical vs. horizontal issue, pointing out the
difficulty of achieving 80% coverage as a horizontal
programme when in competition with other
priorities; also that vertical programmes were not
very cost-effective. It was also pointed out that in
Nigeria the onchocerciasis and LF programmes
overlap - for example, 12 million people had already
been treated for “river blindness” - and that the
APOC/OCP institutional memory could also be
used for LF. Finally, the Rapporteur Dr Bernhard
Liese (World Bank) said that the onchocerciasis
programme, which had already been in operation
for 13 years, should be able to show what
Mectizan® (ivermectin) had done for LF as well
during that time but the response was that no LF
data had been collected.
Ghana
Dr John Gyapong, Acting Director, Health
Research Unit, Ministry of Health, Ghana, began
by saying that Nigeria should actually be
presenting since it had already launched its
programme and Ghana was still gearing up. He
presented facts and figures on:
• The extent of the problem: LF was concentrated
in the north and in the southern coastal belt;
there was no adequate explanation of why the
central regions of Ghana appeared to have a
much lower endemnicity.
• Control measures to date: Mapping of endemic
regions.
• Future plans: The goal set was to attain 80%
treatment coverage and reduce ADL incidence
by 50%.
• Constraints and challenges: Lack of a sense of
urgency, vertical vs. horizontal, control vs.
elimination. “We worry about how to go the extra
mile towards elimination. Then resource
mobilization becomes crucial,” Dr Gyapong said.
“The drug donation programme is excellent but much more is required. We need resources
10
"
-
■
-
Region of the Americas
Dr John Ehrenberg, Regional Advisor in
Communicable Diseases at WHO for the Americas
presented an overview of LF in the Americas, noting
the endemic countries as Brazil, Costa Rica, the
Dominican Republic, Haiti, Guyana, Suriname, and
-
The Cost of the Global Programme to Eliminate Lymphatic Filariasis: Years 2000 - 2004. The LF Support Center
of Emory University, USA, Spring 2000.
19
>
I
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
I
'■
4
i
• Albendazole applications would need to be
completed and submitted.
Trinidad and Tobago. All told, WHO estimated that
there were about 420 000 infected persons with the
greatest numbers in Haiti (200 000) and the
Dominican Republic (100 000). Of Brazil’s total
population of 165,5 million, 3 million (1.8%) were
considered at risk. Although the numbers were far
smaller, in terms of percentage of at risk population,
Suriname topped the list with 90%, followed by
Guyana with 8 %.
Major constraints, in Dr Ehrenberg’s view, included:
• Delays in strengthening the regional office;
• Insufficient and delayed funding; and
• Unclearly defined mechanisms for funding field
activities.
“The good news”, he said, was that:
• Lymphatic filariasis was focalized in the
Americas;
• The number of cases is relatively small compared
to other WHO regions;
1
• Tools to eliminate LF as a public health problem
n the region were all available; and
I
Dominican Republic
I
Dr Guillermo Gonzalvez, National Center for
Tropical Disease Control, Santo Domingo,
presented the Dominican Republic Filariasis
Elimination Program. Beginning with country
statistics, he said that the Dominican Republic
occupied two-thirds of the island of Hispanola
(located west of Puerto Rico in the Caribbean)
which it shared with Haiti.
I
• Several groups in the Americas had made
significant contributions to
further LF knowledge.
Demographically a young country, 35% of the
population of 8.3 million was
under 15 years of age and life
Challenges which needed to be
expectancy had grown
over
50%
•
v
v
/v of the
met included the following:
from 44 to 71 years in the short
population Cofthe
space of 18 years (1980-1998).
• Update information on the
Dominican Republic) coulcj
About 65% of the population
current status of lymphatic
be at risk ofthe infection.
were urban dwellers, many of
filariasis in the Americas;
them immigrants. It was
• Raise the profile: until
estimated that over 30% of the
recently, LF had not been perceived as a high
population could be at risk of the infection although
priority by most of the health authorities
the real prevalence of the disease is still unknown.
throughout the region;
To address this situation, a pilot project focusing
• Increase IEC: MoH authorities had had little to
on elementary school students was introduced in
no access to updated information (e.g. scientific
March 1998: in the capital city of Santo Domingo,
publications, reports, theses, etc.) on lymphatic
13% of samples were LF-positive, in the smaller
filariasis or the feasibility of its elimination; and
city and Barahona, it was only 4%. By extrapolation,
it is estimated that the number of LF cases for the
• Build capacity: national programmes were
entire
country may number around 100 000.
technically weak, understaffed under-funded
and/or absent in most of the seven endemic
In February 1999 national mapping activities started
countries.
to ascertain which regions and municipalities were
I
I
I
J
••
affected. By April 2000 prevalence studies had been
concluded in 51 municipalites (out of 154). Eleven
of these municipalities (21%) were found to be
positive with at least 1% prevalence with
W bancrofti antigen.
Dr Ehrenberg listed the regional priorities (Phase 1
of the regional plan of action) as follows:
• National focal points would need to be
designated;
• Plans of actions would have to be written or
modified;
Dr Gonzalvez concluded by saying that the LF
elimination programme was integrated with the
programme for the control of intestinal parasites,
malaria and dengue.
• Financial resources would need to be mobilized;
• National task forces would have to be formed;
and
20
*
PROCEEDINGS OF FIRST MEETING, MAY 2000
Eastern Mediterranean Region
Dr Nikolai Neouimine, CEE Regional Adviser,
WHO Eastern Mediterranean, said that the status
of lymphatic filariasis in the WHO Eastern
Mediterranean Region was “not exactly defined”
in some parts of the region due to scarce information
and the absence of systematic collection and
reporting.
Countries in the region with ongoing transmission
included Egypt, Sudan and Yemen, which would
be priority countries for mass drug administration,
while those with a past history of transmission
included Djibouti, Iran, Oman, Pakistan, Saudi
Arabia and Somalia. Dr Neouimine said that
countries needed to devote more efforts to
verifying the status of LF; to this end, activities
had already been initiated in Egypt, the Syrian Arab
Republic and Yemen.
Regarding progress to date. Dr Neouimine said that
• A regional plan for LF elimination had been
prepared;
• A regional workshop had been organized on LF
elimination for national
programme managers;
• LF elimination would
be an agenda item at the
Regional Committee for
the Eastern Mediter
ranean in October
2000;
r
• In Yemen, with primary health care, leprosy
control and schistosomiasis control.
The region’s main partners in LF elimination were
the Arab Fund for Economic and Social
Development, SmithKIine Beecham and Merck &
Co. Inc. The main constraints were identified as:
-
• Lack of financial resources for LF elimination;
• Weak social mobilization and community
participation;
• Insufficient surveillance systems;
• A need for ICT cards.
Egypt
Dr Khaled Gado, Director of Filariasis Control in
the Egyptian Ministry of Health, outlined the
situation in his country. It was pointed out that
bancroftian filariasis has been endemic in Egypt,
mainly in the eastern Nile Delta and manifesting
itself as clinical elephantiasis, since the times of
the pharaohs. Today 10 of the country’s
26 governorates were LF-endemic, the population
at risk was approximately 2 million and the estimated
number of infected people
150000.
i
Uuneh.ng oftbe E3yptian
programme will take p?« the
thiH quarter of2000.
Efforts at LF control started
as long ago as 1910, based
first on water management
and later on detection
through night-blood samp
ling and treatment with DEC. Egypt was among the
first endemic countries in the world to embrace the
concept of lymphatic filariasis elimination; it had
developed a plan of action in 1996 and begun its
implementation with WHO assistance.
• A national plan for LF elimination had been
prepared in Egypt;
• An assessment plan of LF status in Yemen had
been prepared and ICT cards supplied;
I
As a result, Egypt would be one of the first countries
in the world to initiate a national programme to
eliminate LF within the framework of the WHO
global programme. It had already completed a pilot
project of mass drug administration (albendazole
and DEC) in two villages.
• Verification of LF-free status had been initiated
in Syria;
• A pilot project on mass drug administration had
been completed in Egypt;
• Albendazole had been provided for mass drug
administration in Egypt; and
Launching of the overall programme would take
place in the third quarter of2000. The plan of action
foresaw interruption of transmission through
annual mass chemotherapy plus palliative treatment
of clinical cases; health education and staff training.
Two post-treatment assessments would be
performed to evaluate the efficacy of the
programme.
• WHO documents on LF elimination had been
distributed.
Dr Neouimine stressed that LF elimination should
be integrated with other programmes; for example:
• In Egypt, with primary health care and
schistosomiasis control;
• In Sudan, with onchocerciasis control; and
21
I
I
I
Biss
I
w
I'
■
(
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
successful elimination of lymphatic filariasis;
community cooperation was very encouraging
when the LF elimination programme was
integrated with the control of intestinal helminthic
infections; infrastructure for implementation of
the programme was available in all endemic
countries in the South-East Asia Region.
South-East Asia Region
Dr Chusak Prasittisuk, Regional Advisor, VectorBorne Disease Control, South-East Asia Region,
reported on the current situation in the ten SouthEast Asia countries with a collective population of
1.46 billion or 25% of the global total. He referred to
the region’s strategic plan which noted that an
estimated 600 million of them - 60% of the global
LF burden - were living in endemic areas. About
60 million persons - or half the global figure of
120 million - either harboured microfilaraemia or
suffered from clinical manifestations. All the three
lymphatic filaria parasites were prevalent in the
region11, bancroftian filariasis constituting “the
most predominant infection in continental Asia”.
• Partners: As elsewhere, SmithKline Beecham
supported the programme in South-East Asia
with a free and adequate supply of albendazole;
and other UN system agencies (e.g. the World
Bank) and bilateral agencies were actively
involved.
The region’s targets by the end of the year 2000
included inter alia the following:
T right known endemic countries in the Region
w^e: India (which alone accounted for 44% of all
infections), Bangladesh, Indonesia, Maldives,
Myanmar, Nepal, Sri Lanka and Thailand. Formal
filariasis control programmes already exist in five
of the eight countries: India, Indonesia, Myanmar,
Sri Lanka and Thailand.
• Holding informal consultations with programme
managers of all the Region’s endemic countries;
• Finalizing the Region’s strategic plan;
• Developing advocacy materials/activities for the
elimination of LF from the region; and
• Establishing national task forces in all endemic
countries.
Despite this challenging situation, there were a
number of favourable factors for LF elimination:
Comments: The meeting’s chairperson,
Mr Javid Chowdhury (India) remarked that,
“although the LF elimination goal of 2020 is fine,
we must see some dramatic results within the next
five years if we are to maintain momentum.”
• Biological: Humans are almost the only reservoir
host for lymphatic filariasis in the region;
prolonged exposure with multiple infective
mosquito bites was required to establish
infection in a new human host; the parasite did
not multiply in intermediate mosquito hosts; the
infective larvae were not inoculated into the
human host directly but deposited on the skin
where the majority of them did not survive; and
he incubation interval was prolonged to many
months and would take many years to establish
active transmission in a
new area.
India
Dr Ashok Kumar, Director of India’s National Anti
Malaria Programme, gave a presentation entitled
Lymphatic Filariasis In India: Steps Towards
Elimination, which began with a clinical and
parasitological description of the disease. Turning
to the magnitude of the
problem and its control
strategy in India, Dr Kumar
• Available tools: Low
said
that LF was one of the
cost, safe and very
' about 454 million people in In4i4
major
public health
ai-eatnV
<
effective drugs were
problems
in his country
available for prevention
where
18
states
and union
of infection and treat
territories
were
LF-endemic.
India
’
s
National
Filaria
ment of clinical cases; diagnostic kits and
Control
Programme
(NFCP)
had
been
launched
in
monitoring tools were available within the reach
1955
and
evaluated
in
1960,1971,1982
and
1995.
of endemic countries to detect infection in man
Present estimates indicated that about 454 million
and mosquito; and cost-effective control
people were at risk, 113 million of them in urban
technology had been developed for LF
areas where most NFCP activities were focused,
elimination in many endemic countries.
although more recent attempts had been made to
• Feasible operations: Many countries had
expand the programme to rural areas as well.
acquired valuable experience in the time-bound
n
Wuchereria bancrofti, Brugia nialayi and B. timori
22
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PRXEED^GS OF FIRST MEETING, MAY 2000
Dr Kumar said that the main control strategy
included:
• Recurrent anti-larval measures at weekly
intervals with larvicides;
• Environmental methods to control mosquito
breeding (e.g. filling ditches, pits, low-lying areas,
de-weeding, de-silting and trimming of drains,
water disposal and sanitation);
• Community observance of weekly ‘dry days’
(e.g. emptying of water containers once a week);
• Biological control of mosquito breeding through
larvivorous fish;
• Anti-parasitic measures and DEC treatment;
• IEC for community awareness and involvement.
As a result, LF in urban areas was decreasing, he
said. Funds for these activities (combined with the
urban anti-malarial scheme) for 2000-2001 amounted
to Rs. 10.25 crores (Rs. 102.5 million), equivalent to
US$ 2.4 million.
Following the 1997 WHO resolution that
“elimination of filariasis as a public health problem
should be considered a priority by Member States”,
a project was initiated in 13 districts of 7 Indian
states12 covering about 40 million population. Mass
administration of DEC was being observed as a
‘Filaria Day’ in these districts.
A mid-term assessment of this pilot project in
January 2000 recommended that:
• The pilot project should run for five years as the
impact could be seen only after at least three
years of DEC consumption; it should be
supervised and tablet strength increased to
reduce total number of tablets for consumption;
DEC syrup for children under four years of age
should be provided;
As for next steps, Dr Kumar said that India, as a
parmer of the Global Alliance, was committed to
eliminating lymphatic filariasis by 2020 in
accordance with WHO’s 1997 resolution. The Indian
initiative to eliminate LF was envisaged in two
stages:
• Phase One: The pilot project in 13 districts with
40 million population would be expanded from
the single dose, mass annual administration of
DEC to add albendazole to the regimen: 40 million
albendazole tablets would be required annually.
• Phase Two: 261 endemic districts would be
brought under the mass administration of DEC
and albendazole so that India could keep pace
with the other endemic countries in achieving
LF elimination by 2020. This would require ICT
card mapping and active involvement at all levels
of society.
Concerning financial implications, keeping in mind
that albendazole would be supplied free of charge
by SB through WHO, funding projections for Phase
Two indicated that total costs for IEC and treatment
of about 440 million adults, training for
approximately 10 000 primary health care (PHC)
medical officers, 120 000 paramedics and 30 000
health workers, annual independent assessments
and mapping of endemic areas would amount to
US$24 million.
I
I
Western Pacific Region
Dr Kazuyo Ichimori, WHO scientist in the Country
Liaison Office in Vanuatu, made a presentation on
behalf of the Western Pacific Region where the LF
distribution pattern showed the Philippines (33%
of the people at risk in the region) to be first,
followed by China and Malaysia (22%), Cambodia
(20)%, Viet Nam (20%) and the Pacific Island
countries (5%).
• Proper monitoring, supervision and timely review
at all levels should be conducted;
• Funding and development of site-specific IEC
materials and sensitization of people for
community awareness through campaigns,
meetings, discussion and personal contacts
should be undertaken;
PacELF, she explained, was a regional collaborative
approach to eliminating LF in 22 Pacific Island
countries with a total population of 7 million
(350 000 affected by the disease) by 2010, ten years
ahead of the global elimination target date. Such a
coordinated approach was needed in the Pacific
because these island countries were small and had
• Pre- and post-assessment surveys should be
carried out; and
• Orientation of medical and para-medical officials
for the management of side reactions should be
provided.
12
Based on a multi-centric DEC delivery study carried
out with WHO/TDR support in 1998-1999, it was
recommended that there be greater political
commitment and stronger health sector involvement
with comprehensive training of health workers and
communities involved in drug delivery.
I
I
Bihar, Uttar Pradesh, West Bengal, Orissa, Andhra Pradesh, Tamil Nadu and Kerala.
8
23
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
PacELF’s main partners were WHO and the
Secretariat of the Pacific Community (SPC).
limited resources and there was a great deal of inter
island travel. Therefore, working together, sharing
resources and helping one another to implement a
comprehensive regional strategy would be
necessary.
I
The Philippines
Dr Leda Hernandez, NFEP’s Programme
Coordinator, Department of Health, Philippines,
introduced the Philippines as a tropical developing
country with a dominant agricultural sector and a
population of over 70 million people scattered on
about 7000 islands in WHO’s Western Pacific
Region.
The progressive targets for PacELF were to certify
LF-free status for individual countries by 2005,
followed by declaration of region-wide elimination
by 2010. The strategy involved mass treatment with
annual single dose combination drugs (albendazole
and DEC), repeated three to five times.
Filariasis was first identified there in 1907. By 1998
endemic areas were spread throughout the
archipelago with a prevalence rate of 9.7% cases
per 1000 population. New endemic areas recently
registered some of the highest recorded infection
rates.
Group 1 (low or non-endemic countries) included
Guam, Kiribati, the Marianas, Marshall Islands,
Nauru, Palau, Pitcairn and Tokelau.
i|
Group 2 (endemic island countries with
pulations under 500 000) included American
Samoa, Cook Islands, French Polynesia,
Micronesia, New Caledonia, Niue, Samoa, Solomon
Islands, Tonga, Tuvalu, Vanuatu, and Wallis and
Futuna.
With WHO’s declaration of “Filariasis Elimination
as a Priority” in 1997, the programme began work
with its filariasis control units on a plan to eliminate
the disease in the Philippines. The first step was
mapping of endemic areas, disease rates and other
epidemiological data. (See Filariasis in the
Philippines, A Compilation of DOH Data, 19601998 for details).
Group 3 (LF-endemic large countries with
population of over half a million) included Fiji and
Papua New Guinea.
There would be an integrated programme combining
blood survey and follow-up, mass drug
administration, mosquito control, morbidity control
and an EEC awareness-raising campaign. American
Samoa, with its high LF incidence but also 96%
drug coverage rate, would serve as a model.
8
*
i
After WHO’s global call for Elimination of Filariasis
in 1998, the programme shifted its strategy from
control to elimination. Today, Dr Hernandez said,
the main goal is to reduce the LF prevalence rate in
endemic areas to less than 1 per 1000 population.
The objectives are to:
Pacific Island members stretching from Palau in the west to the Pitcairn Island in the east
(
Hawai
i
Northern
' Mariana Islands
PACIFIC OCEAN
Guam
Marshall Islands
Palau
Federated States of Micronesia
Nauru
Papua
New Guinea
I
Solomon Islands
I
1 Tanuatu
.i
Samoa
Fiji
Niue *
Kingdom
of
Tonga
New Caledonia ’
Australia
V'-’ ■; <
Tokelau
Tuvalu
Wallis &
Futuna
Coral
Sea
Equator
Kiribati
3»
Samoa
-J—
American
Samoa
Cook
Islands
French
Polynesia
Pitcairn
Tasman
Sea
_____
HHHHBbHhhBbHHHmBhEGOMhHbHHHhBm
24
I
PROCEEDINGS OF FIRST MEETING. MAY 2000
Timeframe for elimination of LF in the Western Pacific
Pacific Region
Step
Year
Group 1 (CFF)
Step 1
1999
2000
Planning
BO
2001
2002
__ Planning
j
8
Step 2
2010
Group 3 (LCS)
Plannini
E
■1/
mtervendon
.
Evaluating
Evaluating
2003
2004
2005
2006
2007
2008
2009
Group 2 (PIS)
-
Country Elimination: Certificate
Planning
Follow
•------ up
. and Confirmation
i
i
Evaluating
Regional Elimination: Declaration^
wskhbe
if’
1) Diagnosis: Rapid assessment methods used in
endemic mapping.
1) Identify all endemic municipalities within the next
two years;
2) Provide mass treatment in established endemic
municipalities; and
2) Treatment: Mass treatment in three pilot sites.
Results showed no significant barrier to
proceeding with national implementation.
3) Continue surveillance of endemic areas for five
years after completion of mass treatment.
3) Research: A research agenda was prepared and
disseminated to other health partners; rapid
assessment studies conducted on ICT; ongoing
health systems research.
Dr Hernandez highlighted major components of the
NFCP as:
• Mapping of endemic areas using ICT and
deformity surveys;
4) Database Development: Recording/reporting
forms; EPI-INFO FL database; publication of
DOH Filariasis Data(1960-1998).
. Capability building through advocacy for
participation;
5) IEC Plan: Brochure entitled Wipe Out Filariasis
in the Philippines, flipchart, posters and leaflets
to advocate for support from local officials and
endemic communities.
6) AdvisoryGroup-.CreationofaNarwna/AJvfrory
Group for Filariasis composed of LF experts,
academics, medical societies, etc.
• Training of health workers and community
organizers;
• Annual mass treatment for a minimum of four
years using the combination drug regimen of
DEC-albendazole for all persons older than two
years in established endemic municipalities;
7) Human Resources Development: Training of
Trainers workshops in all endemic regions.
• Morbidity control with municipal self-help
support groups and surgical referral centres for
hydrocoele cases;
• Integration with other public health
The challenge, said Dr Hernandez, is to start
developing an efficient NFEP system, a feat in itself
for a developing country. The task at hand will be
to launch a high-profile activity to catch the
attention of national political leaders and health
managers, to institutionalize a “Filariasis Health
Week” in endemic communities, to ensure funds,
procurement and delivery of ICT cards, DEC and
albendazole; to develop a module on morbidity
programmes;
• Monitoring, evaluation and post-intervention
surveillance.
Dr Hernandez cited the following indicators for
progress to date in the Philippines:
25
1
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
II
•■
Over the past decade, due to a continuous decline
in Papua New Guinea’s Government service
delivery capability, the private sector resource
developers have found themselves filling the
vacuum. After being approached by the WHO
Collaborating Centre at James Cook University in
1995, MML was asked to provide support for a trial
programme of work to test the effectiveness of three
means of LF drug delivery.
control; and to generate funds for information
systems that would facilitate coordination and
tracking of the programme’s long-term effects.
“We need to remind ourselves once again of the
need to eliminate this disease so that every child,
present and future, in endemic areas can be free
from the scourge of filariasis,’ she concluded.
Private Sector Partners: LF and the
Case of a Gold Mine Manager in
Papua New Guinea (PNG)
Beginning on Misima Island, the programme
expanded gradually throughout the district over
three years to cover a population of some 40 000
Presented by Mr James Cheyne (WHO) on behalf
distributed among many islands spread over some
ofMr Arthur Hood, Misima Mines Ltd.
80 000 square kilometres. The bottom
line: the total cost turned out to be only
Mr Cheyne introduced this case study
US$ 0.30 per person treated. Drugs cost
on behalf of Mr Arthur Hood, Misima
Leave
behind
a
only USS 0.04 per person per year
Mines Ltd. in Papua New Guinea, with
meaning that it cost less than USS 500
better
future!
the purpose of providing a model for
to treat the whole island. In future MML
th le a private sector company could
hopes to expand its health care initiative
play in the delivery of public health
to include HIV/AIDS, immunization
sector programmes and show how it
programmes, directly observed treatment, and a
could support government priorities and capacity
short-course against TB. MML would also like to
building for mutual benefit.
see the LF programme expanded throughout the
Misima Mines Ltd. (MML), Mr Cheyne explained,
Province, a population of some 300 000 and is
was situated 600 kilometres south-east of Papua
encouraging the Provincial Department of Health
New Guinea’s capital Port Moresby, on a small
to do this.
island in the Solomon Sea. In operation since 1990,
This effort was all part of a broader Placer Dome
it was 80% owned by the Placer Dome mining
corporate social-responsibility strategy to ‘Leave
conglomerate and employed about 800 local
Behind a Better Future” and brought the parent
residents out of a total population of 13 000 on the
island.
Regional location
Lihir Is.
BISMARK SEA
RabaulV
*
PACIFIC OCEAN
’J
SOLOMON SEA
Gull of Papj£§$
^Moresby
'SOLOMON
ISLANDS
ilara
York
IQ’S
MISIMAI
ISLAND,
CORAL SEA
150°E
v-.
16O°E
_
-u.' •• "■
26
■
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PROCEEDINGS OF FIRST MEETING, MAY 2000
company in as a founding member of the World
Alliance for Community Health.
sector partner whose motto is to “Just do it!”,
Mr Cheyne concluded.
While the LF programme had been a joint effort
between MML and the Papua New Guinea
Department of Health, MML provided the
leadership and initial medical staff. Over time, the
process shifted from “top down to bottom up” and
was integrated horizontally under a delivery
protocol entitled, “Educate - Delegate - Regulate
- Motivate”.
Message from Misima Mines Limited
i
I
Now a WHO-approved project, MML’s
“enlightened self-interest” demonstrated what
could be accomplished with a committed private
I
“Just do it! ”
c>.
Video Synopsis of SmithKline Beecham video
Target LF: For a Future without Lymphatic Filariasis
Action began in Samoa on the eve of the new millennium and with the start of a new programme to
eliminate LF there. The narrative then referred to the global situation - 120 million people in at least 80
countries affected, another billion at risk, especially children.
Private-sector support was highlighted, focusing on SmithKline Beecham’s 1998 commitment to provide
free drugs (albendazole) and Merck & Co., Inc.’s promise to extend its 13-year drug donation programme
of Mectizan® (ivermectin) to combat LF as well in African countries where LF and onchocerciasis co
existed. Both commitments were open-ended - that is, for as long as was needed to eliminate LF from
the world. The output in terms of drugs was described as “enormous”.
The video made three “clincher” points:
I
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1
I
• Donating drugs was by no means the end of the story;
• Distribution - getting the drugs to the people who needed them - was a real challenge; and
• Samoa, which had reached 94% of its population, should be considered a model in terms of information,
drug supply and monitoring. The needs were exponentially greater in countries like Brazil, India and
Nigeria.
“This is the way partnerships should work - beating back the diseases of poverty,” said
Dr David Heymann, WHO Executive Director for Communicable Diseases, commenting on the fragility
of lives lived “on the margins of help.”
■is
't~ 7.... ... .. '.. “;r
3
-
Fo, , Future mtUut Lyttle r,lan35|S
. Jnis
7 minute y^d^pi-esented by SmithKline Beecham provided an example of
lisZ-rpii
'of 51
TFe video ™v Be weu on tl« Sm.thKl.ne Beecham webs.te
.
7
. (e-maihbrian.bagnall@5b.com )
By quoting either PAL ol-NT5C video fol ..
27
I
Gl-OBAL ALLIANCE TO B-MNATE LYMPHATIC FLAR1ASS
Working Groups’ Discussions
• There seemed to be no clear, effective LF
communications strategy in place;
Participants divided into working groups focused
on the following six themes: communication and
information, creative ways of seeking LF support
(including funding), the role of NGDOs, meeting
country needs, critical elements for a successful
LF programme, and maximizing regional
-^ordination. This part of the agenda was a
_jmonstration of the Global Alliance’s principal
function to “...provide a free non-restrictive
partnership forum for the exchange of ideas and
coordination of activities''^.
• The lack of definition and basic programme
knowledge w ere causing confusion;
• Communications were not received by all
partners in timely manner, no “filtering down”;
• It was not feasible to have a “flexible, open
structure” and, at the same time, committees with
authority determined by only one partner,
• The lack of effective, ongoing communications
resulted in increased costs and inefficiencies.
Working Group 1: Addressing Global
Alliance Communications and Infor
mation Needs
The following suggestions were then presented:
• A focal point should be designated/hired to
manage effective and efficient communications
for the Global Alliance;
Discussion leader: Ms Brenda Colatrella, Merck
& Co., Inc.
Presenter: Dr Philip Coyne, World Bank
• Funding for this function and person should be
cost-shared by Alliance partners;
In identifying the Alliance’s communication and
information needs and assessing how they could
best be addressed, the group began with some key
messages:
• Communications were
essential and could
“make or break’’ the
programme;
• Effective communi
cations were a huge
challenge; and
‘
• A representative of each partner should be
designated to solicit feedback and provide input;
• An Alliance website
in addition to WHO’s
w w vv.filariasis.org should
be created;
effective LF communications
,
strategy in place.
UK?
• Communications activities needed higher
prioritization.
• Communications
should be regionalized/
decentralized wherever
possible;
• A Global Alliance ‘bulletin’ should be instituted
and discussions held on which partners should
produce and disseminate it.
The group then presented some questions and
observations:
• Where did the communications responsibility
reside - with WHO or with the Alliance itself?
!
I
13
Terms of Reference of the Global Alliance to Eliminate Lymphatic filariasis - Meeting report, 2 December 1999,
London.
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PROCEEDINGS OF FIRST MEETING, MAY 2000
a
3
3
Working Group 2: Seeking Support
(including funding)
Working Group 3: Defining the Role
of Non-Governmental Development
Organizations (NGDOs) in National
Programmes to Eliminate LF
Discussion leader: Dr Brian Bagnall, SmithKline
Beecham
Discussion leader: Dr Nevio Zagaria, WHO
Presenter: Dr David Molyneux, Liverpool School
of Tropical Medicine LF Support Centre.
Presenter: Dr Frank Richards, Carter Center
Global 2000
It was suggested that the Alliance create a
Development Task Force to undertake an
assessment to analyse the needs of the Alliance,
sources of support, needs of supporters, trends in
philanthropy, the competition and the Global
Alliance’s market position.
This Task Force would then use the information
gleaned to develop marketing plans which could
include:
• Exploiting LF imagery;
• Establishing a brand image;
• Creating a global LF non
governmental organization
to address the funding
needs of all partners;
The group began by asking positioning questions
for NGDOs (i.e., who, what, where, when, why and
how they could contribute) and supplying the
following answers:
Who are the NGDOs relevant to the elimination of
LF? They consist of not-for-profits, private
voluntary organizations (PVOs), special interest
groups, lobbying/political action groups,
international development, humanitarian and
emergency relief agencies,
international agencies, national
the NGDOs
and sub-national groups and
local/community organizations.
What can these NGDOs do for
LF? For the NGDOs involved in
the LF elimination programme, a
broad spectrum of attributes were identified,
including:
• Weaving human rights and
social exclusion issues into the LF campaign;
• Recruiting prominent spokespersons;
• Demonstrated skills in facilitation, promotion and
rapid response;
• Implementing lessons learned from other
programmes (e.g. polio, leprosy);
• “On the ground”, community-based presence
(often the only means of delivering services in
remote areas or during periods of civil unrest);
• Emphasizing the childhood and reproductive
health aspects (i.e., LF as a disease which begins
in childhood and is later an impediment to sexual
and reproductive health); and
• Role as providers of essential resources
(e.g. financial, material, human, infrastructure);
• Exploring opportunities to link up with major
service organizations (e.g. Rotary International,
Lions Club).
• Status as a neutral (i.e., non political) party which
remains relatively stable despite changes in the
government and politically-driven MoH
structure;
It was suggested that the task force, created by
WHO acting as the Alliance’s Secretariat,
coordinate with LF support centres and report back
within a year after wide-ranging consultation with
Alliance members. Where appropriate, the Task
Force would also use consultants in philanthropy,
finance, public relations, and marketing.
• Advocacy efficacy at all levels from community
to business to national government to global
governance;
• Focus on non-fatal diseases despite other health
emergencies;
• Consistency, loyalty to the cause and
sustainability;
• Crucial intermediary role in mass drug
administration campaigns;
• Involvement in patient care, morbidity control,
hygiene, surgery;
29
r
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GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
I
Suggestions of the working group regarding
NGDOs:
• Contribution to legal drug importation, tracking
and accountability, inventory control (e.g.
parallel use issue);
• In keeping with the LF Strategic Plan (September
1999) which asserts that “NGDOs are key
partners” who “will play a critical role in LF
elimination” and “given adequate funding, are
likely to embrace the challenge of LF elimination
with enthusiasm”, it is suggested that this
programme be developed as a “true”
partnership; that is, that both WHO and relevant
MoHs demonstrate the will to provide a welcome
“place at the table”, in full partnership status.
• Bridging function in communications between
diverse partners;
• Technical expertise in areas such as planning,
training, monitoring and evaluation.
Where could NGDOs work for LF? Virtually all
levels, from the broadest international level
(e.g. governance) to regional and national coalitions
to the state, district and community level
(“grassroots”), as well as in cyberspace.
• In keeping with the LF Strategic Plan’s objective
3.6.4.1 that “NGDOs in the LF endemic countries
be made aware and be convinced of the
importance of mobilizing and supporting local
community activities for LF’, it is suggested that
the following targets be endorsed and promoted
throughout the relevant NGDO community:
When should NGDOs be involved in the LF
initiative? At all stages, starting now, at the
beginning of this new initiative. NGDOs should
r tribute to the MoH’s planning of national task
force structures, to the execution of programmes
and to the monitoring and evaluation phase.
- By the end of 2000: Development of
information packages and promotional
material in the appropriate languages for
NGDOs working in LF countries;
establishment of a formal network of
NGDOs active in LF elimination to share
experiences and exchange ideas.
Why would NGDOs want to be involved in the LF
initiative? For a number of reasons; inter alia,
because the LF initiative is:
• A “good fit” with their mandate (e.g. disease
burden and geographic area);
• A “good programme” deserving of support;
• Compatible with other activities or strategies
(e.g. community development, child survival,
onchocerciasis,
intestinal
parasites,
schistosomiasis, malaria, vitamin A).
- By the end of 2001: Recruitment of
increasing numbers of NGDOs.
Working Group 4: Meeting the Needs
of Countries: How the Alliance can
best support more effective country
action
How would NGDOs become involved in the LF
initiative? In their individual capacities or through
coalitions. NGDOs need to feel that they are
' elcomed’ at the table and are regarded as full
. miners in the programme. In this capacity, they
can contribute substantially to LF advocacy. It is
suggested that the Global Alliance advise the
NGDO community that
Discussion leader: Dr J. Gyapong, Ministry of
Health, Ghana
Presenter: Dr Maged El-Setouhy, Ain Shams
University, Cairo, Egypt
Advocacy: Help build a sense of urgency for
• There is an open invitation for their participation,
LF programmes in countries, supported by
that there are opportunities, roles and
WHO-Geneva, WHO regional offices, collaborating
responsibilities in
centres, and focusing on
under-served endemic
potentially endemic areas
areas;
. To maximize communications, 3
(which need to be
• There are resources or
good ‘prospects’ to
implement the NGDO
programmes;
j
;
list ofall potential partners shouH
be developed.
convinced that LF is a
problem). Provide leader
ship by collecting back
ground disease-specific
information and providing technical expertise. The
Alliance should coordinate with its regional/
country members and drive Global Alliance support
down to country level.
• They must conform to certain criteria (board
structure, fiscal management, track record, etc.).
30
-F
I
PROCEEDINGS OF FIRST MEETING, MAY 2000
Regionalization: An LF focal point at WHO
regional/country level was needed as people
currently have so many responsibilities that LF
priority is low. Funds should be provided for
country start-up activities (mapping, training). For
this, technical expertise was needed to provide,
inter alia, assistance with the drug application
process, identify training needs, etc. A regional
synchronization of activities should be promoted
with regional meetings organized and funded:
• Strengthen regionalization: NGOs, regional or
country partners should create decentralized
Allliance groups convened by WHO, the
province, the country or the region. A list should
be developed of all potential partners to maximize
communications between local partners and
MoHs; partners should be involved in country
planning to build ownership.
• Partner recruitment: There must be a
coordinated message, partner recognition,
invitations and involvement and improved
communications.
• Regional meetings: These should promote
coordination and synchronization of activities,
high coverage and uniform ramp-up of activities,
mutual country motivation and friendly
competition. They should also coordinate
mapping, train countries on how to begin
activities and implement the application process,
etc., foster social mobilization strategies and
coordinate communication (health reviews,
newsletter, website).
• Partner recruitment: There should be a
coordinated message, partner recognition/
invitations/ involvement and improved
communications.
• Multi-sector approach: There was a need to
integrate health activities, sharing costs,
enhancing efficiency (monitoring, surveillance)
and improving integration with other ministries,
with research institutes and with other academic
institutions. The Global Alliance could promote
such integration.
• Translation/interpretation: There was a need
to ensure that non-English-speaking countries
were regarded as full partners in meetings,
training opportunities, etc. through appropriate
bi-/multi-lingual translation and interpretation
services.
Working Group 5: Identifying Critical
Elements for Successful LF
Programmes
Discussion leader: Dr Leda Hernandez, Ministry
of Health, Philippines
Presenter: Dr Patrick Lamniie, Centersfor Disease
Control and Prevention, USA
The following eight elements were identified:
• Political advocacy and commitment from the
international to the local level (trickle-down);
• Baseline data: Endemic mapping, prevalence,
etc.;
• Strengthening operational capacity: Capacity
building through training of health personnel,
long term funding, logistics (e.g. systematic
inventory and distribution/quality assurance of
drugs, laboratory and IEC supplies, systematic
data information systems, programme monitoring
Country-specific activities:
and surveillance, develop-ment of materials for
• Funding: There was a
....... community mobilization,
strong need for specific
and inte-gration with other
is a strong need for specific
LF funding in addition to
existing
public health
LF funding in addition to "basket'
“basket” funding of i
" r j. >
programmes);
funding
health needs (LF might ;
rUDqing
• Institutional frame
not be high enough
work: Formal collaboration
priority at MoH to get funds), as well as a need
amongst government officials, expert groups,
to develop expertise, to find specialty funds
etc., including the Technical Advisory Group,
(mapping, personnel, training, development and
expert groups at the international, regional and
production of IEC material); to provide disability
national levels, non-governmental organiza
prevention and rehabilitation funds and
tions, ministries and inter- and intra-sectoral
coordination; to fund drug costs, infrastructure
coordination;
and personnel; to ensure recurrent programme
funds from year to year and to coordinate the
roles of the private sector (e.g., Misima Mines).
Application process: The requirements should be
simplified and streamlined, all the while fulfilling
the requirements of the Programme Review Group,
SmithKline Beecham, the Mectizan® Donation
Program, and Merck & Co., Inc.
pf3
31
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GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
<
The functions of a Regional Coordinating Group
were perceived as follows:
• Community mobilization
• Morbidity control: IEC on morbidity
(e.g. effective hygiene programmes), support
groups;
• To recommend approval of drug applications;
• To coordinate information activities (e.g., com
munication, advocacy, information exchange
through direct dialogue and electronic
networks);
• Evaluation
• Sustainability (five years minimum).
Working Group 6: Maximizing
Regional Coordination
• To assist with the development of national plans;
• To organize and report on regional meetings,
review progress and provide technical support;
Discussion leaders: Dr K. Ichimori, WPRO and
Dr J. Ehrenberg, PAHO
• To mobilize resources (in cash and/or in kind);
Presenter: Prof. Charles Mackenzie, Mectizan®
Donation Program
• To facilitates supplies to countries (e.g. DEC,
ICT cards);
The group began by defining a Regional
ordinating Group as “a free affiliation
of countries, a non-legal body”, established to
1) review national plans and recommend on
albendazole donation applications; 2) foster links
through communication, coordination, advocacy
and sharing of resources and, 3) interact with
existing structures, such as WHO Regional Offices,
TCC of APOC, and the SPC in Western Pacific, to
their evolving needs.
• To activate political support for health-related
legislation;
• To facilitate NGDO involvement
In response to the question of how such a
regionalization process would occur, the group
found that a useful sequencing of approach would
be to:
• Begin by devolving the decision-making for
national drug approval applications for
albendazole to the regional group;
The case for regionalization was then examined and
a number of arguments set forth. The following
responses were given to the question, “Why
regionalize?”:
• Closer to the problems; more insight into the
viability of potential solutions;
• Then develop other functions (e.g. com
munication, information, resource mobilization)
which would be specific to the needs, situations
and circumstances within the region;
• Able to respond more efficiently to local issues;
more effectively to cross-border issues;
• Actively involve countries in the decision
making process;
• Enlist a member of the coordination group
initially to facilitate idea flow and continuity;
Speedier drug application process;
• Easier to share experiences through
regionalization;
• Already have the appropriate technical
resources and facilities for sharing;
• Suggest a framework to be presented at regional
programme managers’ meetings for which the
country focal point solicits national opinion and
reports back to the group.
• Better positioned to deal with regional shipping
issues;
The proposed membership of such a regional body
would be comprised initially of:
• Well-placed to deal with accountability issues
between drug companies and recipients;
• Representatives from countries within the region;
• A member of the existing Programme Review
Group;
• Able to capitalize on cultural similarities
(e.g. language);
• Partners and potential donor-partners;
• Easier to mobilize regional funding sources;
• WHO.
• More readily able to cope with the financial
aspects related to drug tariffs, etc.
WHO, Geneva has an important role in fostering,
facilitating and supporting regional groups.
32
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PROCEEDINGS OF FIRST MEETING, MAY 2000
Closing Statements
SmithKline Beecham
I
two diseases (LF and onchocerciasis) co-existed.
The
significant lesson learned, Fettig said, was “the
Dr Brian Bagnall, Director, Project Management,
importance
of partnerships in addressing public
Lymphatic Filariasis Corporate Affairs, expressed
health
problems
in the developing world”. The
SB’s satisfaction with the rapid progress made since
Global
Alliance
must
include the participation of
signing the Memorandum of Understanding with
health
authorities
and
governments, and should
WHO only two-and-a-half years ago, setting the
welcome,
even
seek,
participation
by NGDOs, the
stage for other public/private sectors partners to
private
sector,
international
organiza-tions
and
create a broad alliance to eliminate LE Now the
others.
We
must
strive
to
Global Alliance was a
improve
com-munication,
”
reality and the first
he
said,
“
build
trust,
put
countries were already
aside our personal
launching their pro
agendas
and accept one
grammes. Now, with the L ;
longyegrs'seivicetothe
another
as
full and equal
“massive new numbers” L onchoceraqsis and LF initiatives.
partners
in this LF
of tablets required to
alliance.
”
supply really large
initiatives (e.g. the 40-million-person pilot project
Although he would be
in India), he pleaded for advance planning - and
retiring on 1 June 2000, Mr Fettig said he was sure
patience as the company gears up production in
that Merck & Co., Inc.’s participation, with Ms
the coming months..
Colatrella representing the company and Dr
Meredith representing the Mectizan® Donation
SB was committed not only to supplying
Program,
would be “in good hands”. Mr Fettig
albendazole, he said, but also to other aspects of
received
a
standing ovation in recognition of his
the initiative, such as company support staff and
long
years
’
service to the onchocerciasis and LF
grants to support start-up projects. Finally, he
initiatives.
announced that - although an imminent merger
would transform SmithKline Beecham into Glaxo
The World Bank
SmithKline within the coming months - the new
Dr Bernhard Liese, Senior Advisor, Human
corporate management would be equally committed
Development,
Africa Region, gave the closing
to the LF Global Alliance.
statement on behalf of the World Bank, saying that
Merck & Co., Inc.
in order to deal seriously with poverty, the world’s
second
largest disabling disease — namely,
The closing remarks were delivered by Mr Charles
IjTnphatic
filariasis - could not be ignored. He said
Fettig, Senior Director, Worldwide Human Health
it
would
be
an uphill battle to build a constituency
Marketing, who said he hoped that the LF
a
battle
which
would require stamina, strength
programme would enjoy the same success as the
and
endurance.
onchocerciasis programme before it, one with which
he had long been involved. He said that the
Despite these challenges - and the clamouring of
donation of Mectizan® for the onchocerciasis
other urgent issues like HIV/AIDS, malaria and
programme over the past 13 years had opened his
health sector development, the World Bank was
eyes to the medical needs of the less fortunate in
committed to eliminating LF as a public health
developing countries. In October 1998, Merck &
problem within the year 2020 target timeframe. “We
Co., Inc. also committed to extend this donation
must bring the human dimension to the forefront,”
programme to LF in African countries where the
said Dr Liese, pointing to the eagerness of the
33
J
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GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS
I
onchocerciasis team to take on this related disease
and give the LF programme the benefit of their
experience. “It will be an endurance test,” Dr Liese
reiterated, “but, practically speaking, country
financing is not a problem if the governments make
LF a high enough priority.”
arguments.. .which show the economic and social
benefits of people living LF- free lives, as well as
the poverty angle” which positions LF as a
disease which both causes, and is a consequence
of, poverty. Both these points underpin why this
initiative matters.
The way ahead lies in partnerships, he continued,
and building a broad constituency. Now the Global
Alliance has been created. The World Bank stands
firmly behind it
Mr Mason said that he had often seen the genesis
of programmes and that they moved through three
stages:
Department for International
Development, United Kingdom
• someone believes that it could happen;
Mr Phil Mason, representing the United Kingdom
as a donor-partner, said that he had been impressed
and “genuinely surprised by how much is already
ing on. I want to record our positive views on
the progress being made, particularity since the
Partners’ Forum in Geneva in October 1998. We
have really come a long way”. Noting that “great
ideas need landing gear as well as wings”, he felt
that the Alliance’s inaugural meeting showed that
the wings were in good order and landing gear being
defined with help from the working groups.
“We are at that third stage of genesis now,” he
said, having gotten there through the generosity
of SmithKline Beecham. Now that there was a
coherent, organized framework, “our task is to wzZZ
that it must happen”. After two years of hard work,
Mr Mason concluded that “when the history' comes
to be written, this meeting may be seen as the real
starting point for actually getting down to
business.”
• someone dreams that it should happen;
• and someone wills that it must happen.
Interchurch Medical Assistance
(representing NGDOs)
Mr Mason mentioned four messages he had
gleaned from the meeting:
Speaking as Vice-Chair of the NGDO Coordination
Group for Mectizan® Distribution on behalf of the
• Sector-wide approaches: He had often
NGDOs,
Mr Paul Derstine, IMA President,
considered them as donor-created solutions to
expressed
appreciation for the tone of the Global
donor-created problems and recommended
Alliance meeting and for
“thinking this through
p.^,dialoguing opportuvery carefully”;
nities it had provided for
"Greqt ideas need landing gear
• Value-added meetings: >
more clearly defining the
The value and colle
role of NGDOs in the LF
giality generated by
elimination programme. In
forums like this was
addition to the points
“vital and essential,” he said, “the glue... that
raised by WorkingGroup 3, he put forth some
allows dialogue... and holds us accountable to
related thoughts: firstly, the Global Alliance as “a
each other”;
three-legged stool” composed of public, private and
non-profit partners, the latter needing a stronger
• Needs analysis: The UK/DFTD was still the only
presence in the LF programme. “During the course
donor government attending the meeting. In
of the past two years, NGDOs have been shown a
order to encourage the active involvement of
new world of opportunity with new tools to tackle
other donors agencies, there must be a clear
an old health problem which has caused suffering
‘product’ to buy into. Mr Mason urged
and disability to millions of people,” Mr Derstine
endorsement of the recommendation to conduct
a needs analysis for the Alliance, and use the
said.
Liverpool School of Tropical Medicine LF
Although the NGDOs road had been “littered with
Support Centre to do this quickly and at no extra
unclear road signs”, now with the creation of the
cost to the Alliance. He hoped that, in approving
Global Alliance, there would be better opportunities
the final report of the meeting, there would be
for meaningful involvement. He expressed the hope
agreement on “some clear steps forward”.
that WHO would assume a “more active role as a
• LF’s economic argument: In ‘selling’ the LF
broker of intellectual capital” and rallying point for
initiative, Mr Mason agreed that “we need to
all partners. In conclusion, he said he hoped that
the NGDO Coordination Group for Mectizan®
make more of the powerful economic
34
II
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fI
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PRCXDEED^GS OF FIRST MEETING, MAY 2000
I
Distribution could use its good offices to expand
the alliance through a workshop during the group’s
next bi-annual meeting 13-14 September 2000 at
WHO headquarters in Geneva. Mr Derstine
concluded by saying that the NGDO community
was eager to be involved as an active partner and
he urged the Alliance to follow the roles for NGDOs
outlined in the LF Strategic Plan.
World Health Organization
Dr Maria Neira, Director, WHO Department of
Control, Prevention and Eradication, began her
closing statement in French to underscore the need
for bi/multi-lingual communications. She
highlighted the Alliance’s public/private sector
partnership as something “really unique - two very
important pharmaceutical companies ‘holding
hands’, along with the NGDOs”.
“In two short years, a lot has happened,” Dr Liese
noted, highlighting comments by the meeting’s
opening speakers. First there was the “re-discovery
of communicable diseases” and recognition of the
fact that, even in this day and age, they accounted
for 45% of global mortality.
Then there was the realization of the links between
disease and poverty, especially “those at the end
of the road, the rural poor” who constitute the
majority of LF’s victims. Finally, there was the
growing appreciation by bilateral donors of a need
for “new development paradigms” and a move from
aid to partnerships. Important components of these
included flexibility, an empirical approach and
ownership by all participants.
The meeting’s chairperson had “focused on what
really matters”, describing LF as a truly debilitating
disease characterized not
She pointed to the need to
only by economic losses
focus resources on LF
SmithKline
pfedqe to
ne Beecham's pfec
but also by social stigma.
endemic countries and the
He
equated disability with
people who would be the
“
denied
opportunities”
ultimate beneficiaries,
which
limited
life, lowered
saying that WHO’s role
self esteem and were
was to act as a “platform, a facilitator to circulate
traumatic for those living with LF.
ideas and generate energy”.
The global LF overview presentation stressed the
Turning to government supporters. Dr Neira again
importance of “walking on two legs,” Dr Liese said
thanked the Spanish Government for its generosity
- both the interruption of transmission and
and said that Spain and the UK should “compete
morbidity control. In the first area, substantial
to see who could help the most.” She hoped that,
progress has been made in a short period of time,
by this time next year, all of the targets set (e.g.
especially through the safety of drug combinations;
WHO’s commitment to cover 15 million people at
in the second, a lot of work remained to be done.
risk with LF programmes) would have been met “I
He singled out the comments on LF in children as
hope we shall be able to say, ‘For once, we were
“striking”, saying that this had implications for new
too successful!”’
intervention channels.
Rapporteur’s Round-up
Dr Liese then went on to recap the presentations of
Dr Bernhard Liese (World Bank), the meeting’s
the Technical Advisory Group which focused on
indicators for quality monitoring, DEC drug supply,
Rapporteur, began by pointing out that “this is a
first” - the first meeting of the Global Alliance to
morbidity and LF in children, and of the Programme
Eliminate Lymphatic Filariasis - and thus a crucial
Review Group which had encouraged the
first step which was felt by participants to have
devolution of drug distribution to the regional level
in future.
been a success.
Recapping the events that preceded it, Dr Liese
highlighted the “constellation of factors” that paved
the way for the formation of this alliance, in
particular SmithKline Beecham’s pledge to donate
drugs that “shook the sleepy area of LF like an
earthquake”, the development of ICT cards to
facilitate evidence-based disease mapping, and
ground-breaking work to reduce morbidity and
alleviate suffering.
Highlights were selected from the second phase of
the meeting which centered around regional and
country overviews, singling out the need for more
work in locating the disease as shown in Egypt
“Mapping is a first priority; partnerships are
another,” Dr Liese said, pointing out that virtually
all regions and countries had underscored their
importance.
35
:
GLOBAL ALLIANCE TO ELMNATE LYMPHATIC FILARIASIS
On the challenges ahead, he singled out
improvements in the weak infrastructures of
ministries of health, especially in the largest and
poorest LF-endemic countries; the importance of
integrating disease treatment, the difficulties of
social mobilization exacerbated by distance and
illiteracy; and the importance of seeing LF control
as “more than just drug distribution”. The future
will demand a “huge operational research agenda”,
he said.
—3 were described as having
The working groups
featured “rich,"engaged debate” after which there
would be a need to consolidate the messages,
highlighting the importance of mapping and
epidemiology, morbidity control and integration of
j jp treatment with that of other diseases.
Dr Liese concluded by saying that “In Santiago,
the Global Alliance has been transformed from
being an idea with a name — to a concrete reality.
I
I
I
Meeting Chairperson
Mr Javid A. Chowdhury (India) claimed “the last
word”, saying that appointing him chairperson had
“nudged India into making LF a central programme
to be monitored and administered,.” He was
heartened by this evidence of solidarity and crosssectoral cooperation towards a humanitarian cause,
especially SB’s generosity and commitment to the
programme.
I
“This disease is effortlessly curable,” Mr
Chowdhury said. With the help of NGDOs, “we
must convince the people, the rural peasants, to
access treatment However, he said, it would be “a
long haul” for India and that interim target dates
would be necessary between now and the year 2020.
/o issues stood out for Dr Liesei firstly, the social
impact of LF and the fact that it had so long been “a
neglected disease”; secondly, his perception that
LF control was less a matter of funding than of
public health administration.
I
6
Then Mr Chowdhury made a formal commitment
on behalf of the Indian Government to launch “a
pilot project with 40 million
people and to achieve
. ------- ...------compliance with WHO’s
This is the way partnerships
should
r-_ f
2020 targets”, starting with
I
Looking to the future, he
pointed to the need for
broad-based partner
- beating
back the diseases or
million people already
ships, rapid progress to Y"work
’
poverty/
tvM/Pi+v
thjg yean “A major
ensure on-site drug
supplies, a strong con
government effort will be
!
- Dr David Heymann, Executive Director
tinued commitment by
crucial - it takes a massive
for Communicable Diseases,
pharmaceutical partners,
build up in a country like
World Health Organization. (Extracted
in particular from Smith- F
India,” he said, “but, in the
from the video presentation'Target LF:
Kline Beecham and Merck ;
end , we are dependent on
& Co., Inc., a more clearly I for a future without lymphatic filariasis*)
our partners in the
defined role for NGDOs, a
pharmaceutical industry;
stronger regional focus,
we will be helpless if the
nd the need to bring new
drugs don’t arrive - and also on the quality of the
partners on board. DFID’s crucial early support was
NGOs.”
recognized, as was that of the Liverpool School of
“Our greatest anxiety is funding,” he said, “and yet
Tropical Medicine LF Support Centre.
our needs are very modest - only about
“To sum up,” Dr Liese said, “the first big step has
US$ 50 million - and here we have the World Bank,
been made. The Global Alliance has moved from
the most resourceful funder on earth, sitting right
infancy to being a toddler - one with many parents,
next to me.”
all of whom share commitment to a common cause.”
He said that India would “contribute to the Global
All these partners had committed to dealing with
Alliance in a substantive way” and concluded by
this disabling disease, to putting its elimination
issuing an invitation on behalf of the Indian
higher on the world’s development agenda, and to
Government to host the second meeting of the
restoring dignity, respect and health to its victims.
alliance.
r
. ...
l
----------------------
%
r?-
X-
-
36
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proceedings of first meeting. MAY 2000
Annex: List of participants
National Ministries of Health of Endemic Countries
National Ministry of Health, Comoros
SSSKSRSS?" s,n't "“*• •" ’**•«*«*—.
Tel: 269-74-40-70, Fax: 269-73-18-25, E-mail: pnac@snpt.km
National Ministry of Health, Dominican Republic
t Dr CuilkHno Gonzalvez, Director General, Centre Nacional Para El Control de Las Enfetreedades
Tel: 809-536-9604, Fox: 809-536-2281, E-mail: malaria@aacr.net
National Ministry of Health, Egypt
I
m
“a,’b’Director’General Department of Malaria, Filariasis and Leishmaniasis Control
2Xe"
pulation’22 E1’Fal,aki
Ca,ro’Egypt
Dr Khaled M^A. Gado, DirectorofFilariasis Control Department, General Department ofMalaria
Te^'S202 W-W laS'S COntrO1’MiniStry °fHealth and P°Pulation>22 E™ Street, Cairo, Egypt
i I
National Ministry of Health, Fiji
t Dr Joe Koroivueta, Ministry of Health and Social Welfare, Wellcomi
ie Vims Laboratory,
Tamavua Hospital, Private Mailbag, Suva, Fiji
Tel: 679-322-0066, Fax: 679-320-344, E-mail: joekv@is.com.fi
National Ministry of Health, Ghana
Tel: 233-21-230-220, Fox: 233-21-226-739. E-mail: gyapong ©ighmail.com
National Ministry of Health, Haiti
kDrtr-aEu,-Znce0Md00rd°nnateUr
PrOgramme Filari°Se
^nistSre de la Same,
Tel: 509-222-15-35, Tel/fox: 509-222-12-48 or 509-228-25-19
National Ministry of Health, India
Tel. 91-11-301-8863, Fox: 91-11-301-4252, E-mail: secyhealth®nli.nic.in Chairman
Tel: 91-11-391-8576, Fax: 91-11-396-832, E-mail: nmep@ren02.nic.in
+
*
TAG Member
Unable to attend
37
’k
*
&
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILAPLASIS
National Ministry of Health, Philippines
Dr Leda Hernandez, Medical Specialist, National Filariasis Elimination Program Coordinator,
Communicable Disease Control Service, Department of Health, San Lazaro Compound, Sta Cruz, Manila,
Philippines
Tel: 632-711-6808, Fox: 632-711-6804, E-mail: j_abella@doh.gov.ph
National Ministry of Health, Sri Lanka
Dr Tilaka S. Liyanage, Acting Director, Anti Filariasis Campaign, Ministry of Health,
Colombo South Hospital Complex, Kalubowila, Sri Lanka
Tel/Fax: 94-1-827-208, E-mail: dashi@sltnet.ik
National Ministry of Health, Sudan
» Dr A.K.A. AI-Faki, Director, Preventive Medicine, Federal Ministry of Health, Khartoum, Sudan
Tel: 249-11-773-000, Fox: 249-11-780-652 or 778-704
1
National Ministry of Health, Togo
Dr K. Yao Sodahlon, Coordinateur adjoint du Programme national d’elimination de la filariose lymphatique,
Chef de la Division des Laboratoires au Ministere de la Sante, BP 8474, Lome, Togo
Tel.: 228-25-48-05 or 228-04-55-40, Fax: 228-22-07-99, E-mail: yasodah@syfed.tg.refer.org
I-
IB
National Ministry of Health, Viet Nam
Dr Nguyen Duy Toan, Chief, Parasitology Department, National Institute of Malariology,
Parasitology and Entomology (NIMPE), BC 10200, Tuliem, Hanoi, Viet Nam
Tel: 84-4-854-2350, Fox: 84-4-854-3015, E-mail: ntoan2@fpt.vn
International Organizations
B-
World Bank, USA
♦ Mr Bruce Benton, Manager, Onchocerciasis Coordination Unit, The World Bank, Room J8-007,
1818 H Street, N.W, Washington D.C. 20433, USA
Tel. 1-202-473-5031, Fax: 1-202-522-3157, E-mail: bentonb@yvorldbank.org
Dr Philip Coyne, Medical Consultant, Onchocerciasis Unit, The World Bank, Room J8-029,1818 H Street
N.W, Washington D.C. 20433, USA,
Tel. 1-202-458-1511/473-4733, Fax: 1-202-522-3157, E-mail: pcoyne@worldbank.org
Dr Bernhard H. Liese, Senior Adviser, Human Development, African Region, The World Bank,
Room J8-095,1818 H Street, N.W, Washington, DC 20433, USA
Tel. 1-202-458-4491, Fax: 1-202-522-3157, E-mail: bliese@worldbank.orgRapporteur
Private Sector
SmithKline Beecham, USA
Dr Brian Bagnall, Director, Lymphatic Filariasis Corporate Affairs, SmithKline Beecham,
One Franklin Plaza FP 2135, RO. Box 7929, Philadelphia PA 19101, USA
Tel. 1-215-751-6168, Fax: 1-215-751-4046, E-mail: brian.bagnall@sb.com
H
Dr Mark Bradley, International Medical Department, SmithKline Beecham, Great West Road
Brentford Middlesex TW8 9BD, U.K.
Tel. 44-181-975-5687, Fax: 44-0208-975-3514, E-mail: mark.x.bradley@sb.com
b-.
cI
Ms Naomi Teshima, Supply and Demand Manager, SmithKline Beecham Laboratoires pharmaceutiques,
o, esplanade Charles de Gaulle, 92731 Nanterre Cedex , France
c ■ 33-1-46-98-49-03, Fax: 33-1-41-37-49-03, E-mail: naomi.l.teshima®sb.com
*
J
Unable to attend.
38
I
F
proceedings of first meeting, MAYPmn
Merck & Co. Inc, O^eAfc^DrivYwhT
D°nation PoIicy’s Programs WS1AF 35
Tel: 908.423^047.
W
Mr Charles Fettir. . n °8
NJ08889-0100, USA
b^.eolatrella@merck.com
'reCtOr’Marketlng- Merck & Co. Inc, One Merck Drive, Whitehouse Station
Tel: 908.423-6937. Fax; 908-735-H64, E-^U: ^rles-fe^^
International Development Agencies
Sr; fD™z un"ea Kinad°m
Center fnrna ■ -
4’ E'mail:P^^^dfid.gov.uk
o ■
**t Dr J. Habbema, Center for Decision *ZTCalDiSeaSe Contro1’ The Netherlands
F Z31?1/ ^aSmUS Univeraity Rotterdam^ RO.BonjSS^OOODR^'SeaSeContro1' DePartment of Public
Tel: 31-!0-408-79-83. Fax: 3.-^08-94-331.
Non-Governmental Organizations
Panum Institute, Denmark
jI
3tDSc^XrNT.Xm™“,O8y'P"
H
XXTor F“ "J"’5 “S
loor, B legdams vej
Norway
144
N-^FageritrnSN^
T,: 47mW2. rm:
Medicos Do Mundo, Portugal
1900-240ListorPoi^^ied,COS D° MUnd°’Rua Frederico Peny Vidal, Bloco 9,1» Piso,
xr2'^"3, f“
1900-240 LisbM.rX'^r11'005
Ml',ldo’Rua Fred«ri«>Peny Vidal. Bloco9,1' Piso,
F“" 15‘-2'-S49-IS4taem”^
Kingdom
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r...
Fm wsl_,„,205i
• Jn“ xirGroup (tag) member-
•* Unable to attend, present at TAG meeting only.
39
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global alliance to eliminate lymphatic FILARIASIS
y
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i
Carter Center Global 2000, USA
|v
Dr Frank Richards, Technical Director, Carter Center Global 2000 The Kirbo Ruildino
1149 Ponce De Leon, Atlanta, GA 30306 USA
Building,
t’-
Tel: 770-488-4511, Direct fax: 770-488-4521, E-mail: fxrl@cdc.gov
i
Catholic Medical Mission Board, USA
Kf'
10 West 17* Street, Ne^rk^lX'.USA1"3'0"’
B'
M'SSiOn B card,
r
Tel: 212-242-7757, Fax: 212-242-0930, E-mail: sdadian@cmmb.org
Interchurch Medical Assistance Inc.. USA
.P.O.Box 429,
L
Tel: 410-635-8720, Fox: 410-635-8726, E-mail: Pauldersiine@interchurch.org
Mectizan® Donation Program, USA
te ■
T,l: l-mj7I.Ums?2-lS60. Fa, l-IM.37i.u3s.
1
Tel: 1-404-371-1460, Fax: 1-404-371-1138. E-mail: cmackenzie@taskforce.org
Centres for Partneships in Health, Australia
UJ3J. fax. 61-7-4781-6336. E-mail: douglasrandell@ozemail.com.au
Academic and Research Organizations
Centers for Disease Control and Prevention (CDC) USA
el. 1-770-488-4054. Fox: 1-770-488-4108. E-mail: pjll@cdc.gov
-bS m™ rDiseases’Centers for Dise- c°-°-
Tel: 1-770-488-7763, Fax: 1-77^488-7761'^2.^XXT^^^ 30341-3724’^
DrAn°u
Sch°o1 of Publlc Health at Emory University, USA
il
Tel: 1-404-727-3558, Fox: 1-404-727-4590, E-mail: achaddi@sph.emory.edu
ClknCRoal,KES“
The Rollins School of Public Health at Emory University, 1518
Tel: 1-404.727-2425, Fax: 1-404-727-4590, E-mail: rrheing@sph.emory.edu
Federal de Pernambuco, Brazil
Ain Shams University, Egypt
-
cairo, Egypt Set0Uhy’ Ass‘Prof-of Public Health, Am Shams University, College of Medicine, Abbasia,
Tel. 202-403-9761. Mobile: 2010-1417-616. Fox: 202-483-7888. E-Mail: setouhy@menanet.net
t
tag member.
40
h
PR
^GS OF FIRST MEETING. MAY 2000
Chinese Academy of Preventive Medicine, PR China
National Institute of Communicable Diseases, India
t Dr K.K. Datta, Director, National Institute of Communicable Diseases, Directorate General of Health
Services, 22 ShamNath Marg, Delhi 110 054, India
Tel. 91-11-5087520, Fax: 91-11-3922677, E-mail: dirnicd@bol.net.in
Institute for Medical Research, Malaysia
Sulaiman, Head of Parasitology Division, Institute for Medical Research, Jalan
Pahang, 50588 Kuala Lumpur, Malaysia
Tel: 603-440-2437, Fax: 603-293-8306, E-mail: lohnan@imr.gov.my
Universiti Putra Malaysia
Pr0f C P; Ramadiandran, Professor of Clinical Parasitology, Faculty of Medicine and Health Sciences
PUtra Mala>'sia-8A-4^- Belvedere, 1/63, off Jalan Tunku, Bukit Tunku,
50480 Kuala Lumpur, Malaysia
Tel: 603-298-7275, Fox: 603-298-6152, E-mail: cprama@medic.upm.edu.my
National Institute for Medical Research. UR Tanzania
t Dr Mwele Malecela, Director of Research, National Institute for Medical Research, P.O. Box 9653
Ocean Road, Dar es Salaam, United Republic of Tanzania
Tel: 255-51-130-770 or 131-864. Fox: 255-51-130-660, E-mail: mmalecela@tyviga.com
Instituto de Salud Carlos III, Espana
P
Gdrate’Chief of Section’ Responsible of the Helminthiasis Group, Instituto de Salud Carlos HI
C.N.M. Parasitologia, crtra. Majadahonda-Pozuelo, km 2.2,28220 Madrid Espana
Tel: 34-91-509-7901, Fox: 34-91-509-7034, E-mail: tgarate@isciii.es '
Faculte de Medecine, Universite de Tours, France
Prof. Dominique Richard-Lenoble, Chef du Service de Parasitologic et mddecine tropicale,
Faculty de M6decme, University de Tours, 2 bis, boulevard TonnelM, 37000 Tours France
Fox: 33-2-4737-6955, E-mail: drl@med.univ-tours.fr
Institut de Recherche pour le Developpement (IRD), France
Dr Frederic Lardeux, Entomologiste medical. Departement Societes et Santd, Institut de Recherche pour
le Developpement (IRD), 213, rue laFayette, 34032 Montpellier Cedex 01, France
Tel: 33^67-04-32-22, Fox: 33-467-04-32-22, E-mail: lardeux@mpl.ird.fr
Dr Gaston Pichon, Directeur de Recherche, Entomo-parasitologiste, IRD Centre dTle-de-France 32
avenue Henn Varagnat, 93143 Bondy Cedex, France
Tel: 33-148-02-59-76, Fax: 33-148-47-30-88, E-mail: pichon@bondy.ird.fr
Liverpool School of Tropical Medicine, United Kingdom
Dr David Molyneux, Professor of Tropical Health Sciences, Livetpool School of Tropical Medicine,
Lb Support Centre, Pembroke Place, Liverpool, 1.3 5QA, U.K.
Tel: 44-151-708-9393, Fax: 44-151-709-0354, E-mail: fahy@liv.ac.uk
Tel: 44-151-708-9393, Fax: 44-151-709-0354, E-mail: fahy@liv.ac.uk
t
TAG member.
>41
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILAWASIS
School of Nursing and Midwifery, United Kingdom
Dr Steven Ersser, Head of Nursing Development, School of Nursing and Midwifery, University of
Southampton, Level B (11), South Block, Southampton General Hospital, Tremona Road, Southampton
SO166YD,UK
Tel: 2380-79-6549, Fax: 2380-79-6922, E-mail: sjel@soton.ac.uk
Programme Review Group Members
School of Public Health and Tropical Medicine, USA
Dr Barnett L. Cline, Professor Emeritus, Tulane University, School of Public Health and Tropical
Medicine, Center for International Community-based Studies SL29,1501 Canal Street, Room 513,
New Orleans, LA 70112-2824, USA
Tel: 1504-584-3555, Fox: 1504-587-7313, E-mail: blchome@momern.net
Vector Control Research Centre (VCRC), India
Dr P.K. Das, Director, Vector Control Research Centre, VCRC (Indian Council of Medical Research),
Medical Complex, Indira Nagar, Pondicherry 605006, India
>1: 91-413-372-422, Mobile 98430-69401, Fox: 91-413-372-041,
^-mail: mosquito@vsnl.com or pradeep@das.org
College of Medicine/FriendlyCare Foundation. Philippines
Dr Jaime Z. Galvez Tan, Professor, University of the Philippines, College of Medicine,
Department of Family and Community Medicine, 1086 Del Monte Avenue, Quezon City 1105, Philippines
Tel: 632-374-3745, Fox: 632-413-8669, E-mail: galveztan@pacific.net.ph
President and Chief Executive Officer, FriendlyCare Foundation, Inc. P.O. Box 13922, Ortigas Center,
Post Office Ortigas Center, Pasig City, 1605 Metro Manila, Philippines
E-mail: jzgt@friendlycare, corruph orjzgt@starplace.com
International Trachoma Initiative, Tanzania
Dr Peter Kilima, Regional Representative, International Trachoma Initiative, P.O. Box 3545, Dar-EsSalaam, United Republic of Tanzania
Tel: 255-51-127102, Mobile 0812 787-347, Fox: 255-51-122350, E-mail: kilima.iti@twiga.com
Kyushu University, Graduate School of Medical Sciences, Japan
Prof Isao Tada, Emeritus Professor, Department of Parasitology, Kyushu University, Graduate School of
Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812, Japan
'7?/r 81-92-921-7705, Fox: 81-92-642-6115, E-mail: isaotada@parasite.med.kyushu-u.ac.jp
L
I
accident & Family Health Care, New Zealand
♦ Dr J. Williams, Accident & Family Health Care, 1-627 Mt Wellington Highway, Mt Wellington,
New Zealand
Tel: 64-9-276-8640, Fax: 64-9-276-9849, E-mail: jjwilliams@clear.net.nz
TAG Chairman
t Dr K, Y. Dadzie, Chairman, P.O. Box 01905, Osu, Accra, Ghana
Tel: 233-21-40-13-53, Fox: 233-21-40-13-53, E-mail: yankumdadzie@iname.com
?■
'4
j
TAG member.
Unable to attend.
42
II!
PROCEEDINGS OF FIRST MEETING, MAY 2000
WHO Secretariat
Headquarters, Geneva
Dr Gautam Biswas, Lymphatic Filariasis Elimination, (CEE/FIL), Strategy Development and Monitoring for
Eradication and Elimination, WHO, CH-1211 Geneva 27
Tel: 41-22-791-3225, Fax: 41-22-791-4777, E-mail: biswasg@yvho.int
Mr J. Cheyne, Department of Control, Prevention and Eradication (CPE), Strategy Development and
Monitoring for Eradication and Elimination, WHO, CH-1211 Geneva 27
Tel: 41-22-791-4802, Fax: 41-22-791-4850, E-mail: cheynej@who.int
Dr J. Lazdins-Helds, Manager, Macrofil R & D, Communicable Diseases Research and Development,
including TDR (CRD), WHO, CH-1211 Geneva 27
Tel: 41-22-791-3818, Fax: 41-22-791-4854, E-mail: lazdinsj@who.int
Dr Maria Neira, Director, Department of Control, Prevention and Eradication (CPE), Strategy Development
and Monitoring for Eradication and Elimination, WHO, CH-1211 Geneva 27
Tel: 41-22-791-3977, Fax: 41-22-791-4777, E-mail: neiram@who.int
Dr Eric A. Ottesen, Project Leader, Lymphatic Filariasis Elimination, Strategy Development and
Monitoring for Eradication and Elimination, (CPE/CEE/FIL), WHO, CH-1211 Geneva 27
Tel: 41-22-791-3225, Fax: 41-22-791-4777, E-mail: ottesene@who.int
Dr Nevio Zagaria, Coordinator, Strategy Development and Monitoring for Eradication and EKaination
(CPE/CEE), WHO, CH-1211 Geneva 27
Tel: 41-22-791-2534, Fax: 41-22-791-4777, E-mail: zagarian@who.int
Regional Office for Africa
Dr J.B. Roungou, OTD/AFRO, Regional Office for Africa, c/o OCP/APOC, B.P. 549, Ouagadougou 01,
Burkina Faso
Tel: 226-342-953/959, Fox: 226-342-875, E-mail: roungou®ocp.oms.bf
Dr Boakye A. Boatin, Director, Onchocerciasis Control Programme in West Africa, WHO/OCP,
P.O. Box 549, Ouagadougou 01, Burkina Faso
Tel/Fax: 226-342-981, E-mail: boatin@ocp.oms.bf
Regional Office for the Americas
Dr John P. Ehrenberg, Regional Adviser in Communicable Diseases, Regional Office for the Americas/
Pan American Sanitary Bureau, PAHO/WHO, 525 23rd Street, N.W. Washington DC, 20037, USA
Tel: 1-202-974-3894, Fox: 1-202-974-3866, E-mail: ehrenbej@paho.org
Regional Office for the Eastern Mediterranean
Dr Nikolai Neouimine, CEE regional Adviser, WHO/EMRO, Regional Office for the Eastern
Mediterranean, P.O. Box 1517, Alexandria, 21511 Egypt
Tel: 203-48-300-96, Fox: 203-48-38-916 or 203-48-24-329, E-mail: neouiminen@who.sci.eg
Regional Office for South-East Asia
Dr Chusak Prasittisuk, Regional Advisor, Vector Borne Disease Control (VBC), SEARO,
Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road,
New Delhi 110002, India
Tel: 91-11-331-7804/7823 , Fox: 91-11-331-8607, 332-7972, 331-8412, E-mail: chusakp@whosea.org
Dr. RJ. Kim-Farley, WHO Representative, Nirman Bhavan, Room 533-35, “A” Wing, Maulana Azad Road,
New Delhi-110011,
Tel: 91-11-301-8955/8988, ext. 2507, Fax: 91-11-301-2450, E-mail: kimfarleyr@whoindia.org
Regional Office for the Western Pacific
Dr Kazuyo Ichimori, Scientist, Office of the WHO Country Liaison Officer in Vanuatu, P.O. Box 177,
Port Vila, Vanuatu
Tel. 678-227-93, Fox: 678-226-91, E-mail: ichimorik@who.org.vu
43
y / 5 ' 9-C>- 3
TDR/Gen/97.1
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Chagas disease
Leprosy
Lymphatic filariasis
Onchocerciasis
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Prospects for
elimination
I
Chagas Disease
Leprosy
Lymphatic filariasis
Onchocerciasis
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:
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The designations employed and the presentation of the material in this report do not
imply the expression of any opinion whatsoever on the part of the Secretariat of the
World Health Organization concerning the legal status of any country, territory, city or
area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
© World Health Organization 1997
ii
Prospects for the elimination of some TDR diseases
/ </•
j 4/ i
*
1
/
PROSPECTS FOR THE ELIMINATION
OF SOME TDR DISEASES
Page
Introduction
3
Disease Elimination and Research Needs
3
LEPROSY
5
ONCHOCERCIASIS
11
LYMPHATIC FILARIASIS
17
CHAGAS DISEASE
23
Prospects for the elimination of some TDR diseases
3
Introduction:
Elimination or Eradication?
For the purpose of the present report, eradication of a disease is the reduction of
worldwide incidence to zero as a result of deliberate efforts, obviating the necessity for further
control measures. Similarly, elimination of a disease is the reduction of the morbidity to a level
that does not constitute a major public health problem, but still requires a basic level of control
and surveillance. This threshold varies from disease to disease and it is measured as a prevalence
rate. For example, since manv of the diseases have a zoonotic component they cannot be
eradicated but can be controlled if they are reduced to a low target level.
Disease Elimination and Research Needs
1. There remains an unfinished TDR research agenda for each of the four diseases that
can be eliminated - Chagas disease, onchocerciasis, leprosy and lymphatic filariasis - which
should be continued either until elimination is achieved or until the research brings even better
tools to bear on the problem, e.g. a macrofilaricide. One target is to show how to combine
common interventions effectively for different diseases, e.g. bednets for malaria and filariasis,
ivermectin for filariasis and onchocerciasis, and spraying for local control of the vectors of
several diseases. Another is to develop more specific and sensitive tools for surveillance and
evaluation of impact.
2. It will be essential to invest for a period of 8-10 years to reduce each of the four
diseases - Chagas disease, leprosy, onchocerciasis and lymphatic filariasis - to a level which
assures that they are unlikely to re-emerge and will no longer be major public health problems.
In certain focal areas, the effort at eradication may be worth undertaking, as in the case of leprosy
or onchocerciasis. The failure to make that investment will lead to real risk that elimination will
not be achieved and that prior investments in research and control may be wasted.
3. The defined time to elimination as a public health problem represents a special case
intervention, since the cost of eliminating the last cases of any disease is never cost-effective in
itself. The framework for the economic analysis should be the savings, not in one year, but over
the remaining century or more that the diseases are no longer major public health problems. Here
the issue of discounting should be reconsidered, because recurrent costs are permanently
eliminated or reduced.
4. The efforts directed towards elimination of TDR diseases have certain features in
common, e.g. the need for tests of high specificity for surveillance, and the likelihood of the
diseases remaining for long periods in remote areas and areas of conflict or declining social
cohesion. There is thus good scope for cross fertilization and economization between the
elimination efforts for different diseases.
I
4
Prospects for the elimination of some TDR diseases
5. Elimination as a public health problem will also require an increase in operational
research to solve problems in the field and improve surveillance, which is essential to avoid risks
of re-emergence and to assure the aims of the programmes have been achieved for a finite period.
Monitoring is required as much for "disappearing diseases" as for newly emergent diseases, and
sentinel sites and continuing support for the activity and flexible responses to hot spots will be
required.
6. Global travel and immigration will remain continuing threats to the elimination of
these diseases, and special efforts to maintain surveillance must be made.
7. While elimination implies some level of national vertical planning, to be effective,
these programmes must be integrated at the district and community level. For some, treatments
are sufficiently simplified and safe that they can be carried out at the community level by the
community itself, e.g., onchocerciasis.
8. There are costs to a health service in terms of dislocation and disruption and diversion
of personnel to elimination programmes. These should be anticipated, and planned and
compensated for, from the beginning of a programme. Resources should be set aside and
incorporated into elimination programmes, and used to assure that other important health and
control functions are not compromised by elimination programmes. Expertise that would be
difficult to redevelop in the case of future needs should also be maintained at a certain level.
9. Furthermore, there must be a plan for devolution of the disease programmes and
services as the diseases are eliminated, and alternative training for scientists and health workers
involved must be planned for from the beginning.
10. The development and maintenance of geographic information systems will be
important for elimination activities.
11. Education and communication training and packages will be essential for assuring
effective programmes at the community level.
12. Experience to date indicates the importance of modelling as a scientific and control
tool; improved models can facilitate evaluation and monitoring of disease elimination both
locally and globally.
13. TDR has anticipated the transition of leprosy, onchocerciasis, lymphatic filariasis
and Chagas disease from major research problems to a level of research required to assure
disease elimination, and they represent now less than 22% of the TDR budget.
14. At the same time, elimination of leprosy, onchocerciasis, lymphatic filariasis and
Chagas disease as public health problems will require an investment of new, specially planned
research funds for a finite period of time. The investment in disease elimination must be for a
defined period, but one sufficient in time and magnitude to assure disease elimination, prevent
recrudescence and maintain surveillance.
Prospects for the elimination of some TDR diseases
5
LEPROSY
1. The disease
Leprosy is a chronic communicable disease caused by the bacillus Mycobacterium leprae,
which is closely related to the M. tuberculosis bacillus that causes tuberculosis. Both diseases
are believed to be transmitted through bacteria-laden droplets form the nose and throat, and have
been treated with the same or related drugs. In both cases, treatment has been lengthy,
compliance has been a problem; and the development of drug resistance has threatened control.
However, the two organisms have very different targets - leprosy affecting mostly the skin and
peripheral nerves, and tuberculosis mostly the lungs. And whereas strains of M. tuberculosis
have developed multi-resistance to most known drugs, mercifully leprosy is being very
effectively controlled with a two- or three-drug combination.
Leprosy presents a great variety of forms depending on the individual immune response
to the infection and its duration. Most infections appear to remain symptomless. At one end of
the disease spectrum is lepromatous leprosy, in which cell-mediated immunity to leprosy is
absent (though present in infections with other agents) and where M. leprae bacilli multiply
uncontrolled, leading eventually to damage to mucous membranes, the eyes and peripheral
nerves, and ultimately to deformity. At the other end of the spectrum is tuberculoid leprosy, in
which the immune system has control of the infection, few bacteria can be found, and the
symptoms are mild, often taking the form of desensitized, pale and sharply defined skin patches.
Tuberculoid leprosy is usually self-limiting, but can sometimes lead to peripheral nerve damage.
Lepromatous cases are tho^ught to be the main source of transmission of the disease.
In control programmes, for choice of drug regimen, cases are generally divided into two
groups: paucibacillary cases, which broadly coincide with cases of tuberculoid leprosy; and
multibacillary cases, which broadly coincide with cases of lepromatous leprosy. But much finer
divisions and distinctions are also possible.
2. Disease situation and trends
The prevalence of this disease has been reduced from 5.4 million in 1985 to 940 000 in
1996 and the number of patients cured with multidrug therapy (MDT) was more than 8 million
at the end of 1995 (Table 1 and Figure 1).
I
I
I
6
Prospects for the elimination of some TDR diseases
10000 -r
J 8005!
8000 -
J5341
6687
5078 .» 4908
^3866
6000 -
.5659
137371
4098^
4000 -
^2082894
^Smi433
11319
2000 93
46R_^M
-J 515
628
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Thousands
1671
11292 |
984
1205
854
89
2292.
____
■111181 |912i
T
90
91
92
93
T
94
941
849
95
Registered cases
IS
Cases on MDT
H
Cumulative number of cases cured with MDT
!
Figure 1
I
Leprosy prevalence and MDT coverage
by WHO Region, 1996 (*)
Table 1
WHO Region
Registered
cases
Prevalence
per 10 000
Cases on MDT
(%)
Cured with MDT
Cumulative Total
MDT coverage
Africa
92 517
1.70
85 942
92.9
450 877
Americas
163 277
2.15
123 366
75.6
225 450
South-East
Asia
635 490
4.61
595 301
93.7
7 059 926
Eastern
Mediterranean
18 188
0.43
16 738
92.0
55 919
Western
Pacific
31 043
0.19
27 874
89.8
213 019
TOTAL
940 515
1.69
849 221
90.3
8 005 271
(*) excluding the European Region
Figure 2:
Tow
ds the elimination of Lt rosy:
The Timetable
Study of dapsone resistance ( I IIELEP)
Experimental chemotherapy (THELEP)
Short-term clinical trials (THELEP)
I
|80
I
I
85
1- I I I90 I
95
00
I
'77777777^77777777,7777/777.
777777^/7777/77/7/
I I I I---- J
7ZZZZZZZZZ77777Z777ZZ777Z. '77Z77ZZ77ZZZ.7777.
■■■■■■■ V//7777////Z/Z/7Z////,
Development of WHO/MDT and recommendation for its use
MDT Field evaluation studies (THELEP)
^7ZZZZZZZZZZZ z77ZZ/ZZZ777Z7Z7ZZZZZ7ZZ77777777777Z77A
j
Implementation of MDT in national programmes
WHA resolution on the elimination of leprosy as a public health problem
International conference on the elimination of leprosy, Hanoi, Viet Nam
75% global MDT coverage
Alternate MDT regimens for field use (THELEP)
Vy///////7////////7////////77////////7777t
i
I
Prospects for the elimination of some TDR diseases
9
3. Strategy for elimination
It won't be long before the question of whether to work actively towards a leprosy
eradication strategy will arise, but the tools currently available and the existing knowledge on
the subject do not permit such a strategy. If eradication is to be seriously considered, the first
step would be to embark on research to develop laboratory tools that can identify "at risk" groups
as well as intervention tools to carry out the task.
What would be the cost-effectiveness of this research, particularly in relation to the gains
to be made by completely stopping the occurrence of leprosy? If the costs of such an eradication
strategy prove to be very' high, investment in the research could turn out to be questionable.
On the other hand, beyond the year 2000, even with the success of the elimination
strategy, there may be a felt need, at least in some parts of the world, to totally eradicate leprosy
within a short period of time. This would require a strategy based on: (a) epidemiological
surveillance of the small numbers of cases that may continue to occur, and. more importantly,
on surveillance of subclinical infection in the population; and (b) effective interventions to abort
subclinical infections apart from curing the occasional disease. The most important
consideration in this strategy is cost-effectiveness, which requires that technologies for
identifying subclinical infection (laboratory tests) and interventions (e.g. vaccines) be simple,
affordable and acceptable to the community. As with the current elimination strategy of
identifying and treating clinical leprosy, identification of and interventions for subclinical
infection will be quite a challenging task for difficult-to-access areas and populations. Thus the
need to invest in leprosy research even beyond the year 2000 is quite obvious.
4. The timetable towards elimination
The main landmarks are indicated in Figure 2 (control activities shown as solid bars,
research activities as hatched bars) and can be summarized as follows:
Study of Dapsone resistance
Experimental Chemotherapy (e.g. Minocycline, Ofloxacin)
Short-term clinical trials
Development of MDT and recommendation for its use
MDT field evaluation studies
1982-2000 and beyond: Implementation of MDT in national programmes
WHA Resolution on the elimination of leprosy as a public health problem
1991:
International Conference on the elimination of leprosy Hanoi, Viet Nam
1994:
Achievement of 75% Global MDT coverage
1995:
Alternate MDT regimens for field use
1998:
1978-1984:
1978-1996:
1978-1996:
1981- 1982:
1982- 1994:
5. Future Research Needs
Diagnostic tools to identify subclinical infection:
- to monitor transmission,
Vaccine development:
- to prevent infection/disease.
Prospects for the elimination of some TDR diseases
11
■
ONCHOCERCIASIS
1. The disease
Onchocerciasis is an important public health and socio-economic problem, especially in
Africa where over 99% of all infected persons live. The most severe consequence of
onchocerciasis is blindness, which may afflict over one third of the adult population of the most
affected communities. .Another important problem is severe skin disease associated with
maddenins itching which cause great suffering to millions of people according to recent TDR
research.
2. Disease situation and trends
The Onchocerciasis Control Programme in West Africa (OCP). which was launched in
1975 and extended in 19S9. covers the savanna areas of 11 West African countries. The principal
control stratesv has been vector control and this has been highly successful in interrupting
transmission of the disease. Onchocerciasis is now under full control throughout the OCP area.
Some 1.5 million people, originally infected, are no longer so; an estimated 125 000-200 000
people have been prevented from going blind; 30 million people are no longer at risk of infection
and blindness, and 25 million hectares of land have been made available for settlement.
In the endemic countries in Africa outside the OCP, there are an estimated 15 million
people infected with Or.choccrca volvulus, representing 85% of all infected people in the world
todav. It has been estimated that, in 1990. 335 000 persons were blind as a result of
onchocerciasis (40 000 new cases of blindness per year). 4-6 million were affected by skin
lesions, and more than 6 million people were suffering from troublesome itching. Untortunatelv.
aerial larviciding was not considered technically feasible or cost-effective outside the OCP, and
virtuallv no action used to be taken to control the disease in the non-OC? countries. Tms changed
when ivermectin was introduced in 1987 and made available by the manufacturer, Ale.^k. Sharp
& Dohme. free of charge and for "as long as needed". Several endemic countries, supported by
a sroup of international non-govemmental orgamzations. have started ivermectin-bas-d control
and it was estimated that, in 1994. some 15 percent of those infected outside the OCP areas
received ivermectin treatment.
3. Strategy’for elimination
It is expected that global elimination of onchocerciasis as a public health problem will
be achieved during the next decade as a result of the control operations of the OCP and of two
recently created international onchocerciasis control programmes. The time frame of the different
control operations and of the major supporting research activities is given in Figure 3 (control
shown as solid bars, research as hatched bars).
In the OCP, onchocerciasis is no longer a public health problem. Nevertheless, vector
control, supported by ivermectin treatment, will continue in some areas until the vear 2002 to
ensure that the parasite reservoir is virtually eliminated and that the risk of recrudescence of the
infection is minimal throughout the OCP area.
Figure 3:
Towards The elimination of Onc.aocerciasis:
The Timetable
75
Onchocerciasis Control Prograrnmelr? West Africa
H
ool |
85
Control in original area
Larviciding research
Development of DNA probes for O.volvulus
Epidemiological modelling in support of control
_
I
9T
...
00
05
08
I I I I I
gSSftl
H h H
i H ! .
Extension areas: vector control + ivermectin
. ..
Ivermectin
Clinical trials and registration of ivermectin
J. J i i I I I
Community trials of ivermectin
Expanding use of ivermectin in control
Onchocerciasis Elimination Programme in the Americas
! I
. .
44 |
i
Operational Research
Rapid Assessment of Endemicity
Rapid Epidemiological Mapping in Africa
|
I
I
I
I
V7/Z////77/
Reassessment of the importance of skin disease
i '(ZZZ/Q—I
Assessment of economic impact of skin disease
I J
Studies of community directed treatment with ivermectin
Trials of efffect of ivermectin on skin disease
I
I ti/ZZZA I
1 I
j
African Programme for Onchocerciasis Control
Development of a macrofilaricide
L
Prospects for the elimination of some TOR diseases
13
Outside the OCP, onchocerciasis control will be mainly based on ivermectin treatment.
Assuming that ivermectin treatment is equally effective against the skin manifestations of
onchocerciasis as it is in the prevention of ocular disease and onchocercal blindness, the disease
can be eliminated as a public health problem from all communities where adequate ivermectin
treatment coverage is achieved and sustained. However, large-scale ivermectin treatment does
not result in interruption of transmission and treatment will therefore have to continue for a very'
long time, even after the disease is no longer a problem of public health importance.
In 1993, the Onchocerciasis Elimination Programme in the Americas (OEPA) was
launched. OEPA covers all six endemic countries in the Americas and the control strategy is also
based on ivermectin treatment. OEPA is scheduled to come to an end after a period of 10 to 15
years. The residual control activities required after this period have not yet been defined.
A new7 African Programme for Onchocerciasis Control (APOC) has been created to cover
all endemic African countries outside the OCP area. It has the objective: "to establish, within
a period of 12 years, effective and self-sustainable community-based ivermectin treatment
throughout the remaining endemic areas in Africa and to eliminate the disease by vector control
in selected foci”. APOC control operations are expected to begin in 1997.
TDR undertook an extensive operational research programme to prepare the technical
basis for APOC. Among the issues addressed were the development and application of rapid
methods to locate all high-risk communities requiring treatment, the psycho-social and public
health importance and economic impact of onchocercal skin disease, the effect of
ivermeciintreatment on onchocercal skin disease and troublesome itching, sustainable approaches
to community-directed treatment, simple methods for monitoring control and the feasibility of
vector eradication from isolated foci.
If the OCP is brought to a successful conclusion as scheduled by the year 2002, and if
both APOC and OEPA achie\ e their objectives within the planned period, the global elimination
of onchocerciasis as a public health problem will be achieved before the year 2008. However,
the parasite reservoir will not have been eliminated by that time, and residual control activities
will be required to ensure that the achievement of elimination is sustained.
4. Research for eradication of onchocerciasis
The risk of resistance to ivermectin is remote within the time frame of .APOC and OEPA.
However, the history of parasite disease control based on chemotherapy suggests a cautious
approach should be adopted, and recent model simulations and molecular biological studies
indicate that resistance could become a problem over a 20-30 year time period. It is important,
therefore, to continue the development of alternative drugs for the treatment of onchocerciasis.
Particularly useful would be a macrofilaricidal drug which kills or sterilizes the adult worms,
thus ensuring a more definite impact of control on the reservoir of the parasite and possibly
achieving its eradication. The development of a macrofilaricide is the mandate of the
MACROFIL project which is funded jointly by OCP and TDR.
In order to assess whether the eradication of onchocerciasis would be feasible if a
macrofilaricide became available, a computer simulation study was undertaken by the Centre for
14
Prospects for the elimination of some TDK. diseases
Decision Sciences in Tropical Disease Control (CDTDC) of Erasmus University of Rotterdam
using the microsimulation model ONCHOSIM. The long-term impact of mass treatment with
a macrofilaricide on the parasite reservoir and transmission was simulated under realistic
assumptions of drug efficacy (with efficacy defined as the percentage of macro filariae killed or
sterilized at each treatment) and treatment compliance. Eradication was defined as the attainment
of an epidemiological situation in which the probability of recrudescence of the disease after
cessation of control is less than 1%. The results of the simulations were compared with the
predicted long-term impact of repeated ivermectin treatment on the parasite reservoir and
transmission.
Though ivermectin is principally a microfilaricide, it also has an effect on the adult
worms. In the analysis of five-year follow-up data from the community trial in Asubende
(Ghana), it was found that the trends in microfilarial counts could only be explained by assuming
an irreversible reduction in fecundity of female worms of about 35% (Journal of Infectious
Diseases. 1995.172:204-10). Thus, ivermectin can also be considered a macrofilaricide but with
a modest efficacy of 35%. However, according to the model predictions, it would take up to 50
years with annual ivermectin treatment at a coverage of 65% of the total population (typical for
coverage with annual treatment in the OCP areas), or more than 15 years with six-monthly
treatment, to achieve eradication.
The results of simulations for more powerful macrofilaricides with efficacies of between
60% and 90%, and administered at six-monthly intervals, are shown in Figure 4. The simulation
is for a highly endemic focus with a community microfilarial load (CMFL) of 70 mf/skin-snip.
The dashed line shows the prospects of eradication by ivermectin treatment. The solid lines show
the combination of intervention period and treatment coverage required to achieve eradication
using macrofilaricides with assumed efficacies of 60%, 75% and 90% respectively. When
compared to ivermectin, a dramatic reduction in the required duration of control can be realized
even with a drug which kills only 60% of the worms (leaving the other 40% unaffected).
However, at a coverage level of 65%. a period of four years (drug efficacy 90%) to seven years
(efficacy 60%) of six-monthly treatment is still needed.
The above results are based on the assumption that treatment compliance is random, i.e.
that for each indhadual in the population, at each administration round, the probability' of beine
treated is the same, irrespective of attendance or non-attendance at previous rounds. This is
clearly net realistic and in order to explore the importance of systematic non-compliance, a
second senes of simulations was done using the extreme assumption that a certain percentage of
the population never gets treated (because of non-compliance or contraindications against the
drug). The results are shown in Figure 5. The solid line is for a macrofilaricide with 75% efficacy
and random compliance, similar to that shown in Figure 4. The dashed line is for the same
macrofilaricide but assuming systematic non-compliance in all cases. For this line, a coverage
of 0.9 means that 90% of the population always gets treated while 10% never receives treatment.
Figure 5 snows that the predicted feasibility of eradication depends greatly on the assumptions
made with respect to compliance. If non-compliance is mainly systematic, eradication is not
attainable under realistic assumptions of treatment coverage and within a reasonable period of
time.
Prospects for the elimination of some TDR diseases
15
30 -
60%
2.
I
I
1
20 -
75%
90%
0 —
0.00
0.20
0.40
0.60
0.80
1.00
Fraction treated per round
Figure 4: Potential of a macrofilaricide (solid lines) vs. ivermectin (dashed line) for
the eradication of onchocerciasis. Lines indicate the combination of duration of
control (Y-axis) and treatment coverage (X-axis) which leads to eradication (i.e.
recrudescence risk = 1 %). Above each line, eradication is almost certain; below the
line, recrudescence is likely. Treatment frequency is two times per year. The
percentages denote the drug-efficacy (% of worms killed per treatment).
30
75%
2
I
I
20
random
non-compliance
2
!
0 —
0.00
0.20
0.80
Figure 5: Potential of a macrofilaricide for the eradication of onchocerciasis. Lines
indicate the combination of duration of control (Y-axis) and treatment coverage (Xaxis) which leads to eradication (i.e. recrudescence risk = 1%). Above each line,
eradication is almost certain; below the line, recrudescence is likely. Treatment
frequency is two times per year. The drug is assumed to kill 75 % of the worms per
treatment. The solid line denotes a situation of random non-compliance; the dashed
line a situation of systematic non-compliance (see text for details).
In conclusion, when eradication of the parasite is the primary objective of control, there
is a definite role for a macrofilaricide in addition to ivermectin. However, an important
requirement for such a drug is that it should not have major contraindications which would lead
to systematic exclusion of certain population groups, and it should not be accompanied by severe
side effects which could lead to non-compliance at later treatment rounds. These operational
aspects, in addition to the need for obtaining and maintaining a high treatment coverage, appear
more important for the feasibility of eradication than improvements of 5%-10% in the
macrofilaricidal efficacy of the drug.
16
Prospects for the elimination of some TDR diseases
5. The timetable towards elimination
The main landmarks are indicated in Figure 3 (control activities shown as solid bars,
research activities as hatched bars) and can be summarized as follows:
Onchocerciasis Control Programme in West Africa
1975-1993: Control in original OCP area
1977-1999: Larviciding research
1983-1992: Development of DNA probes for O. volvulus
1983-1999: Epidemiological mapping in support of control
1989-2002: Vector control+ivermectin in extension areas
Ivermectin
1980-1986: Clinical trials and registration of ivermectin
1987-1991: Communit}- trials of ivermectin
1990-1995: Expanding use of ivermectin in control
1993-2003: Onchocerciasis Elimination Control Programme in the Americas
Operational Research
1991-1992: Rapid assessment of endemicity
1993-1996: Rapid epidemiological mapping in Africa
1993- 1994: Reassessment of the importance of skin disease
1995-1996: Assessment of economic impact of skin disease
1994- 1996: Studies of community-directed treatment with ivermectin
1995- 1996: Trials of effect of ivermectin on skin disease
1996- 2008: African Programme for Onchocerciasis Control
1982-2008: Development of a macrofilaricide
Prospects for the elimination of some TDR diseases
17
LYMPHATIC FILARIASIS
1. The disease
*
Infection with filarial parasites may lead to elephantiasis, a dramatically disfiguring
disease usually affecting one or both legs, or to hydrocele, an equally grotesque inflation of
the testicles. Infection can also cause acute fevers, inflammation of the lymphatic system, and
the bronchial-asthmatic condition known as "tropical pulmonary eosinophilia".
The most widespread filarial parasite is Wuchereria bancrofti, which affects about 106
million people in the tropical areas of Africa. India, South-East Asia, the Pacific Islands, and
South and Central America. India has by far the largest number of cases. The closely related
Brugia maloyl and Brugia timori affect 12.5 million people in South-East Asia.
The parasites are transmitted by mosquitos. In rural areas, particularly in Africa, W.
bancrofti is transmitted by Anopheles mosquitos - a genus which also includes species that
transmit malaria. In cities, widespread species of Culex mosquito, which can breed in latrines,
sewage, and ditches, are major vectors. In the Pacific region, Aedes, a genus which includes
species that transmit yellow fever, dengue, and dengue haemorrhagic fever, and which can
breed in tiny amounts ofclean water in the axils of plants, up-turned containers or old tyres,
transmit the parasite. B. malayi is mostly transmitted by Mansonia mosquitos.
Adult worms or "macrofilariae", both male and female, settle into the lymphatic system
and take 3-15 months to mature. They survive in the body for 4-8 years. Once established and
fertilized, the females constantly produce large numbers of larvae known as "microfilariae'.
which invade the blood stream. From there, the mosquito host can ingest them with a blood
meal and transmit them to another person. The larvae metamorphose through a sequence of
larval forms before becoming adults.
The vast majority - millions - of microfilariae, however, remain in the body as
immature forms, and die after some six months to two years. These sizable creatures - each
up to a third of a millimetre long (and times some millions, that amounts to several kilometres
of worm) - moving, secreting, excreting and dying as foreign bodies, can do immense damage
and place an enormous burden on the host. The adults are several centimetres long and block
lymphatic ducts. A combination of these effects, complicated by bacterial super-infections,
causes the symptoms and pathology of the disease.
2. Disease situation and trends
Figures on global prevalence of infected and disease cases are shown in Table 2 below.
The burden of disease due to lymphatic filariasis amounted to 0.85 million DALYs (0.56
million for men and 0.29 million for women) in 1990, and the disease has been identified as
the second leading cause of permanent and long-term disability (WHO World Health Report,
1995).
18
Prospects for the elimination of some TDK diseases
3. Strategy for elimination
The following points are considered as ±e basis for the future development of a global
strategy aimed at the elimination of this disease:
- The most important recent achievement leading to new optimism for successful
control of lymphatic filariasis is the simplification of the recommended therapeutic regimens.
Specifically, it is now recognized that a single dose of DEC (6 mg/kg) achieves essentially the
same result as the long-recommended two-week course of this drug, i.e., a 90-95% reduction
of circulating microfilariae even one or two years after treatment. Single-dose ivermectin (400
mcg/kg) is equally effective as single-dose DEC, and the combination of single doses of these
two drugs appears to be the most effective regimen tested so far (with reductions to less than
2% of pre-treatment microfilaraemia levels two years after treatment). Actual utilization of
these single-dose, once-yearly regimens in community7 treatment programmes has confirmed
both their therapeutic effectiveness (figures 6 and 7) and their social acceptability. Thus, use
of DEC or ivermectin alone or in combination once a year is a newly recognized control
strategy for lymphatic filariasis that promises to be at least as effective as the once-a-year dose
of ivermectin currently in use for onchocerciasis.
Table 2: Prevalence of lymphatic filariasis infection and disease
Disease due to Wuchereria bancrofti (figures in thousands)
Number of
disabled3
Population at risk of
infection
Population infected
AFRO
AMRO
EMRO
SEARO
WPRO
260 300
6 680
3 700
518 880
113 270
40 424
395
342
54 967
10 483
14 800
90
117
21 220
3 690
Total Wuchereria
bancrofti
902 830
106 611
39 917
WHO Region
Disease due to Brugia malayi
SEARO
WPRO
203 060
83 790
6 946
5 544
1 890
920
Total Brugia
malayi
286 850
12 490
2 810
Total of all
lymphatic
filariasis
1 094 060b
119 101
42 727
(a) For Wuchereria bancrofti infections: only lymphoedema/elephantiasis or hydrocele; for Brugia malayi infections: only
lymphoedema'elephantiasis; essentially all infected individuals however have damaged lymphatics with abnormal function.
(b) The total number of persons at risk is the number at risk for Wuchereria bancrofti infection plus two thirds of the number of persons
at risk for Brugia malayi infection, since approximately one third of the population at Brugia malayi risk lives in areas where
Wuchereria bancrofti is also present.
i
1
Prospects for the elimination of some TDR diseases
19
- Use of table/cooking salt fortified with very low concentrations of DEC (0.15%
to 0.3%) has long been recognized as an effective means to control lymphatic filarial
infection in communities where the salt supply can be restricted - regularly,
microfilaraemia rates decrease almost to zero and transmission is essentially halted.
Recently, the first commercially prepared DEC-salt was manufactured and distributed for
sale in India, and DEC-fortified salt is now an available tool with the potential for playing
a major role in future filariasis control programmes.
- Control of morbidity (i.e., arresting the progression of elephantiasis and
lymphoedema or their reversal) has also been greatly advanced by the observations that
intensive local hygiene to an affected limb, with or without the use of topical antibiotic
and antifungal agents, appreciably decreases the local inflammatory burden on a patient's
compromized lymphatic system and results in dramatic clinical improvement. Preliminary
evidence suggests that community-based patient self-help groups work extremely
effectively to stimulate and maintain personal compliance with the vigorous hygiene
regimens required for this morbidity control, and such a strategy is clearly one that can
be exploited worldwide, because nowhere do patients lack the intense desire to rid
themselves of their ostracizing deformities.
- Studies on control of the mosquito vectors of lymphatic filariasis, using either
the toxin-elaborating Bacillus sphaericus or polystyrene beads in breeding sites, have
demonstrated unequivocally a decrease in vector numbers and hence a decrease in the
transmission of infection. Exactly how and when these vector control tools are costeffective and useful in large-scale control programmes for lymphatic filariasis are,
however, not yet clearly defined.
- Use of new technologies for diagnosis:
- Lymphoscintigraphy
- Ultrasound
- DNA probes for vector infection
- DNA probes for blood infection
The transfer of the above technologies into country control programmes has
begun, e.g. in China, Sri Lanka, India Australia and Papua New Guinea.
20
Prospects for the elimination of some TDR diseases
VECTOR INFECTIVITY CHANGES
Effects of DEC Treatment in Papua New Guinea villages, 1996
Percentage Pre-treatment vector Infectivity
120
100
80
♦ Ngahmbule
-e»- Yanatong
60
40
20
-
0
0
4
2
6
14
12
10
8
Months after teatment
Source: Bockarie et al. 19S6 (uroubl.)
Figure 6
VECTOR INFECTIVITY CHANGES
Effects of DEC + IVER Treatment in Papua New Guinea villages,
1996
Percentage Pre-treatment vector infectvity
i
120
100
80
-o-Peneng
-r- Nanaha
60
• Albulum
40
i
20
0 L
0
2
4
6
8
10
12
14
Months after treatment
Source: Bockarie et a: 1996 (unpubl.)
Figure 7
4. The timetable towards elimination
The main landmarks are indicated in Figure 8 (control activities shown as solid
bars, research activities as hatched bars) and can be summarized as follows:
1989- 1996: Multicentre drug (DEC, ivermectin) clinical trials
1990- 1996: Multicentre morbidity control trials
1990-1993: Multicentre vector control trials
1990- 1996: Antigen detection assays
1991- 1996: DNA probes for detection of infection in mosquitos
1992- 1996: Development and production of DEC-fortified salt
1994-1996: Enunciation of the global control strategy
1996-1999: Initiation of control activities by region
Prospects for the elimination of some TDR diseases
21
5. Future Research Needs
The research priorities that have been identified fall into two main areas, namely
epidemiology/operational research and chemotherapy.
Epidemiology/operational research
Geographical targeting: rapid assessment methods for mapping the distribution of
infection/disease. to replace collection of blood at night.
Design of drug deliver}' strategies: identification of the optimal target age group; and
optimal frequency, duration and coverage of treatment. Mathematical modelling
frameworks could be particularly helpful here.
Logistics of intervention: examination of options for integrating drug delivery into
existing systems (e.g. leprosy control PHC clinics) or for incorporating filarial
vectors into existing vector control programmes (e.g. for malaria).
Cost analysis: optimization of the cost-effectiveness of targeting, monitoring and
intervention.
Chemotherapy
- Ivermectin is effective against lymphatic filariasis but is not yet registered for this
indication. Diethylcarbamazine is also effective, and is registered, but is contraindicated
in onchocerciasis (due to the Mazzotti reaction and ocular pathology). Therefore, there
is no drug registered for use for lymphatic filariasis in the onchocerciasis endemic areas
of Africa. Yet, paradoxically, the drug currently distributed for onchocerciasis is
effective against lymphatic filariasis.
- This argues for the registration of ivermectin for lymphatic filariasis control in the
African region. In this respect, negotiations are under way with Merck Sharp and Dohme
Pharmaceuticals Co.in the USA.
Figure 8:
Towards t?e elimination of Lymphatic Filariasis:
The Timetable
90
Multicentre drug clinical trials
95
2000
Z/Z/ZZA VZZZZZZZZZZZZZ ZZZZZZZZZZZZZZZ^ZZZZZz zzzzza
f
Multicentre morbidity control trials
WSSSSfSSSfSSSSSSSSSSSSfSSSSSSSSfSSfSSSSSfffW
Multicentre vector control trial
V/VZZZ7ZZ/y77ZZ/7ZZZZZ/.
Antigen detection assays
DNA probes for detection of infection in mosquitos
Development & production of DEC-fortified salt
Enunciation of global control strategy
Initiation of control activities by WHO Region
Development of rapid assessment techniques
Optimizing drug delivery strategies and programme cost-effectiveness
zzzzzzzzzzzzzz
Prospects for the elimination of some TDK diseases
23
CHAGAS DISEASE
X. The disease
Chagas disease exists only on the American continent. There are two stages of the
human disease: the acute stage, which appears shortly after the infection; and the chronic
stage, which may last several years and irreversibly affects the autonomic nervous system
of internal organs (heart, oesophagus and colon) and the peripheral nervous system. These
incurable lesions develop some 10-20 years after the initial acute phase in one third of
those infected, and include chronic cardiopathy (in 27% of those infected) as well as
chronic digestive lesions (in 6% ) and neurological disorders (in 3%). Patients with
severe chronic disease become progressively sick and ultimately die, usually as a result
of heart failure.
The disease is caused by a flagellate protozoan parasite, Trypanosoma cruzi, which
is transmitted to humans by blood-sucking triatomine insects and by blood transfusion.
The risk of infection with Chagas disease is directly related to socio-economic
factors: the parasite is transmitted by bugs which live in crevices in the walls of poor
quality houses in rural areas and unplanned urban developments. Rural to urban human
migration is a factor which contributes to the spread of the infection by blood transfusion.
2. Disease situation and trends
Data on the prevalence and distribution of Chagas disease have improved in quality
during the 1980s as a result of demographically representative cross sectional studies
carried out in countries where accurate information is not available. A group of experts
met in Brasilia in 1979 and devised standard protocols to carry out countrywide
prevalence studies on human T.cruzi infection and triatomine house infestation.
These studies were carried out during the 1980s with the collaboration of the
ministries of health of Chile, Colombia. Ecuador, Honduras, Nicaragua, Panama,
Paraguay, Peru and Uruguay. The accurate information obtained has permitted better
planning and evaluation of national control programmes by individual countries.
On the basis of these countrywide surveys it is now estimated that the overall
prevalence of human T.cruzi infection in the 21 endemic countries is 17 million cases.
Some 100 million people, i.e. 25% of all the inhabitants of Latin America, are at risk of
contracting the disease.
Incidence is estimated as 1 000 000 new cases per year, and 45 000 deaths annually
are due to the cardiac form of the disease.
According to the World Development Report (1993), the number of Disability-adjusted
life years (DALYs) lost due to Chagas disease is 2 740 000. From a global perspective,
Chagas disease represents the third largest tropical disease burden after malaria and
24
Prospects for the elimination of some TDR diseases
schistosomiasis. If, according to the UNDP Human Development Report (1994), the
estimated average annual per-capita income in Latin America is USS 2390, the economic
loss for the continent due to this disease currently amounts to USS 6500 million, which is
equivalent to 1.3% of the external debt of the whole continent.
Infection of blood in blood banks in selected cities of the continent varies between 3%
and 53%, thus showing that the prevalence of T.cruzi infected blood is higher than that of
hepatitis B/C or HIV infection.
3. Strategy for elimination
3.1 Initiative of the southern cone countries
Since the vector of T.cruzi, Triatoma infesians, is intradomiciliary in the countries
of the Southern Cone (Argentina, Brazil, Bolivia, Chile, Paraguay and Uruguay),
sustained implementation of vector control measures can interrupt transmission. In 1991,
the ministers of health of Argentina. Bolivia, Brazil. Chile, Paraguay and Uruguay, launched
the ’’Southern Cone Initiative for elimination of transmission of Chagas disease**.
Progress towards elimination of vectorial and transfusional transmission of Chagas
disease in Uruguay, Chile, Argentina and Brazil has been documented in various scientific
publications.(2)’(3)> (4)> (5)
By eliminating the transmission of Chagas disease in the above countries, the incidence
of the disease in the whole of Latin America will be reduced by more than 70% (Figures 9
and 10).(6)
Chagas disease is recognized as an important public health problem and is given
increasing priority for control, as demonstrated by the above government initiative which
is very successful and is paying high dividends. By cutting the transmission of this
disease in the countries of the Southern Cone in a short period of time, the incidence of
Chagas disease will be reduced by over 70%. From an estimated 1 000 000 cases per
year, it will fall in 1999 to less than 300 000 cases a year for the whole of Latin America.
A total of US$ 207 million has been allotted from national sources of the six
countries for control operations since the start of the initiative in 1991. With this
investment, it is estimated that the economic loss due to Chagas disease will be reduced
by USS 4550 million.
Current data on house desinsectation, coverage of blood banks screening and
serology in children and young adults indicate that the vectorial and transfusional
transmission of Chagas disease will be interrupted in the following countries in the coming
years: Uruguay (1997), Chile (1998), Argentina (1999), Brazil (1999), Bolivia and
Paraguay (2003).
Prospects for the elimination of some TDR diseases
25
3.2 Initiative of the Andean countries and the Central American
countries
As the vectors of Chagas disease in these countries are not strictly domiciliated, it
is necessary to develop and test new vector control strategies for the local entomological
conditions. The initial focus is on blood banks control to prevent transfusional
transmission of the disease.
Thus in Colombia. Ecuador, Peru and Venezuela, the target is to iadapt
’
existing
universal blood screening infrastructure, tentatively by 1996-97. In Venezuela this has
already been accomplished.
In Costa Rica, El Salvador. Guatemala, Honduras, Nicaragua and Panama, the target
is to adapt existing universal blood screening infrastructures by 1997-98. In Honduras this
has already been accomplished.
SOUTHERN CONE INITIATIVE
Elimination cr < ransmission: Prevalence of
Rates (%'
q
9.1
T.cruzi infection
1980-95
ARGENT1NA(18yrs)
B RAZJ L(7-14yrs)
CHILE(<15yrs)
*URUGUAY(<12yrs)
1
1.2 - -
\o.2
0.1
80
90
85
I
95
Source. Repot? cy Nations Ctagas disease control programmes. 1993-95
Figure 9
SOUTHERN CONE INITIATIVE
Elimination of ransmission: House Infestation by triatomines
40
Rates (%)
------
35 r-
1982-95
32.5
30 -
26.4
24^5
25 -
-*■ ARGENTINA
-^BRAZIL
-o-CHILE
20
15
URUGUAY
11
10
6
5
o
------80
------------- -----------------------------85
90
0.6
~—■---95
Source Reports c. National Cnagas disease control programmes. 1993-95
Figure 10
26
Prospects for the elimination of some TDR diseases
In these countries there are 5-6 million infected individuals and 25 million are at risk
of contracting the infection.
Control activities are progressing as scheduled in Bolivia and Paraguay, but at this stage
there are no entomological or epidemiological data available to assess the impact of the
control programmes in these two countries or to estimate a date for interruption of
transmission. These data should be available in 1999, after 4 to 5 years of continued control
activities and completion of cross-sectional entomological and serological surveys.
An international independent commission has been appointed to certify the interruption
of transmission in the above-mentioned countries.
3.3 Some detailed epidemiological situations
Argentina
In Argentina, transmission of Chagas disease occurs in the zones north of latitude
44°45', which cover about 60% of the country. The main vector is Triatoma infestans, which
is a domiciliated species.
The strategy employed by the Vector Control Sendee until 1990 was to use highly
trained personnel for the application of insecticide to houses in endemic rural areas.
As a result of field research sponsored by TDR, the control methodology was adjusted
and the Vector Control Service decided to change its strategy. Community-based
participation and appropriate technology replaced specialized personnel. A sensor device to
detect house infestation by the vector, fumigant canisters and portable pumps for use by
primary health community agents were developed and tested for efficacy.
Between 1983 and 1991, the average number of houses sprayed was 80 000 a year.
Using the new approach, this number rose to 110 000 houses in 1992 and to more than 140
000 in 1994. Besides, there were more than 7500 rural agents working on this programme
throughout the country in 1994.
This increase in house spraying resulted in important reductions in the proportion of
houses infested by the vector in each province. The reduction ranged from 30.9% in Chaco
to 94.3% in La Pampa, with an average reduction of 50.5% in house infestation in the
country as a whole.
Figure 11 shows the decreasing prevalence of infection in 18-year-old males by
province. There was a reduction of 75% between 1981 and 1993 in this age group.
Figure 12 shows the decrease in number of disease morbidity cases in different age
groups compared with the expected figures had no control activities been carried out. In the
age group of less than 18 years, an impressive decrease of 81.0% is observed, while in the
age group of 18-35 the decrease is 43.6%, and in the group of 35-50 the reduction is 24.3%.
Prospects for the elimination of some TDK. diseases
27
The monetary savings resulting from both direct and indirect costs for the number of
human cases prevented by the control programme amount to an impressive figure of USS
2800 million, or about one-twentieth of the total external debt of Argentina in 1993!
To prevent transfusional transmission of Chagas disease, the screening of T.cruziinfected blood has been compulsory since 1983 and the coverage of screening in blood
banks of the country was 100% in 1994. Continued quality control and laboratory
performance evaluation, carried out by INDIECH in provincial laboratories, ensures the high
sensitivity and specificity needed for the tests used in the screening system.
Interruption of transmission
Argentina r.o’oence and treated houses 1983-94
Incidence (%)Houses treated (X 10Q0)
1’200
TOGO
4
800
3
• Houses treated
600
< Incidence in <18 years
2
400
1
200
o-------------------------------------------------------83
84
85
86
87
83
89
90
91
92
93
94
0
95
Source.Boletm Ep1Oerr.c-.05 co Naoona Buenos Aires 1994, 2 3-16
Figure 11
MORBIDITY BY CHAGAS DISEASE
Prevented care:omyopathy cases by age group, Argentina 1995
Thousands
250
200 K
i
150 •
100 •
n
a
-i Si
50 ■
fA
LI_
[ I ire’ Recorded
It Expected
I.
0
<18 years
18-34
35-50
> 50
Figure 12
Brazil
In 1970, the endemic area covered over 36% of the country; 2493 districts (over 50%)
were infested by Triatoma infestans, the main vector of the disease. A total of 49 million
persons lived in the endemic zone, with 53% in rural areas. T. infestans is the most important
species responsible for vectorial transmission of the disease. It is exclusively domestic and
shows higher infection with T cruzi than other species of triatomine.
28
Prospects for the elimination of some TDR diseases
The control programme has produced important results: in the State of Sao Paulo, the
vector, T infestans, has been eliminated from human dwellings since 1982 and no new acute
cases or seropositive reactions have been detected since 1983 in the group of 1 - 4 years. In
the rest of the country, there were 711 municipalities infested by T.infestans in the endemic
states in 1983, while in 1993 there were only 83 municipalities infested, representing an
89% reduction as shown in Figure 13.
Interruption of transmission
Brazil:Infested Municipalities (T.infestans) 1975-93
Number of Infested Municipalities
800 ;--------------- —-----------------------------------------------------------------------------------
600 f
400 -
-♦ Municipalities
200
Q 1-----------------------------------------------------------------------------------------------------Sou?c^: Gadelha AMC^evista da Socie&^e Brasileira de£ftd;cma Tropica:'95
26(Sup):27-32, 1993
Figure 13
In 1993, only 1800 insects were captured by programme field workers in the whole
country, a number that could easily be found in one single house before inception of the
control programme. This represents an average of 2.5 insects in every 1000 houses, a house
infestation rate far below the minimum threshold necessary to ensure transmission of the
parasite.
In 8 of the 11 endemic states, a reduction of house infestation rates ranking from 100%
in Mato Grosso to 20% in Goias was observed between 1983 and 1993. For the country as
a whole, an average reduction of 71% in house infestation is observed. Focal areas still
infested vdth T infestans remain only in the states of Bahia. Tocantins and Rio Grande do
Sul.
Serc-epidemiologic surveys carried out in 1994 in ten endemic states among 7-14 year
olds showed that the incidence of infection in this age group is less than 0.5% in nine of the
states, indicating a reduction of over 96.0% as compared to 1980. In other words,
transmission of the disease by vector has been virtually eliminated (Table 3).
Similar trends are observed in relation to the decreasing proportion of T.cruzi-infected
blood in blood banks between 1982 and 1991. In 1982, 6.5% of blood was found to be
infected in the whole countrj', whereas in 1991 this proportion was only 1%. In 1995,
coverage of screening in blood banks reached 98%.
Current vector control activities are targeted towards the elimination of T. infestans in
the remaining focal areas of the states of Bahia, Goias and Rio Grande do Sul, and it is
estimated that this will be achieved in 1998.
Prospects for the elimination of some TDR diseases
29
Table 3:
Percentage sero-reactivity (human infection) in 7 -14 year olds, Brazil 1980 - 1993
STATE
1980 (%)
1993 (%)
Bahia
5.4
0.25
96.0
Goias
7.4
0.10
99.0
Maranhao
0.1
0.00
100.0
Mato Grosso
2.8
0.18
94.0
Minas Gerais
8.8
0.06
99.0
Paraiba
3.5
0.36
99.0
Piaui
4.0
0.16
96.0
Rio Grande-Norte
1.8
0.03
98.0
Rio Grande-Sul
2.5
1.52
40.0
TOTAL
4.2
0.15
96.5
Reduction(%)
Chile
Chile extends from parallel 18° 30' to 52° 30' and has a population of 13 380 000. of
whom 82% live in urban conglomerates. Approximately 1 654 000 live in the endemic area
from parallel 18° 30’ to parallel 34c 35' and hence are at risk of contracting the infection.
In the 1980s, the proportion of infected persons in all age groups in the country was
17.0% and the average house infestation rate was 28.8% . The prevalence of infected
subjects among blood donors in 1984 was 3.6% for the whole country'.
Two main species of triatomine are responsible for the vectorial transmission of Chagas
disease in Chile. Triatoma infestans. a domestic insect, is the most important vector.
Vector control operations using insecticides with residual activity and carried out by
the national programme between 1982 and 1993 have reduced the house infestation rates by
79% in Arica and by 96% in Iquique. with an average reduction for the whole country of
89.5% (Table 4). The entire country is likely to be free of insect transmission by the end of
1998.
Transmission through blood transfusion is under control, due to compulsory blood
screening and 100% coverage in endemic areas.
30
Prospects for the elimination of some TDR diseases
Table 4
Prevalence of house infestation by triatomines, endemic areas, Chile, 1982 and 1993
House infestation rates (%)
1993
Reduction (%)
Region
Health
Services
1982
I
Arica
12.5
2.6
79.2
I
Iquique
18.6
0.7
96.3
II
Antofagasta
45.7
4.1
91.0
III
Copiapo
51.2
8.0
84.4
IV
Coquimbo
49.9
2.4
95.2
V
San Felipe
18.0
2.0
89.0
V
Vina del Mar
34.6
1.6
95.4
VI
O’Higgins
28.1
1.8
79.3
28.8
3.0
89.5
Total
The marked reduction in vectorial transmission is reflected by the drop in the proportion
of T crzo-infected blood donors between 1983 and 1992, as shown in Table 5.
Table 5.
Prevalence of infected blood in blood Banks, Chile, 1982 and 1993
Region
Health
Services
T.crwzz-positive blood donors
(%)
1982
1993
I
Arica
2.5
1.9
I
Iquique
1.6
1.2
II
Antofagasta
3.5
2.5
III
Copiapo
6.5
3.0
IV
Coquimbo
7.0
4.7
V
San Felipe
3.5
0.0
V
Vina del Mar
0.0
0.0
Santiago
1.5
0.9
3.6
1.3
Metropolitan
Total
Prospects for the elimination of some TDR diseases
31
A countrywide sero-epidemiological study was completed in Chile in 1996. It showed
a prevalence rate of 1.9% in the age group of less than 15 years as compared to 9.1 % in the
same age group in 1983, indicating the advanced degree of control and imminent
-------interruption of vectorial transmission in this country (Figure 14).
SOUTHERN CONE INITIATIVE
T.cruzi infection.. CHILE
Prevalence of
% Prevalence of Infection In < 15 years o]d
10
9.1
I
8
6
Human infection
4
2
o
1982
-
84
-
86
8S
90
*
91
93
95
97
Source. National control programme Santiago 1995
Figure 14
\ i •
Uruguay
In Uruguay, domiciliary transmission is effected through Triatoma infestans. In 1983,
this insect infested human dwellings and their annexes in the following departments.
Artisas, Rivera, Tacuarembo, Salto, Paysandu, Rio Negro, Soriano, Colonia, Durazno and
Cerro Largo, i.e. in 80 % of the territory of Uruguay.
The National Chagas disease control programme, which was reorganized that year,
carried out a spraying programme of human domiciles and peri-domiciles with residual
activity insecticides. The sustained spraying helped eliminate the infestation by T infestans
in Artigas, Colonia, Durazno and Soriano, and markedly decreased the rate of house
infestation in the remaining areas (Table 6).
In 1985, a country-wide serological survey to detect human Trypanosoma cruzi
infection, sponsored by TDR, showed a prevalence rate of 3.4% for the whole population
with a prevalence rate of 2.4% for the age group of less than 12 years.
32
Prospects for the elimination of some TDR diseases
Table 6
House Infestation Rates (%) by department, Uruguay, 1983 - 1992
Reduction
(%)
House
Infestation Rate
Department
(%)
1983
1992
ARTIGAS
2.9
0.0
- 100.0
RIVERA
15.3
1.9
-93.5
TACUAREMBO
22.2
2.3
-90.0
SALTO
8.8
n.d.
CERRO LARGO
2.6
0.23
PAYSANDU
0.0
0.0
RIO NEGRO
1.4
0.06
-96.0
COLONIA
0.9
0.0
- 100.0
DURAZNO
1.7
0.0
- 100.0
SORIANO
0.7
0.0
- 100.0
-99.0
A sero-epidemiological survey carried out in 1995 in different rural areas of the
endemic departments in children under twelve years old has shown very low (0.2%) or zero
infection rates in this age group. This could be interpreted as confirmation of the interruption
of vectorial transmission of Chagas disease in the country (Figure 15).
SOUTHERN CONE INITIATIVE
T.cruzi infection, URUGUAY 1985-1994
Prevalence of
% Prevalence of infection in < 12 years old
3
2.5
2
— Human infaction |
1.5
1
0.5
0
1982
84
86
88
90
92
Source. National Co-roi Programme MontevKteo 1995
Figure 15
94
96
Prospects for the elimination of some TDK, diseases
33
In addition, transmission through blood transfusion is also interrupted due to the very
low number of infected donors and the 100% coverage provided by compulsory blood
screening in the country.
These data mean that Uruguay is the first Southern Cone country to have accomplished
the aoals set by the ministries of health of Argentina, Bolivia, Brazil, Chile, Paraguay and
Uruguay for the elimination of vectorial and transfusional transmission of Chagas disease
since the multicountry programme was launched in Brasilia in June 1991.
4. The timetable towards elimination
The main landmarks are indicated in Figure 16 (control activities shown as solid bars.
research activities as hatched bars) and can be summarized as follows.
1980-1985: Prevalence cross-sectional studies on human infection and house
infestation in nine countries
1980-1985: Standardization of serological techniques and creation of a continental
network of reference laboratories
” ; on the course of human infection
1984-1990: Follow-up prospective studies
of parasite genome and production of defined antigens for
1987-1989: Cloning
<
improvement of diagnostic techniques
Industrial production of kits for blood banks control
1990:
1988-1992: Development of new tools for vector control
1988-1993: Multicountry field studies for evaluation of new vector control tools
Industrial production of paints, canisters and sensor boxes
1992:
Initiative of the Southern Cone countries
1992:
Initiative of the Andean countries
1993:
Initiative of the Central American countries
1993:
1995-1998: Evaluation of impact and projection of trends
1998-2000: Certification of interruption of transmission
5. Future Research Needs
Future research priorities have originated from the operational questions detected by the
control programme and refer to the evaluation of impact of the control activities, the
monitoring of insecticide efficacy to detect possible development of vector resistance, and to
include:
the promotion of vector surveillance through the mass media. They include.
* Studies on prevalence, clinical management and cost-effectiveness of interventions for the
control of congenital transmission.
* Monitoring of efficacy of insecticides in the national control programmes.
* Development of techniques for detection of peri-domestic infestation.
* Studies on periodicity of insecticide spraying based on residual density of triatomines.
Figure 16:
Towards the elimination of Chagas Disease:
The Timetable
5H
LfH
rw
Cross sectional studies
'//////////7///7
Standardization of serology
r'7777777Z777777777V7\
Follow-up studies on course of infection
Cloning genome and production of defined antigens
Industrial production of kits for blood-bank control
Development of new tools for vector control
Industrial production of paints and canisters
Initiative of Southern Cone countries
Initiative of the Andean countries
Initiative of the Central American countries
Evaluation of impact and projection of trends
Certification of interruption of transmission
V////////////////////7/A
\///////(^\
L?5. |
1
I 99
Prospects for the elimination of some TDR diseases
35
* Evaluation of sensitivity, specificity and costs of improved kits for blood screening using
defined antigens and the polymerase chain reaction (PCR) technique.
I
* Improvement and assessment of methods for disinfection of blood intended for transfusion.
* Modelling and development of indicators to assess elimination of transmission.
* Influence of climatic changes on the populations of vectors.
* Evaluation of the use of the media by the community for promotion of entomological
surveillance.
* Evaluation of the efficacy of control and surveillance activities carried out with active
community involvement.
6. References
(1) Weekly Epidemiological Record. Geneva, World Health Organization. 1994, 6:38-40.
(2) Weekly Epidemiological Record. Geneva, World Health Organization, 1995, 3:13-16.
(3) Weekly Epidemiological Record. Geneva, World Health Organization, 1996, 2:12-15.
(4) Weekly Epidemiological Record. Geneva, World Health Organization, 1997, l:l/2-l.
(5) Schmunis G. Zicker F, Moncayo A. Interruption of Chagas’ disease transmission through
vector elimination, The Lancet, 1997, 348:9035, p.l 171.
(6) WHO/CTD Progress Report, Geneva, World Health Organization, 1997 (in press).
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'L
LYMPHATIC FILARIASIS INFECTION & DISEASE:
CONTROL STRATEGIES
EXECUTIVE
SUMMARY*
Page
E-l
The Problem and the Outlook for its Solution
i
E-2
Control of Infection
i
E-2.1
Treatment of the human population: New strategies
i
E-2.2
Reducing the vector mosquito population
ii
E-3
Control of Disease (Morbidity): New Strategies
ii
E-4
Monitoring the Success of Control Programmes: New Techniques
iii
E-5
Management of Control Programmes
iii
E-6
Costs and Cost-Effectiveness of Specific Control Strategies
iv
E-7
Operational Research Needs
iv
*Report of a WHO/CTD TDR CShsultative Meeting held at the
Universiti Sains Malaysia,
Penang, Malaysia, 22-24 August 1994
© World Health Organization 1994
The designations employed and the presentation of the material in this
document do not imply the expression of any opinion whatsoever on
the part of the Secretariat of the World Health Organization concern
ing the legal status of any country’, territory, city or area or of its
frontiers or boundaries.
Authors alone are responsible for the views expressed in this docu
ment and for the presentation of the material therein.
iijuliiiiM*!___ iJ.iSHHl.JMMJ.i_l'-
E-l
The Problem and the Outlook for
its Solution
Lymphatic filariasis persists as a
major cause of clinical morbidity and a
significant impediment to socioeconomic
development in much of Asia, Africa and the
Western Pacific as well as in certain regions
of the Americas. Indeed, the prevalence of
this mosquito-borne infection is increasing
worldwide, in large part due to the rapid
unplanned urbanization in many endemic
areas. It is estimated that at least 120 million
persons are infected, with essentially all
manifesting either the overt findings of
lymphoedema, elephantiasis, hydrocoele and
recurrent infections or the newly recognized,
subclinical abnormalities of lymphatic and
renal function.
Despite these disappointing numbers,
however, simplified, safe, and cost-effective
methods to control and potentially eradicate
this infection have recently become available.
For example, instead of the older 12-day
treatment regimens using diethylcarbamazine
(DEC), it is now clear that much simpler
treatment strategies employing single yearly
doses of DEC or even its daily consumption
as an additive to common table/cooking salt
are equally effective for control programmes
and much easier and less expensive to deliver.
Indeed, use of these and other techniques
have already caused the elimination of
lymphatic filariasis from Japan, Taiwan,
South Korea and the Solomon Islands; and
China too is in the final stages of an
exceptionally effective control programme.
Lymphatic filariasis has recently been
identified by the International Task Force for
Disease Eradication as one of only six
"eradicable" or "potentially eradicable"
infectious diseases. This fact, coupled with
the recognition that appropriate control efforts
can be effectively and inexpensively linked
with pre-existing national and local public
health infrastructures, now provides strong
impetus to initiate widespread chemotherapy
programmes, with concurrent vector control,
where possible, aimed at finally controlling
this parasitic infection and the morbidity that
it causes in all endemic areas.
E-2
Control of Infection
The two general strategies (which
need not be mutually exclusive) to reduce
transmission of filarial infection are:
(1) treating the human host to decrease
microfilaraemia and (2) decreasing human
vector contact, usually by reducing the density
of the mosquito vectors. Optimal control
strategies will necessarily differ for different
endemic countries, since each must take into
account the particulars of the local host-vector
combination, existing health care
infrastructure, and cultural practices.
E-2.1
j
Treatment of the human population:
New strategies
■
‘Mass distribution’ programmes
should completely replace those based on a
‘selective treatment’ strategy (i.e., detection of
microfi laraemics who are then treated
‘selectively’). The recommended regimens
for mass treatment would be either of the
following:
(a)
DEC-fortified salt (0.2 - 0.4% w/w).
Use of DEC-fortified salt for a period
of 9-12 months has been shown to be
simple, cheap and effective in
dramatically reducing or eliminating
lymphatic filariasis. It is generally
well tolerated, safely used in
pregnancy and can be incorporated
into iodized salt. It can be utilized in
most control programmes but cannot
yet be recommended in areas where
there is coexisting onchocerciasis or
loiasis.
(b)
Single annual or semi-annual mass
administration of DEC (6 mg/kg body
weight). This regimen appears to be
as effective as the older ‘standard
12-day course of DEC, has fewer
adverse effects, and results in
enhanced population compliance and
decreased delivery costs. Adverse
i
reactions, though greater than those
seen with DEC-fortified salt, are well
tolerated, but this regimen definitely
should not be used in areas where
onchocerciasis or loiasis coexists.
If, as anticipated, ivermectin sub
sequently becomes registered for use in
lymphatic filariasis, two additional
chemotherapy tools would become available:
programmes based
administration.
Reducing the
population
vector
mosquito
Vector control has played an
important supporting role for filariasis control
in certain local programmes, and reduction of
vector density can be an important contributor
to achieving long-term sustainability of
transmission interruption. However, filariasis
control programmes should not be based on
vector reduction alone. Rather, vector control
should be implemented whenever feasible as
a complementary tool to filariasis control
ii
drug
biocides: especially Bacillus
sphaericus (a toxin-producing
bacterium) to control Culex
quinquefasciatus\
polystyrene beads: to limit breeding
of culicine vectors in specific urban
situations with enclosed (e.g. latrines,
cess pits) breeding sites;
insecticide-impregnated bed nets and
curtains: to limit host-vector contact;
indoor spraying of long-lasting,
residually active pyrethroids:
especially for the adult-stage of Culex
and Mansonia mosquitoes;
community participation in integrated
vector management: difficult to
sustain in the urban setting, but
successfully used in controlling rural
Mansonia.
The single-dose ivermectin regimen
appears equivalent to single-dose DEC
regimens in efficacy,' safety and tolerance,
and, in addition, it has the advantage that it
'an be used safely in areas where
onchocerciasis or loiasis may also coexist.
The combination regimen, however, appears
to be superior to either drug alone for long
term reduction of microfilaria density and
prevalence, and it would almost certainly
become the ‘annual-dose treatment’ of choice
(except in O. volvulus and L. loa endemic
areas) if ivermectin became appropriately
registered.
£-2.2
on
Certain technologies are now
emerging that should improve vector control
capabilities, though all still require large-scale
validation and assessment of their impact on
filarial transmission as well as the subsequent
clinical effect in the human population.
These measures include the following:
Ivermectin 400 pg/kg given once
yearly;
Ivermectin 400 pg/kg + DEC 6 mg/kg
given once yearly.
The exact duration for which these
various treatment strategies need to be
sustained has not been established, though
current estimates suggest 5-10 years for
yearly-dose strategies and 9-12 months for
DEC-salt.
primarily
E-3
Control of Disease (Morbidity):
New Strategies
Dramatic advances in our
understanding of the pathogenesis of
lymphatic filariasis, especially recognizing the
importance of local microbial superinfection
in exacerbating lymphatic pathology and
recognizing the appreciable subclinical
pathology in the lymphatics of
‘asymptomatic’ microfilaraemic individuals,
have led to specific, on-going clinical trials
that appear likely to yield the following
treatment recommendations:
(a)
for adenolymphangitis (ADL):
treatment (and possibly prophylaxis)
with antibiotics, since the majority of
these acute episodes appear to be of
bacterial aetiology;
(b)
(C)
for lymphoedema/elephantiasis:
rigorous local hygiene with/without
local antibiotic and anti-fungal agents
to prevent ADL episodes and permit
the reversal of existing lymphoedema;
for asymptomatic microfilaraemia:
early treatment to prevent further
lymphatic and renal damage; in the
absence of specific data, the long
standing "standard" courses of DEC
(6 mg/kg/day for 12 days [IF.
bancrofti] or for 6 days [B. malayi])
remain appropriate.
prediction and evaluation of control strategies
in other parasitic infections, and such models
should be particularly valuable for lymphatic
filariasis because of the complexity of the
interactions among the vector, human and
parasite populations and because of the long
time-scales involved in filarial infection and
disease.
Models that can serve as costeffective tools for studying the population
dynamics of transmission and for assessing
the consequences of control interventions and
their relative cost-effectiveness are under
development.
E-5
For other clinical syndromes
associated with lymphatic filariasis (e.g.
tropical pulmonary eosinophilia, chyluria, etc.)
there is no new information available to
change the current recommendations for their
extended treatment with DEC.
E-4
Monitoring the Success of Control
Programmes: New Techniques
Surveillance of potential transmission
or established human infection in an
unsurveyed population is necessary to
determine where control efforts should be
initiated, how effective they are, and when
they may be discontinued. There is a major
need to replace night blood surveys as the
primary method for determining the level of
endemicity in a community. Evaluation of
antigenaemia rates in daytime, finger-prick
blood specimens from children or other
selected cohorts of the population has proven
to be a workable alternative to night blood
surveys, and analysis of infection rates in
mosquito vectors with entomologic or DNAbased techniques shows equal promise.
‘Rapid assessment’ techniques, such as review
of existing health reports and hospital records
or clinical examination of adult males for
hydrocoeles to assess the prevalence of
infection, are also being developed as ‘tools’
for identifying endemic communities in
previously unsurveyed areas.
Mathematical models have provided
increasingly powerful tools for analysis,
Management
Programmes
of
■
Control
The new control strategies based on
anti-filarial chemotherapy do not require
complex management structures.
The strategy requiring the least
management input is DEC-fortified salt
distribution.
While specific inputs are
required for production, advocacy and
community empowerment, the distribution
itself can use existing (health or non-health)
delivery systems. Additionally, this approach
can take advantage of inherent cost recovery
through consumer purchasing and, thus, might
require no sustained financial input.
i
Single-dose, annual or semi-annual
mass treatment also removes the need for the
complex management structures necessary for
detecting individual cases, and it provides the
opportunity for integration into existing
Primary Health Care systems for delivery
implementation.
Morbidity control, too, can be effected
with only minimal management input other
than training the community in the importance
of local hygiene to affected limbs or
organizing self-help support groups among
patients and their families.
While vector control generally
requires a separate management structure, it
often provides the opportunity for an
increased level of community participation.
.I
iii
i
safe for patients with onchocerciasis
and loiasis);
Opportunities also exist for integration with
existing vector-based control programmes for
other diseases (e.g., malaria).
(C)
E-6
Costs and Cost-Effectiveness
Specific Control Strategies
of
DEC-fortified salt requires the least
resource input since it relies on existing
community purchasing practices. There is,
however, some increase in purchasing cost to
the consumer, with recent experience in India
suggesting that high quality, re-crystallized
DEC fortification will add US $0.80 per year
er adult to the average bill for purchase of
salt.
The replacement of active case
detection and courses of multi-dose treatment
of the population by use of single-dose mass
treatment provides the opportunity for
increasing coverage "without additional cost
through reallocation of existing resources.
Operational Research Needs
Though currently available
information is sufficient for immediate
initiation of large-scale filariasis control or
elimination programmes, there are still certain
issues which, if resolved, would enhance
’•rogramme design and implementation;
specifically, these are:
(a)
(b)
iv
more precise estimates of the global,
regional and national burden of illness
caused by lymphatic filariasis, and
rapid assessment techniques to help
make these estimates;
a control strategy that can be used
safely and effectively in areas where
bancroftian filariasis might coexist
with onchocerciasis or loiasis (i.e.,
one based on ivermectin delivery or
use of DEC-fortified salt, if proven
cost-
between mass-delivery
and
fortified-salt
approaches
to
controlling lymphatic filariasis
(including how the delivery of
anti-filarial medication can be
integrated with other health and
non-health delivery systems);
for vector control - not as a
stand-alone option for filariasis
control, but as a potential
adjunct to chemotherapy-based
strategies;
of surveillance and rapid
assessment procedures under
actual conditions of
implementation - in particular,
comparing DNA-based
techniques and mosquito
dissection for detection of vector
infectivity, and comparing blood
antigenaemia detection with
microfilarial detection by
microscopy and clinical or recall
techniques
for determining
prevalence of infection in a
community;
The affordability of filariasis control
is particularly important because of the
relatively low priority often accorded it by
health planners.
E-7
detailed, comparative,
effectiveness analyses (CEA):
(d)
identification and quantification of the
economic and social costs of filarial
disease, including costs both to
individuals and to the national health
care budget for management of
elephantiasis, hydrocoele and
adenolymphangitis;
(e)
further definition of the clinical
consequences
of ‘asymptomatic’
microfilaraemia, with its newlyrecognized accompanying
abnormalities of lymphatic and renal
function, and an estimation of their
contribution to the social and
economic burden of filarial disease;
(0
evaluation of the personal and social
psychology of compliance with
annual mass drug treatment or long
term use of fortified-salt, and of
decision making in the personal
choice use of fortified salt;
(g)
development of predictive models
which provide the kinds of
information required by managers for
planning and monitoring control
programmes;
(h)
uniform surveillance, clinical
assessment and monitoring technic ^es
so that types of site-specific cc . j1
strategies can be defined, as we r as
those areas where total eradication jf
infection will be most readily
achieved.
!
£
|
V
LYMPHATIC FILARIASIS INFECTION & DISEASE:
CONTROL STRATEGIES
Report of a WHO/CTD/TDR Consultative Meeting held at the
Universiti Sains Malaysia,
Penang, Malaysia, 22-24 August 1994
Page
1.
Global Prevalence, Distribution and Disease Burden of Lymphatic
Filariasis
1
1.1
Prevalence
1
1.2
Geographical Distribution
2
1.3
Patterns of Infection and Disease
2
1.4
The Global Burden of Disease
3
1.4.1
Disability
3
1.4.2
Economic
4
1.4.3
Research priorities
4
2.
Current National Control Strategies
4
3.
New Research Findings Giving Rise to New Control Strategies
7
3.1
Infection Control (Chemotherapy)
7
3.1.1. Drug regimens available for filariasis control - Comparative efficacy
7
3.1.2
Adverse reactions
9
3.1.3
Macrofilaricidal activities of DEC and ivermectin
9
3.2
Morbidity control
10
3.2.1
Adenolymphangitis and lymphoedema/elephantiasis
10
vii
r
Page
3.2.2
"Asymptomatic" microfilaraemia
10
3.3
Vector control
11
3.4
Programme development/oversight
12
3.4.1
New tools for diagnosis and epidemiological assessment and monitoring
12
3.4.2. Predictive models
Social and economic issues in control programmes
3.4.3
14
14
3.4.3.1
Socioeconomic findings
14
3.4.3.2-
Community participation
14
4.
Conclusion
15
4.1
Recommended Control Strategies
15
4.2
Operational Research Needs
15
Tables
17
References
23
List of participants
27
viii
rtwntrfiiinirtfa-rfi
if ■i-z
aft it i'lnrlfti
VI'
4
STRATEGIES FOR CONTROL OF LYMPHATIC
FILARIASIS INFECTION & DISEASE
r
A meeting was held at the Universiti
Sains Malaysia, in Penang, Malaysia from
22-24 August 1994 (list of participants
appended). The purposes of this meeting
were to define as precisely as possible the
current understanding of the epidemiology
and global impact of lymphatic filariasis; to
review current control efforts in selected
endemic countries; to identify the dramatic
recent advances in clinical understanding,
therapeutic options and assessment techniques
of potential value to control programmes; and
then to determine specific control strategies
that can be recommended for immediate
implementation in endemic countries.
1.
Global Prevalence, Distribution and
Disease Burden of Lymphatic
Filariasis
1.1
Prevalence:
Information about
distribution and prevalence is an obvious
prerequisite for any meaningful discussion of
the public health importance of a disease. For
lymphatic filariasis, caused by Wuchereria
bancrofti, Brugia nialayi and B. timori
parasites, estimates of global prevalence have
been made previously by WHO (1,2), with the
latest published figures (2) indicating
infection of some 72.8 million people with
W. bancrofti and 5.8 million with B. malayi or
B. timori. These figures are based largely on
reports by member states to the WHO Expert
Committee on Filariasis, except for the
countries of Sub-Saharan Africa where most
estimates were derived from much earlier
surveys (3). Although the WHO estimates
have proved important in indicating the
numerical scale of the problem, they provide
less information relevant to the public health
importance of these infections since separate
estimates of disease are not available. A
more recent detailed assessment of available
information has attempted to correct for age,
gender, and disease-specific biases in the
earlier figures, and it estimates that
approximately 119.1 million individuals are
now infected with lymphatic filariasis
worldwide, 106.2 million having bancroftian
filariasis and 12.9 million having brugian
filariasis (table 1; refs. 4,5). The number
with overt physical disabilities from their
infections is approximately 43 million, with
bancroftian filariasis accounting for almost all
(40 million) of these cases.
These recent estimates (4,5) were
based on all published and unpublished
quantitative data from the last 20 years that
was retrievable from the open literature, from
the WHO regional offices and from individual
countries. ‘Corrections’ to this broad dataset
were undertaken in two steps. The first step
consisted of estimating age-specific rates of
infection and disease (hydrocoele in males
and lymphoedema for both sexes) in each
study, with data recorded to the nearest age
class when available. Age-specific rates for
studies that provided only crude overall
infection and disease rates were derived as
follows: first, age-specific rates from all
studies in a region providing such information
were combined to produce standard regional
age-prevalence curves; then, these curves
were applied to the ‘crude overall rates’ given
in studies in that region to derive the
corresponding age-specific infection and
disease rates for the study community.
Similarly, sex ratios of infection and disease
prevalence, and, in the case of males, the ratio
of hydrocele to lymphoedema were calculated
from studies providing the required data in
each region and then used to generate genderand disease-specific estimates in those
instances when only composite overall
prevalences were reported.
In the second ‘corrections’ step the
direct and derived age-specific rates from
these studies were then combined to obtain
national and regional burdens. First, age
estimates from each study in a particular
country were averaged to obtain the
corresponding national gender-specific, age
prevalence curves.
Then, with available
demographic data, these curves were
converted to numbers of individuals afflicted
in a particular country by sex and age-class.
Wherever possible, WHO estimates of the
size of the national populations living in
1
I
■
endemic regions (derived from information
reported by Member States) were used in
these calculations. The exception is China,
where some recent estimates (6) have ignored
the populations of provinces having infection
prevalences below 1%.
For the present
estimates, however, populations of all
provinces where infection is present have
been considered as the exposed, endemic
population. For global estimates, the total
number of country or regional cases were
summed, and average prevalence (expressed
in percentages) calculated using the total
endemic population as the denominator
(Tables la,lb).
The new estimate of the world burden
of 119.1 million cases of lymphatic filariasis
's higher than the 1992 WHO estimate of
/8.6 million but, given the difference in the
methods of estimation, not very remarkably
so. Indeed, the similarity encourages the
belief that the true burden lies in the vicinity
of these figures, and probably closer to the
more recent estimate, since most available
figures tend (for technical reasons) to
underestimate both microfilarial and disease
prevalence; also ‘cryptic’ infections (i.e., not
manifested by either overt lymphatic
pathology or microfilaraemia are not taken
into consideration at all in these calculations
because of the difficulty in diagnosing them
objectively and with certainty).
1.2
Geographical Distribution
The 1992 report of the WHO Expert
Committee on Filariasis (2) indicates that
brugian infection is endemic in 8 countries in
Asia, while W. bancrofti occurs in 7 countries
in the Americas, 4 in the EasternMediterranean region, 8 in South-East Asia
and 8 in the Western-Pacific region; an
additional 38 countries lie within the
W. bancrofti endemic areas of Sub-Saharan
Africa. The prevalence estimates in Table la
indicate that India, with 45.5 million cases
and Sub-Saharan Africa, with 40 million
cases, have very similar burdens of W.
bancrofti infection. Individually these regions
account for about 38% and 34% respectively
of the total world burden, a conclusion
contrasting with that from previous estimates
which suggested that the majority of filarial
2
infection and disease was confined to India.
In fact, in terms of prevalence, (Table la),
slightly higher infection and disease rates are
observed for the Sub-Saharan African region
than for India. Given the public health
significance of this finding for Africa, it is
clear that there is an urgent need for more
precise information on infection prevalence in
this region, including information to quantify
current at-risk population sizes or, at least, to
identify all endemic countries. The region
with the third highest number of cases
(14.5 million) and prevalence (1.83%) of
bancroftian filariasis is Asia (excluding China
and India) and the Pacific islands, followed
by China with a total burden of 5.46 million
cases. Though focally important, only low
burdens of infection and disease are observed
for ‘Latin-America and the Caribbean’ and for
the ‘Middle Eastern Crescent’.
The regional estimates for brugian
filariasis (Table lb) indicate that China (32%)
and India (20%) account for half of the global
burden, with the South-East Asian countries
of Indonesia, Thailand, Malaysia, Philippines,
Viet Nam and South Korea accounting for the
rest.
1.3
Patterns of infection and Diseases
The global age-specific estimates seen
in Tables 2a,2b indicate the markedly age
dependent nature of lymphatic filarial
infection and disease.
Numerically, the
largest number of cases (microfilaraemia and
disease) for both parasite genera occurs in the
15-44 year age-group, but the prevalences of
microfilaraemia and disease are highest in the
45-60+ age-group. Gender-specific estimates
indicate a male bias for microfilaraemia,
apparently 10% more cases in bancroftian
filariasis and 25% more cases in brugian
filariasis. Chronic disease due to bancroftian
filariasis also appears to be more prevalent
among males, largely because of the large
number of hydrocoele cases (26.79 million).
When the numbers of lymphoedema cases are
compared, the bias actually appears to be in
the opposite direction, with significantly
greater (about 18% more) disease among
females (7.81 million) than males
(5.36 million cases). For brugian filariasis
both microfilaraemia (males: 6.52 million
a>
cases, females: 3.84 million cases) and
lymphoedema
(males: 1.8 million cases,
females: 1 million cases) appear to be higher
among males.
There is less quantitative information
on acute disease manifestations, but these
appear to be less obviously age dependent
than do chronic manifestations (7), although
the frequency of adenolymphangitis (ADL)
episodes in individuals does appear to
increase with age and the severity of chronic
disease manifestations (8). The frequency of
acute episodes is believed to be related to the
progression to chronic disease, but it is not
known whether the episodes are determined
by intercurrent microbial infection,
immunological mechanisms or exposure to
infective mosquito bites (8).
1.4
The Global Burden of Disease
1.4.1
Disability
The 1993 World Bank Development
Report (WDR) uses Disability Adjusted Life
Years (DALYs) as a standardized metric for
comparing the public health impact of
different diseases and conditions (9). The
global burden of lymphatic filariasis was
estimated at 850,000 DALYs lost, which
represents only 0.23% of the global burden of
parasitic and infectious disease.
If this
current value is seen as a serious
underestimate, then it may equally be
appreciated as illustrating the current lack of
appropriate information and the need for more
quantitative data from which new estimates
can be derived. Such data requirements fall
into two categories: (i) estimation of disease
incidence, and (ii) estimation of the disability
level associated with each disease category.
Current estimates of disease incidence,
necessarily through lack of data, focus on the
more gross chronic manifestations.
How
justified this limited focus may be is
debatable, but what is certainly true is that
such a narrow definition significantly reduces
the estimate of disease incidence, not only
because acute disease is likely to be many
times more prevalent than chronic (8), but
also because acute disease occurs in the
younger age classes which are positively
weighted in the calculation of DALYs and
which constitute the majority of the
population of endemic countries. This age
effect is likely to be particularly important in
Africa where almost no information on
incidence of acute disease exists.
'■
Another important factor in estimating
incidence of disease is gender. The WDR
estimates (9) suggest that the burden in
women is approximately half that in men
(presumably reflecting the differential
occurrence of hydrocoele).
Since acute
disease appears similarly prevalent in both
sexes (7), there is the likelihood that much
disease in women has been overlooked.
The disability associated with chronic
disease is largely unquantified but is currently
under investigation in a series of WHOsponsored studies.
Anecdotal evidence
suggests (10) that the impact of disability may
be both economic (e.g. lost employment
opportunities) and social/psychosocial (e.g.
stigmatisation and reclusion). Studies in a
wide range of endemic countries will be
required to define such impacts since social
and economic consequences are likely to be
highly culture-specific.
The disability associated with acute
disease is even less well understood and has
largely been ignored. ADL appears to occur
from adolescence onwards as well as in the
young adult age-groups where chronic disease
manifestations are rare. A study of chronic
disease patients in India (8) indicates that the
duration of each ADL episode (mean of 4.1
days) is largely independent of age but that
the frequency (mean of 4.2 episodes per year)
increases with both age and disease
chronicity. The study indicates that while
some individuals may suffer ‘filarial fever’
much more often, the average for middle-aged
lymphoedema patients is 30 days a year; and
the figures suggest significant additional
disability for those with pre-existing chronic
disease.
While social and economic
consequences of acute episodes are also
largely undetermined, the existence of specific
local names (e.g. Yanakkalu jwara in Tamil,
and homa ya mitoki in Kiswahili) suggests
that the condition is sufficiently obtrusive to
be commonly recognised.
3
1
I
>•
Calculation of the disability associated
with acute disease would likely have an
appreciable effect on estimates of the disease
burden of lymphatic filariasis. Indeed, not
only might the disability be additive for those
with chronic disease, but it might also appear
as a new source of disability prominent in the
younger age classes which, as stated before,
are weighted more heavily in the estimate of
DALYs and which make up a larger
proportion of the population of developing
countries. Thus, it is clear that the accurate
estimation of the global health burden of
lymphatic filariasis is crucially dependent on
obtaining a more detailed epidemiological
understanding of acute disease. Furthermore,
the newly recognized existence of very
substantial amounts of‘subclinical’ pathology
in essentially all microfilaraemic individuals
J-13) argues that estimates of the global
health burden of filariasis must find ways to
include the health consequences of this type
of pathology as well.
1.4.2
(b)
estimation of the incidence
infection and disease in Africa;
(c)
definition of the epidemiology of
acute disease;
(d)
assessment of disease in women;
(e)
estimation of disability attributable to
chronic ‘subclinical’ disease;
(f)
estimation of the economic impact of
the infection and disease.
(g)
assessment of the psychosocial impact
of the infection and disease.
Such information will permit more
accurate estimations of the global economic
and health burden attributable to lymphatic
filariasis; without it, "lymphatic filariasis will
continue to struggle to compete with more
prominent diseases for scarce health
resources..." (10).
Economic
2.
Establishing an economic case for the
control of lymphatic filariasis will certainly
assist the promotion of filariasis control, as
review of this complex area has recently
indicated (10). While both indirect costs and
direct costs to the household and to the health
care system appear large, they are as yet
unquantified. WHO is currently sponsoring
studies in this area to complement the efforts
of others to estimate global disease burden.
1.4.3
Research priorities
For the emergent strategies for
filariasis control to be adopted by endemic
countries, the best case (health, social,
economic) for controlling this disease needs
to be made.
The following areas are
identified as priorities for providing the
necessaiy data:
(a)
of
adoption of standardized methods
(including rapid assessment
techniques) for collecting, presenting
and interpreting epidemiological data
on infection and disease;
Current National Control Strategies
of Selected Countries
Official representatives or other
knowledgeable individuals from 11 countries
endemic for lymphatic filariasis described the
policies for filariasis control in these
countries. Specific problems, successes and
current directions of these programmes were
reviewed as follows (see also Table 3).
China (14): Efforts to control lymphatic
filariasis have been intensive and concerted
since the first National Programme began in
1956, and the results have been remarkable.
From a prevalence of 31 million cases in
1956, diligent use of DEC-fortified salt and
mass treatment programmes with standard 2week courses of DEC have brought the
number of filariasis cases to an estimated
1.58 million. Indeed, in almost all of the
originally endemic provinces prevalence is
now
less than
1%.
Current efforts at
controlling filariasis are focused on the use of
DEC-fortified salt for periods of 6-9 months
in communities where filariasis still remains.
Egypt (15):
Despite early success at
controlling bancroftian filariasis through DEC
4
delivery and mosquito/environmental control
efforts, after the control programme was
relaxed in 1965 the problem of bancroftian
filariasis began to return. Currently the peri
Cairo, rural and semi-urban area of the Nile
delta have foci where the prevalence of
bancroftian filariasis is greater than 20%. A
division of the Ministry of Health responsible
for filariasis, malaria and leishmaniasis
control oversees filariasis control in Egypt,
and this control is based primarily on
identifying microfilaraemic individuals in
night-blood surveys and treating them with
standard courses of DEC.
Additionally,
limited mosquito control efforts relying on
insecticides, Bacillus thuringiensis and
insecticide-impregnated bednets are also
utilized in some areas.
French Polynesia (16): During the 1950s
lymphatic filariasis was a public health
priority in French Polynesia, as 30% of the
population was microfilaraemic and 10%
suffered from
lymphoedema.
Mass
chemotherapy with various regimens of DEC
was initiated, the schedule ultimately
becoming 6 mg/kg delivered in single doses
twice yearly to the entire population.
Prevalence levels fell dramatically (to 2% by
1982), but after the control programme was
replaced in 1982 by a passive system of DEC
availability and health education, infection
rates returned
progressively towards
pre-control levels. In 1993, the Ministry of
Public Health re-initiated the mass
chemotherapy programme, with DEC
(3 mg/kg) being given every 6 months.
India (17): The National Filaria Control
Programme (NFCP) is a division of the
National Malaria Eradication Programme in
the Ministry of Health. The NFCP budget is
approximately 30 million rupees per year
(approximately US $1,000,000), and primary
control strategies include larviciding and
environmental control measures for mosquito
reduction in urban areas, as well as screening
urban populations by night blood surx eys and
treating with DEC (6 mg/kg/day x 12 days)
those found either to be microfilaraemic or to
have lymphoedema. Almost 4 million blood
films were reported on during 1992. A small
number of programmes using DEC-fortified
cooking/table salt to control bancroftian
filariasis are also currently underway. Though
75% of the population at risk lives in rural
areas, all filariasis control efforts are confined
to urban areas. No assessment of the impact
of these control efforts is routinely carried
out.
■
Indonesia (18): Indonesia is the only country
with all three species of lymphatic filarial
parasites, with both periodic and sub-periodic
B. malayi (feline and primate reservoir hosts),
and with transmission by five different
mosquito genera and a plethora of individual
species.
A National Filariasis Control
Programme was established in the early
1970s, and much pioneering work on ‘spaced’
low-dose DEC, with appreciable community
participation and involvement of the primary
health care system, was carried out
subsequently (19). The current strategy is
based on mass distribution of low-dose DEC
(100 mg for an adult, 50 mg for a child less
than 10 years old) given weekly for 40 weeks
by primary health care workers in endemic
communities where mf prevalence is greater
than 1%. This strategy has proven very
successful in bringing down both microfilarial
rates and the incidence of lymphoedema when
they have been monitored. Efforts to identify
additional villages in which this strategy can
be initiated are currently in progress. It is felt
that the control of lymphatic filariasis is
possible using DEC as the mainstay of the
control strategy.
Malaysia (20): A formal and systematic
Filariasis Control Programme for Malaysia
was started in the early 1960s, with current
control activities incorporated under the
Vector-Borne Diseases Control Programme of
the Ministry of Health. With an annual
incidence of 3-5 cases of microfilaraemia per
100,000 population, 17 control teams are
dispersed throughout the endemic areas to
carry out geographical reconnaissance, night
blood surveys, treatment of cases with DEC
for 6 days, follow-up evaluation and health
education. These activities are concentrated
in the areas of the country with the highest
endemicity levels (Kedah, Perak, Kelantan,
Terengganu, Pahang and Sabah).
Papua New Guinea (21): Though no formal
national surveys have been carried out, areas
5
h'
!
I
J
of heavy endemicity with very high rates of
both microfilaraemia (up to 98%) and
lymphatic pathology have been documented.
Similarly, no national control programme yet
exists for controlling lymphatic filariasis, but
Ministry of Health-approved mass treatment
campaigns with DEC have been undertaken
both in Western Province and in the East
Sepik region with external (Australia, WHO)
funding and assistance.
Philippines (22):
The Filariasis Control
Programme is currently part of the
Communicable Disease Control Service in the
Philippines.
Distribution of lymphatic
filariasis (both bancroftian and brugian) is
widespread, and the true prevalence and
distribution of these infections are not
completely defined. A survey in the 1960s
mdicated that 42 of 56 surveyed provinces
tvere endemic for lymphatic filariasis.
Control activities (treating diagnosed cases
with standard DEC regimens) currently
operate at a low level because of the meagre
financial and personnel resources available.
Sri Lanka (23): No new cases of brugian
filariasis have been reported after 1968. It is
currently estimated that there are 7.5 million
persons at risk of W. bancrofti infection along
the coastal areas of the country. Until 1987,
approximately 1 million blood films per year
were examined for microfilariae;
more
recently about 2/3 of that number are
examined yearly. Although thought to be an
underestimate (because of inadequate sample
’ze), the prevalence of microfilaraemic
persons in these areas was 0.36% in 1993.
All microfilaraemic individuals are given
DEC (150 mg twice daily for 2 weeks, with
an additional course of treatment one month
later).
The programme is administered
through a governmental Anti-Filariasis
Campaign (AFC) established in 1947. A
major part of the control activities has now
become the responsibility of the Ministries of
Health of the newly constituted Provincial
Councils. The national AFC is responsible
for coordinating this activity and also
effecting control measures outside of the
‘classical’ endemic areas.
Tanzania (24): Bancroftian filariasis with
significant clinical disease is endemic in
6
coastal Tanzania and in areas near Lake
Victoria and Lake Malawi. At present, there
is no national programme or implemented
policy for control of either morbidity or
transmission; rather, there is an ‘indirect’
programme whereby externally supported
vector control programmes to reduce malaria
morbidity also help to control filariasis by
using both sprayed insecticides and pyrethroid
impregnated bednets. Polystyrene beads and
Bacillus sphaericus are also used for vector
control of Culex quinquefasciatus.
These
limited control efforts exist primarily in the
urban areas of Dar es Salaam and Tanga, and
there are no broadly applied control efforts in
rural areas of the country. The political will
is present, as well as the necessary expertise,
but funding for filariasis control is not
available except for projects sponsored by
outside agencies.
Thailand (25):
A Filariasis Control
Programme was instituted in 1961; it is now
integrated into the basic health service
programme but supervised by a distinct
filariasis division. No large-scale vector
control measures are in effect, though use of
impregnated bednets and repellents is
encouraged; DEC chemotherapy is the sole
control strategy employed, with various
schedules being used to treat asymptomatic
microfilaraemic persons and clinical cases of
both bancroftian filariasis (found along the
Myanmar border and thought to be imported
by refugees from that country) and brugian
filariasis (endemic in southern Thailand).
Surveillance is performed in index areas once
every two years. The overall objective is to
reduce microfilarial carrier rates to at least
0.6% in all endemic areas and then to
interrupt both transmission and the occurrence
of lymphoedema/elephantiasis.
3.
New Research Findings Giving Rise
to New Control Strategies
3.1
Infection Control (Chemotherapy)
Currently there is but one available
drug, diethylcarbamazine (DEC), registered
for use in treating lymphatic filariasis
(reviewed in ref. 26). However, a second
drug, ivermectin (the current mainstay for
controlling morbidity in onchocerciasis [27]),
has been evaluated extensively in recent years
against lymphatic filariasis (reviewed in
ref. 28), and though not yet registered for
such use, it seems destined eventually to
become another important tool for the control
of both bancroftian and brugian filaria
infection. Furthermore, despite this relative
paucity of drugs for controlling lymphatic
filariasis, remarkable findings about optimal
ways in which DEC and ivermectin can be
used (alone and in combination) have been
made in recent years (29). This information
has spawned the development of both new
control strategies and renewed optimism that
control programmes can be successful.
DEC and ivermectin are primarily
microfilaricidal drugs, though it is clear that
for DEC (and possibly for ivermectin) there is
macrofilaricidal activity as well (26).
Moreover, even if these drugs had only
microfilaricidal effects, success should still be
anticipated in control programmes where they
are used, both because prolonged clearance or
decrease of microfilariae from the blood helps
to reduce transmission of infection, and
because reduced transmission and decreased
levels of microfilaremia in a community have
long been recognized to have a positive
‘clinical effect’ on infected subjects (i.e.,
decreased frequency of ADL attacks which
lead to decreased incidence of clinical
lymphoedema [30]), and thus enhanced
compliance in community treatment
programmes.
3.1.1.
Drug regimens available for filariasis
control - Comparative efficacy
(i)
‘Standard’ 12-dav (W. hancrofti} or
6-day (B. malayi} courses of DEC
administered repeatedly - often at one
year intervals - as mass treatment to
affected communities have commonly
formed the basis of anti-filarial
control programmes (26). Such
regimens, however, have proven to be
expensive and difficult to administer
both because of the drug’s causing
rapid parasite death that leads to fever
and malaise (‘systemic adverse reac
tions’), local inflammatory reactions
(‘localized adverse reactions’) or
gastrointestinal symptoms (the major
DEC pharmacological ‘side effect’) in
many who were initially microfilaraemic but entirely asymptomatic
(31). Indeed, it is largely because this
therapeutic regimen was so unpopular
that alternative treatment regimens
have been sought.
Furthermore,
while these same ‘standard courses’
of DEC have also been used in
treatment programmes focused on
‘selective chemotherapy’ where only
microfilaraemic individuals were
treated, this strategy, too, has proven
to be cumbersome and unworkable
both for the reasons affecting mass
treatment programmes and because of
the additional resources necessary to
carry out diagnostic procedures on the
entire population in order to identify
the microfilaraemic individuals
requiring treatment. Thus, ‘standard
course DEC’ can be effective for
mass chemotherapy but at a cost in
resources, health personnel and
patient compliance that makes it
impractical for most control
programmes.
(ii)
Single-dose (‘spaced dose’) DEC
given at weekly, monthly, 6-monthiy
or yearly intervals has been
enthusiastically advanced for many
years by workers especially in the
Pacific Islands and Indonesia (19,3234); more recently, numerous
controlled clinical trials have
reaffirmed the efficacy of such
regimens (29). While more frequent
single-dose DEC (usually weekly or
monthly) regimens are effective in
decreasing microfilarial prevalence
and density, their advantage over
yearly or 6-monthly DEC may not be
great enough to warrant the increased
expense of more frequent drug
delivery (33).
For bancroftian
filariasis the largest experiences with
control programmes using single-dose
yearly DEC have been those carried
out in Tahiti (n = 50,000; [32]) and
Fiji (n = 7,600; [33]) where 4 or
5 yearly-administrations of single
dose DEC resulted in decreases in
microfilarial prevalence of 57% and
7
1
I
I
I
86% respectively, and decreases in
microfilarial density of 78% and 97%
respectively. Similarly, for B. malayi
a control programme in Kerala, India
(n = 22,700 [35]) with 2 annual
administrations of single-dose DEC
resulted in a decrease in microfilarial
prevalence of 75% and in micro
filarial density of 81%.
It is
impressive that these community
trials, even though lacking complete
coverage of the population at each
round of treatment, yielded reductions
in microfilarial densities that
approximate those seen when
individuals have been treated with
single doses (or with the 12-day
‘standard course’) of DEC and
followed sequentially for 12 or more
months (reductions in microfilarial
density of 92-96% at 1 year [29,3638]).
(iii)
8
Single-dose ivermectin has not yet
been used in large-scale community
control programmes for lymphatic
filariasis, but its effectiveness against
microfilariae of both W. bancrofti and
B. malayi has been evaluated in
individual patients for periods of 1224 months after drug administration.
Numerous earlier studies had
examined the effectiveness of lower
ivermectin dosages, but it is clear
now that a dose of 400 pg/kg yields
definitely superior microfilaricidal
activity (29,39). While microfilarial
prevalence fell by only 36-70% at
12 months post-treatment, this dose
decreased microfilarial densities by
86-99% for 12-24 months post
treatment in both W. bancrofti and B.
malayi infections. Thus, since single
yearly (or even 2-yearly) doses of
ivermectin appear equally effective as
similar dosing with DEC, ivermectin
alone would be a valuable alternative
control tool for use in endemic
communities, especially where the use
of DEC is contraindicated (as in areas
where onchocerciasis or loiasis co
exists).
(iv)
The combination of single doses of
DEC and ivermectin appears to be
significantly more effective than
either drug alone (29). Again, no
community studies have been carried
out, but at 12 and 24 months post
treatment 3 published studies (38,4042) comprising a total of 33 W.
bancrofti infected patients receiving
an
ivermectin/DEC
combination
showed a fall in microfilarial prev
alence of 45-70% and a decrease in
microfilarial density of 96-99+%.
Furthermore, the dose of ivermectin
used in these studies was only
20 pg/kg (with 6 mg/kg DEC), not
the 400 pg/kg ivermectin dosage now
felt to be optimal. In on-going trials
a similar number of patients receiving
the combination regimen of 6 mg/kg
DEC and either 400 pg/kg ivermectin
(in French Polynesia or 200 pg/kg (in
India) also showed superior responses
one year after treatment (>98%
microfilarial reductions) compared to
single doses of ivermectin or DEC
alone (approximately 90%
reductions). Thus, while data on this
combination given at yearly or 2yearly intervals are still preliminary,
the potential value of the
TVER/DEC’ combination for use as
a chemotherapeutic control tool
appears most promising.
(V)
DEC-fortified salt (with DEC
concentrations ranging from 0.10.6%) can be used as a substitute for
normal cooking and table salt since
DEC is chemically stable. When
consumed for periods of 6-9 months
it has regularly decreased microfilarial
prevalence by 70-100% in both
bancroftian and brugian filariasis (43).
DEC-fortified salt has been used as a
mainstay for control programmes in
very large populations in China,
Taiwan and India, with excellent
results that substantiate observations
made on patients followed
individually and in whom prevalence
of W. bancrofti microfilaraemia has
been shown to decrease by 97% after
4 months of DEC-salt usage and
/
I
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7
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i
whose microfilaria] densities fell even
more dramatically, by greater than
990/0 (44). Though this strategy of
DEC-salt usage does appear both
workable and highly effective,
essentially all of the communities in
which it has been employed thus far
have only had access to salt supplies
that were strictly controlled by health
care authorities.
3.1.2
Adverse reactions
The adverse reactions (both systemic
and localized) developing after DEC and
ivermectin treatment (even single doses) have
been extensively reviewed (31,45). The
systemic reactions are likely the manifestation
of host inflammatory responses to parasite
antigens liberated by rapid death of the
microfilariae, while the localized adverse
reactions are probably induced by death of the
adult parasites. Such reactions are almost
unavoidable, but they can be reasonably well
tolerated by individuals or populations,
especially if it is not necessary to have the
‘long-term’ compliance required to complete
the 6-12 day ‘standard-courses’ of DEC.
Interestingly, however, not all of the
chemotherapeutic control regimens described
above induce the same degrees of adverse
reaction.
Without question, the regimen
causing fewest adverse reactions is DECfortified salt usage, most individuals having
no adverse reactions at all (43). Similarly, a
recent study comparing the adverse reactions
induced by different DEC regimens confirmed
earlier anecdotal findings that greater ‘adverse
reactivity’ is seen following ‘standard course
12-day DEC administration than after single
dose DEC (31).
Finally, when adverse
reactions of single-dose DEC and single-dose
ivermectin have been compared, the degree of
reactivity has generally been similar and
clinically very acceptable for both drugs,
though the character of the reactions (greater
systemic reactions with ivermectin and more
frequent localized reactions with DEC) differs
somewhat (31,38,46).
3.1.3
Macrofilaricidal activities of DZC
and ivermectin
Evidence that DEC can kill aduit
worms as well as microfilariae is both indirect
(long-term absence of microfilariae from the
blood post treatment, clearance of parasite
antigen from the blood) and direct
(development of inflammatory nodules
containing dead parasites post-treatment,
observed cessation of activity of adult worms
by ultrasound techniques [26,47,48]). What is
also clear, however, is that not all adult
w'orms are killed by a single dose (or single
course) of DEC and that long-term or
repeated treatment is necessary to eradicate
infection (26,48). The reasons for this onlypartial macrofilaricidal effect of DEC are not
known.
Still less certain is the degree of
macrofilaricidal activity that ivermectin has,
some recent studies suggesting similar levels
of macrofilaricidal activity for ivermectin and
DEC on W. bancrofti parasites (49) and others
suggesting complete absence of
macrofilaricidal activity for ivermectin (50).
3.2
Morbidity control
3.2.1
Adenolymphangitis
lymphoedema/elephantiasis
and
The potential for morbidity control
has been greatly advanced in recent years by
increased understanding of the pathogenesis
of both lymphoedema and acute
adenolymphangitis (ADL) in patients living in
filariasis endemic areas (8,51,52).
ADL
episodes are characterized by pain, lymph
adenitis, lymphangitis, and inflammation in
the affected limb or scrotum, that are usually
accompanied by fever, chills and other
systemic symptoms. Although ADLs have
long been recognized as regularly associated
with filarial disease, their aetiology has
remained uncertain, sometimes being ascribed
to parasite toxins, sometimes to host
immunologic responses, and sometimes to
bacterial infection. Recent evidence, both
from astute clinical observations and from
immunohistological and bacteriological
studies of tissue from lymphoedematous limbs
of affected patients, has suggested that
9
I
I
bacterial or fungal superinfections of limbs
with compromised lymphatic function play
the primary role in triggering most episodes
of ADL (8,51,52), which, themselves, actually
cause or exacerbate the elephantiasis changes
in affected patients.
A major implication of this new
understanding is that simple measures of
hygiene, coupled with local (or in severe
cases, systemic) antibiotics given
prophylactically, can have profound effects in
preventing these damaging episodes of ADL
and even in allowing the host to repair and
recover from some or all of the overt damage
caused by filarial infection and subsequent
superinfections (8,51,52). Trials are m
progress to determine the optimal regimens
for managing such patients, but it is clear that
diligent attention to local hygiene of the
effected limbs will have markedly positive
benefits. Preliminary evidence also suggests
that community-based patient self-help groups
work extremely effectively to stimulate and
maintain personal compliance with the
vigorous hygiene regimens required for this
morbidity control; and this newly enunciated
strategy is clearly one that can be exploited
worldwide, because nowhere are such patients
lacking in the intense desire to rid themselves
of their debilitating and ostracizing
deformities. Further validation and utilization
of this approach should lead to dramatic
decreases in the morbidity caused by filariasis
that should, in turn, have profound socio
economic impact in endemic countries.
.2.2
"Asymptomatic" microfilaraemia
The second new approach to
controlling the morbidity of lymphatic
filariasis derives from now recognizing the
urgency of treating patients with
‘asymptomatic microfilaraemia’. The ability
of such individuals to remain asymptomatic
probably relates to their immunologically
down-regulated state (53), but two sets of
recent observations have revealed that this
being clinically ‘asymptomatic’ in no way
implies freedom from ‘morbidity’. First, it
was recognized that most of these
microfilaraemic individuals have haematuria
and/or proteinuria that reflects low-grade renal
damage which does appear generally to be
10
reversible after treatment (11). Second, and
even more dramatic, were the observations by
several groups of investigators using
lymphoscintigraphy to visualize by
radioisotope tracer techniques the functional
anatomy of the lymphatic vessels (12,13).
What was seen was quite surprising, as almost
all of these infected individuals, even though
asymptomatic, had markedly abnormal,
dilated lymphatics and markedly abnormal
patterns of lymph flow. Though reversibility
of these lymphatic abnormalities with
treatment has not yet been demonstrated, it is
clear that the asymptomatic microfilaraemic
state is not so benign as initially believed, and
such patients should probably be treated as
early as possible to prevent or limit
irreversible damage to the lymphatic and renal
systems.
Finally, the further recognition from
lymphoscintigraphy studies that lymphoedema
is not always the result of occlusion of
lymphatic channels but can also occur when
there are extensive collaterals (12,13)
confirms the expectation that alternative
lymph flow patterns can be established
through lymphatic collaterals. Again, such
findings have important practical implications
for morbidity control, since they suggest that
even the so called ‘burnt-out’ cases with gross
lymphoedema and elephantoid changes can be
helped. The treatment of such cases should
be aggressive and should employ the most
appropriate tools available, be they foot care,
antibiotics, other drugs or even, in those
special cases where indicated, surgical shunt
procedures (54). Not only do the treated
individuals themselves benefit tremendously
from the reversal of such morbidity, but
community control programmes also become
more successful, since these ‘visible’
improvements can be appreciated by all in the
endemic communities.
3.3
Vector control
Vector control has played an
important supporting role for filariasis control
in many local programmes, and the reduction
of vector density can be an important
contributor to sustained interruption of
transmission. However, control programmes
based entirely on vector reduction have rarely
been continued long enough to decrease the
!
I
prevalence of filarial infection in human
populations, and experience suggests that for
its greatest impact vector control should be
implemented within the framework of an
integrated filarias is control programme based
on drug administration.
Certain new technologies are now
available to improve vector control efforts,
though all still require further assessment of
their long-term impact on infection in the
human population.
These include the
following:
(i)
Biocides:
The toxin-producing
bacterium Bacillus sphaericus"is the
most promising new biocidal
candidate for controlling larvae of
Culex quinquefasciatus, the main
vector of lymphatic filariasis in many
endemic areas of the world (55), and
even for controlling the Mansonia
vectors of brugian filariasis in certain
regions (56).
Appropriate
formulations of this microbial agent
have shown significant residual
activity against Cx. quinquefasciatus
and Cx. pipiens in highly polluted
breeding habitats, and this bacterium
has the potential to persist and recycle
under field conditions for up to
3 months. It is environmentally safe
and suitable for integrated control
programmes with community
participation. The estimated cost for
vector control programmes using
B. sphaericus has been estimated as
less than US $0.5 per person per year
in areas where breeding habitats of
mosquito vectors are very common.
In recent large-scale field trials in
north Cameroon, Brazil, India, Sri
Lanka and Tanzania a remarkable
impact of B. sphaericus use has been
observed in reducing vector biting
density by 80% through bi-monthly
treatment of mosquito larval habitats;
in addition, there was a significant
decline in the proportion of Culex
carrying filarial infective larvae.
Thus B. sphaericus (alternated with B.
thuringiensis) may prove to be the
selective mosquito-control agent of
choice for use against Cx.
quinquefasciatus in integrated control
programmes.
(ii)
Polystyrene beads:
Control of
mosquito vector breeding in closed
water systems (pit latrines and
cesspits) through use of expanded
polystyrene beads has been extremely
effective in certain urban areas with
endemic filariasis (57).
(iii)
Insecticide-impregnated bednets
and curtains: Use of insecticidetreated bednets has been successfully
employed in numerous countries to
control the anopheline vectors of
malaria (58). The value of these
methods for filariasis control must
still be determined, but preliminary
findings from Papua New Guinea are
promising.
(iv)
New formulations of pyrethroids:
Synthetic pyrethroids with longlasting residual effects (up to one
year) can be highly successful in
controlling adult mosquitos when used
for total indoor spraying in urban
settings (59). Furthermore, new
repellent formulations (soap with
DEBT and permethrin as active
ingredients) have good efficacy
against Mansonia adults and residual
protection when applied on human
skin (60). Among the household
insecticide products, mosquito «coils
that contain knockdown synthetic
pyrethroids also give reasonably good
protection against Culex and
Mansonia mosquitos.
(v)
Integrated vector management:
Rapid unplanned urbanization is
associated with problems of
inadequate water supply, poor sewage
disposal, insufficient solid waste
management and poor water drainage,
all of which result in a profusion of
breeding habitats for Cx.
quinquefasciatus and in increased
filariasis transmission. While repairing
septic tanks and upgrading the quality
of pit latrines should be considered
important components of vector
11
\
control campaigns in urban areas, the
joint efforts of high-level policy and
decision makers with health
authorities and municipal planners are
also required. Moreover, linkage with
non-health sectors must also occur
within municipalities to ensure their
involvement through carefully
developed intersectoral collaboration.
Finally, eliciting and sustaining
community interest and participation
in mosquito control programmes
should be important components of
integrated vector management, as
clearly indicated in numerous
examples of successful community
participation in the removal of aquatic
plant breeding habitats of Mansonia
mosquitos and in undertaking
commercialization of larvivorous/
phytophagous fish culture in such
habitats, both of which have
contributed greatly to sustainable
reductions of mosquito populations
(61).
3.4
Programme
oversight
development
and
Though the tools necessary to control
lymphatic filariasis may well now be in hand,
it is necessary to develop and evaluate
appropriate implementation strategies that will
not only be economical but also be acceptable
to the community and sustainable for long
periods.
Simultaneous development of
appropriate monitoring and surveillance
methods is also a prerequisite for successful
programme management.
3.4.1
New tools for diagnosis
epidemiological assessment
monitoring
and
and
Diagnosis of active infection is
important for determining the level of
endemicity of filariasis and for evaluating the
success of control measures. At present,
however, the identification of microfilariae in
the blood (usually, of necessity, sampled at
night) is the only absolute indicator of active
infection utilized for large populations, and
the problems associated with this diagnostic
approach are well recognised (including the
12
fact that some actively infected patients have
no circulating microfilariae). In addition,
antibody-based assays, the usual type of
immunodiagnostic test used to date, generally
cannot distinguish between active and prior
infection; they also have significant problems
with specificity, since individuals are often
concurrently infected by ‘cross-reacting’
gastrointestinal parasites.
Important new diagnostic t__L,
tools,
however, have recently become available;
these are the following:
(i)
Assays to detect circulating filarial
antigen (CFA)
The most recent and promising
immunodiagnostics are circulating
antigen assays that can identify
patients with either microfilaraemic or
occult infections; thus, they are of
particular value for determining
endemicity of infection and efficacy
of control measures.
The ‘first
generation’ of such assays detected
circulating phosphorylcholinecontaining antigens and proved
helpful in assessing infection rates in
areas where transmission had been
altered by insecticide spraying, in
evaluating reinfection following
administration of DEC, and in
determining possible infection in
amicrofilaremic persons (62). More
recent diagnostic tests have detected
protein antigens whose epitopes react
with the monoclonal antibodies
Og4C3 (63) and AD 12 (64). These
assays detect circulating antigens in
sera from essentially all
microfilaraemic and a proportion of
amicrofilaraemic persons residing in
W.
bancrofti endemic areas.
Importantly, the levels of circulating
antigen appear constant throughout
the day (unlike microfilaraemia) and
fall to zero after successful
chemotherapy has killed the adult
worms. Unfortunately, no comparable
assays exist for B. malayi infections.
|
(ii)
DNA-detection assays
the distribution of infection in order
to select appropriate control strategies
in specific epidemiological situations.
DNA-based technology can now also
be used for diagnosis of filarial
infection both in humans and in the
mosquito vectors by polymerase chain
reaction (PCR)-based assays which
provide outstanding sensitivity and
specificity. For B. malayi, PCR
techniques can detect a single L3 in
pools of up to 100 mosquitos, a single
microfilaria in 1 ml of blood, or the
equivalent of 1 pg of DNA in 100 pl
of blood (65). Recently a similar
PCR assay for W. bancrofti has been
developed with similar sensitivity
(66). It is estimated that one
technician can now use these assays
to screen up to 3600 mosquitos
(36 runs of 100 mosquitos each) or
1,000 blood samples in one day. The
current cost for materials (primarily
for the enzymes required for PCR) is
US $1.00 per run.
The advantages of PCR-based tests
include high degrees of sensitivity and
species-specificity, their detection of
only current infections, and the
rapidity with which their results can
be obtained (same day). In addition,
samples can be preserved at ambient
temperature for months and shipped
to a central laboratory' for assay. The
primary drawbacks of this technology
are the special training and equipment
required, and the need for its
performance in a central laboratory
with good quality control. In addition,
its use in assessing transmission of
infection in vectors requires further
validation in order to relate the
semiquantitative PCR output to the
transmission indices in standard use
that are based on detection of
infective larvae in dissected
mosquitoes.
(iii)
Rapid epidemiological assessment
In part because lymphatic filariasis is
geographically widespread but often
focal, rapid epidemiological
assessment is essential for mapping
Currently, night blood surveys are the
primary method for determining the
level of endemicity in a community,
and it is this technique that must be
replaced by some more ‘rapid assess
ment’ method such as: (a) estimation
of disease or mf carrier rates through
review of existing health reports and
hospital/clinic records; (b) clinical
examination of adult males for
hydrocoeles, with extrapolation to
gauge overall prevalence of infection;
(c) analysis of mosquito vectors for
infection, using traditionalentomologic methods or even DNAbased larval detection, if costeffective and feasible; (d) evaluation
of antigenaemia rates in daytime,
finger-prick blood specimens from
children or other cohorts of the
population.
3.4.2.
i
■
1
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;
■
■
:
-
Predictive models
Mathematical models now serve as
powerful tools for analysis, prediction and
evaluation of control strategies in several
parasitic infections (67,68), and development
of such models is particularly important for
lymphatic filariasis since the overall
infection/transmission cycle involves
particularly complex interactions among the
human, parasite and vector populations
(69,70). Furthermore, the very long time
scales of the processes of filarial infection and
disease also mean that such models can
provide cost-effective tools for studying both
the population dynamics of transmission and
the consequences of control. Indeed, recent
experience with the simulation model
(ONCHOSIM) developed for the
Onchocerciasis Control Programme in West
Africa (67) has highlighted the usefulness of
such models for aiding the design of control
strategies, analyzing the relative efficacy of
different intervention strategies and providing
precise information on cost-effectiveness of
the various approaches.
13
F
... .
3.4.3
.
I.,!,
Social and economic issues in control
programmes
(i)
the perception that filariasis is not
serious because it is not a fatal
disease,
(ii)
the fact that it has a slow progression
to chronic sequelae,
(iii)
the heretofore absence of hope for
clinical cure among people with
elephantiasis,
(iv)
a lack of awareness of the cause of
the disease, and
(v)
the perception, particularly among
urban dwellers, that lheir taxes are
sufficiently high that governmental
agencies should be able to solve
public health problems without further
community involvement.
3.4.3.1 Socioeconomic findings
Because of a dearth of information on
both social impact and economic costs of
lymphatic filariasis, research studies initiated
by WHO/TDR are currently collecting data on
these aspects of the disease. The important
results of these studies (carried out in India,
Ghana, Tanzania and the Philippines) will be
available in 1995 and will detail social
attitudes towards the disease, the direct and
indirect costs of acute and chronic disease,
and the extent of disease in women. The
results should be useful in quantifying the
socioeconomic burden of the disease and in
providing indicators for evaluating the success
of intervention control strategies.
3.4.3.2 Community participation
Community participation is a
recognized prerequisite for successful control
programmes based on integrated vector
control and filarial disease control (61), but
the type and level of community involvement
will depend on the characteristics of the target
community.
The most frequently encountered
barriers to engendering community
participation in filariasis control are:
14
As demonstrated, however, in many of
the most successful filariasis control
programmes, the characteristics of success in
engendering community participation include
a ‘horizontal’ community-based approach, a
‘bottom-up’ strategy, and, especially, linking
the programme with income-generating
activities (61).
4.
Conclusion
(i)
Lymphatic filariasis is more
widespread and inflicts a very much greater
disease burden worldwide than was
recognized even three years ago at the time of
the last WHO Expert Committee on the
Control of Lymphatic Filariasis (2). The
availability of new, simplified, effective and
affordable control strategies together with the
recent designation of lymphatic filariasis as
one of only six infectious diseases considered
eradicable or potentially eradicable (71)
makes this an ideal time to initiate a global
programme to control or eliminate this disease
from all endemic countries and to assert the
optimistic expectation that such a programme
will be successful.
4.1
Recommendations
Strategies
for
The focus of control efforts should be
on treating the infection in human
populations, with vector control
serving a supporting role when
feasible and affordable.
(b)
‘Mass-distribution’
programmes
should completely replace those based
on a ‘selective-treatment’ strategy
(i.e., detection of microfilaraemics
who are then treated ‘selectively’).
Regimens recommended for mass
treatment in areas where there is no
co-existing onchocerciasis or loiasis
would be either of the following-.
(>)
(ii)
(e)
Adjunctive vector control could
include the use of biocides (especially
Bacillus sphaericus), polystyrene
beads, insecticide impregnated
bednets and curtains, long-lasting
residual pyrethroids, and community
supported vector management, as
locally appropriate.
4.2
Operational Research Needs
Control
(a)
(c)
(>>)
Though currently available
information is sufficient to justify the
immediate initiation of large-scale filariasis
control or elimination programmes, there are
still important issues which, if resolved,
would considerably enhance programme
design and implementation;
specifically,
these issues/needs are the following:
(a)
more precise estimates of the global,
regional and national burden of illness
caused by lymphatic filariasis, and
rapid assessment techniques to help
make these estimates;
(b)
a control strategy able to be used
safely and effectively in areas where
bancroftian filariasis may co-exist
with onchocerciasis or loiasis (i.e.,
one based on ivermectin delivery, on
use of DEC-fortified salt if proven
safe, or on wide-scale vector control);
large areas of Africa would thus be
‘opened’ for treatment of lymphatic
filariasis;
DEC-fortified salt (0.2 0.4%) used in place of regular
salt for all cooking and
seasoning for a period of 9-12
months;
Single, annual or semi-annual
mass administration of DEC
(6 mg/kg body weight) for 510 years.
(c)
(d)
ivermectin (400 p.g/kg) given
once yearly - a regimen safe
in areas where onchocerciasis
or loiasis might also be
prevalent;
ivermectin (400 gg/kg) phis
DEC (6 mg/kg) given once
yearly, except in areas where
onchocerciasis or loiasis co
exists.
When ivermectin becomes registered
for use in lymphatic filariasis, two
additional mass treatment regimens
will be available:
I
detailed, cost-effectiveness analyses
(CEA):
comparing yearly mass
treatment and (DEC)
fortified-salt approaches to
15
i
i
controlling lymphatic
filariasis, (including ways in
which the delivery of antifilarial medication can be
integrated with other health
and non-health delivery
systems);
for vector control - not as a
single option for filariasis
control, but as a potential
adjunct to chemotherapeutic
strategies based on annual
mass treatment or use of
DEC-fortified salt;
of surveillance and rapid
assessment procedures under
actual conditions of
implementation - in particular,
comparing DNA-based
techniques and mosquito
dissection for detection of
vector infectivity, and
comparing assessment of
blood antigenaemia both with
microfilarial detection by
microscopy and with clinical
or historical techniques for
determining prevalence of
infection in a community;
(d)
16
delineation and quantification of the
economic and social costs of filarial
disease, including the costs both to
individuals and to the national health
care budget for management of
elephantiasis, hydrocoele and
adenolymphangitis;
(e)
further definition of the clinical
consequences
of ‘asymptomatic’
microfilaraemia (in addition to the
newly-recognized lymphatic and renal
function abnormalities), as these
consequences are relevant to
calculating the social and economic
costs of filarial disease;
(f)
evaluation of simple measures such as
local hygiene and foot care and the
use of antibiotics locally or
systemically
for preventing or
controlling morbidity;
(g)
evaluation of the personal and social
psychology of compliance with
annual mass treatment or long-term
fortified-salt usage, and of decision
making in the personal-choice use of
fortified salt;
(h)
predictive models, particularly
relevant to the kinds of information
required by control managers for use
as tools for monitoring control
programmes;
(i)
uniform surveillance and monitoring
techniques so that types of site
specific control strategies can be
defined, as well as those areas where
total eradication of infection will be
most easily achieved.
TABLE la
Global burden of bancroftian filariasis by sex and demographic region.
Estimates: upper number = cases in millions; lower number (in brackets) = prevalence (%) in region.
World
Sub-Saharan
Africa
India
China+
Other Asia
and islands
Latin America
and the
Caribbean
Middle Eastern
Crescent
4,119.86*
512
850
1,134
793
441
391
Microfilaraemia - Males
40.86
(L95)
14.74
(5.82)
17.00.
(3.87)
2.25
(0.39)
6.54
(1.63)
0.19
(0.08)
0.13
(0.06)
Microfilaraemia - Females
32.41
(1.60)7
13.13
(5.07)
12.46 )
(3.04)
1.80
(0.33)
4.79
(1-22)
0.13
(0.06)
0.11
(0.06)
5.36 .
(0.26)
1.78
(0.68)
2.60 .
(0.60) '
0.06
(0.01)
0.92
(0.23)
0.014
(0.006)
0.027
(0.01)
2.86
(1.10)
3.98
(0.97)
0.05
(0.009)
0.87
(0.22) ‘
0.017
(0.008)
0.029
(0.02)
Condition and sex
Population
Lymphoedema - Males
0,1
k
Lymphoedema - Females
7.81
(0.39)
Hydrocoele - Males
26.79
(1.28)
10.20
(4.03)
12.88 >
(2.93)
1.68
(0.29)
1.90
(0.48)
0.057
(0.03)
0.06
(0.03)
Total cases - Males**
66.65
(3.18)
24.28
(9.60)
29.43
(6.70)
3.62
(0.62)
8.87
(2.21)
0.246
(O.H)
0.207
(0.10)
Total cases - Females**
39.54
(1.95)
15.74
(6.08)
16.10
(3.92)
1.84
(0.34)
5.59
(1.42)
0.149
(0.07)
0.135
(0.07)
*
♦*
+ N.B.
Total population in regions where significant infection exists. Population figures and regions as given and defined for the World Bank Global Burden of
Disease Study.
Equals sum of the number of patients with microfilaraemia alone plus the number of patients with overt disease (lymphoedema or hydrocoele) less the
number with both overt disease and microfilaraemia (estimated at 0.9% for lymphoedema and 22% for hydrocoele [see ref. 5 for details of this estimation].
The figures in this column are based on estimates as calculated in ref. 5. Official Chinese government estimates are different, as follows: Population (in
millions) 344; microfilaraemia (males: 0.05; females: 0.05); lymphoedema (males: 0.06; females: 0.05); hydrocoele (male only: 0.42); chyluria (males: 0.24;
females 0.23); total cases (males: 0.75; females: 0.33).
TABLE lb
Global burden of brugian filariasis by sex and demographic region
Estimates: upper number =
cases m mdl.ons; lower number (in brackets) = prevalence (%) in region.
Condition and sex
Population
Microfilaraemia - Males
World
India
China+ ,
Other Asia and
islands
2,776.35*
850
1,134
793
6.515 -
1.105
(0.25)
2.235
(0.38)
3.175
(0.79)
0.692
(017)
1.250
(0.23)
1.895
(0.48)
0.582
(013)
0.461
(0.08)
0.761
(0-19)
1.004
(0.07)
0.282
(0.07)
0.271
(0.05)
0.452
(0-12)
8.159
(0.57)
1.635
(0-37)
2.655
(0-45)
3.869
(0.97)
4.752
(0.35)
0.949
(0.23)
1.496
(0.27)
2.306
(0.59)
.he W„M Bmk Glob., Burden
(0-45) j I o'
Microfilaraemia - Females
3.840 1
(0.28)
Lymphoedema - Males
1.804
(0-13) I
Lymphoedema - Females
Total cases - Males**
Total cases - Females**
*
in
e.'Z
Whe" Si8ni,IC", inf“ta “iSB-
“a
- 8>v» and regions as
♦*
+ N.B.
number with bulb over.
° jP“l““s ’'ith
dise,s' (lymphoedema or hydrocoele) less rhe
estimation],
em,a lestimated at 0.9/o for lymphoedema and 22% for hydroeoele [see ref. 5 for details of this
Ihe figures in this column are based on estimates as calculated in ref 5 Offirial cn(m mdhons) 3«; mlerohlaraemla (males. M05. (em.les. 0.0.5); .ympho^^SZS SX^^X^X).
9
J- ....
—/
TABLE 2a
Global burden of bancroftian filariasis by age-group and sex.
Estrmates: upper number = cases in millions; lower number (in brackets) = prevalence (»/o).
Age in years
Condition and sex
Population*
Microfilaraemia - Males
Microfilaraerma - Females
Lymphoedema - Males
Lymphoedema - Females
Hydrocoele - Males
*
0-4
5-14
15-44
45-59
60+
Total
551.89
918.36
1,932.49
432.02
285.10
1.44
(0.51)
4,119.86
5.75
(1.22)
24.54
(2.48)
6.15
(2.81)
2.99
(2.18)
1.21
(0.45)
40.86
(1-95)
5.69
(1-27)
18.22
(1-93)
4.55
(2.13)
2.75
(1.86)
32.41
(1.60)
0.05
(0.01)
0.28
(0.06)
2.84
(0.06)
1.39
(0.64)
0.79
(0.58)
0.08
(0.03)
5.36
(0.26)
0.66
(0-15)
3.61
(0.38)
1.18
(0.85)
1.65
(1-11)
0.06
(0.02)
7.81
(0.39)
1.82
(0.39)
15.62
(1.58)
5.65
(2.58)
3.64
(2.66)
26.79
(1.28)
Total population in regions where significant infection exists. Regions
as defined for the World Bank Global Burden of Disease Study.
TABLE 2b
Global burden of brugian filariasis by age-group and sex.
Estimates: upper number = cases in millions; lower number (in brackets) = prevalence (%).
Age in years
Condition and sex
0-4
5-14
15-44
45-59
60+
Total
Population*
340.19
578.03
1342.36
308.54
207.21
2776.35
Microfilaraemia - Males
0.203
(0.12)
0.899
(0.30)
4.05
(0.58)
0.882
(0.55)
0.482
(0-47)
6.515
(0.46)
0.197
(0.H)
0.552
(0.20)
2.27
(0.35)
0.462
(0.31)
0.348
(0.33)
3.84
(0.28)
Lymphoedema - Males
0.018
(0.01)
0.047
(0.015)
0.759
(O-H)
0.506
(0.32)
0.472
(0.46)
1.804
(0-13)
Lymphoedema - Females
0.008
(0.00001)
0.027
(0.01)
0.349
(0.05)
0.299
(0.20)
0.328
(0.31)
1.004
(0.07)
Microfilaraemia - Females
♦
Total population in regions where significant infection exists. Regions as defined for the World Bank Global Burden of Disease Study.
I
IL
TABLE 3
Filariasis control efforts in selected endemic countries
I
Estimate of
prevalence
(millions)
% under Active
Control Programme
Yearly operational
expenditure for
filariasis control
(US $)
Control **
strategy
China
1.58
100%
1,279,000
D
Egypt
0.35
10%
500,000
D, V
French Polynesia
0.02
90%
50,000
D
India
36
10%
1,000,000
D, V
Indonesia
N.A.
N.A.
N.A.
D
Malaysia
0.003
60%
500,000
D
Papua New Guinea
1.0
<1%
90,000
D
Philippines
1.02
32%
27,100
D
Sri Lanka
0.05
60%
300,000
D
Tanzania
1.5
0%
0
V
Thailand
0.62
30%
1,000,000
D
Country*
*
♦*
All data supplied by country representatives in attendance
D = DEC treatment regimen; V = Vector control programme
N.A. - Not available
REFERENCES
1.
WHO Expert Committee on Filariasis.
Fourth Report. Geneva, World Health
Organization 1984 (WHO Technical Report
Series 702), pp 1-112.
2.
Lymphatic filariasis: The disease and
its control. Geneva, World Health
Organization 1992 (WHO Technical Report
Series 821), pp 71.
3.
Hawking F. The distribution of human
filariasis throughout the world. Part III.
Africa. Tropical Diseases Bulletin
1977;74:649-679.
4.
Michael E & Bundy DAP. The global
burden of lymphatic filariasis. In The Burden
of Disease (eds. CJL Murray & AD Lopez).
Geneva, World Health Organization 1995 (in
press).
5.
Michael E, Bundy DAP & Grenfell
BT. Estimating the global prevalence of
lymphatic filariasis (manuscript in
preparation).
6.
Hui-Jun Z. Geographic distribution
and prevalence of lymphatic filariasis: update
in the Western Pacific region. Geneva, World
Health Organization 1991 (unpublished
document FIL/EC/91/WT.4).
7.
Pani SP, Balakrishnan N, Srividya A,
Bundy DAP & Grenfell BT. Clinical
epidemiology of bancroftian filariasis: effect
of age and gender. Transactions of the Royal
Society of Tropical Medicine and Hygiene
1991;85:260-264.
8.
Pani SP, Yuvaraj J, Vanamail P,
Dhanda V, Michael E, Grenfell, BT & Bundy
DAP. Episodic adenolymphangitis and
lymphoedema in patients with bancroftian
filariasis. Transactions of the Royal Society of
Tropical Medicine and Hygiene 1995;89: (in
press).
9.
World Bank World Development
Report 1993. Investing in health (World
development indicators). 1993; Oxford
University Press, New York, pp 1-329.
10.
Evans DB, Gelband H & Vlassoff C.
Social and economic factors and the control
of lymphatic filariasis: a review. Acta tropica
1993;53:1-26.
11.
Dreyer G, Ottesen EA, Galdino E,
Andrade L, Rocha A, Medeiros Z, Moura I,
Casimiro I, Beliz R, Coutinho A. Renal
abnormalities in microfilaremic patients with
bancroftian filariasis. American Journal of
Tropical Medicine and Hygiene 1992;46:745751.
12.
Witte MH, Jamal S, Williams WH,
Witte CL, Kumaraswami V, McNeil GC,
Case TC, Panicker TMR: Lymphatic
abnormalities in human filariasis as depicted
by lymphoangioscintigraphy, Archives of
Internal Medicine 1993;153;737-744.
13.
Freedman DO, Filho PJ, Besh S, Silva
M, Braga C, Maciel A: Lymphoscintigraphic
analysis of lymphatic abnormalities in
symptomatic and asymptomatic human
filariasis. Journal of Infectious Diseases
1994;170:927-933.
14.
Sun DJ. A great success in lymphatic
filariasis control in China. Chinese Journal of
Parasitology and Parasitic Diseases (in
press).
15.
Harb M, Faris R, Gad AM, Hafez
ON, Rawzy R, Buck AA. The resurgence of
lymphatic filariasis in the Nile Delta. Bulletin
ofthe World Health Organization 1993 ;71:4954.
16.
Perolat P, Guidi C, Riviere F, Roux J.
Filariose de Bancrofti Polynesie Franqaise.
Situation epidemiologique et perspectives
apres 30 ans de lutte. Bulletin de la Societe de
Pathologic exotique 1986;79:78
17.
Biswas H, Sharma SP, Das M, Gopala
Rao V, Yadava RL and Narasimham MWL.
Filariasis control in rural areas through
detection and treatment with
diethylcarbamazine. Journal ofCommunicable
Diseases 1989;21:272-281.
Partono F, Maizels RM, Pumomo.
18.
Towards a filariasis free community:
evaluation of filariasis control over an eleven
year period in Flores, Indonesia. Transactions
of the Royal Society of Tropical Medicine and
Hygiene 1989;83:821-826.
19.
Partono F, Pumomo, Soewarta A, Sri
Oemijati. Low dosage diethyl-carbamazine
administered by villagers for the control of
timorian filariasis. Transactions of the Royal
Society of Tropical Medicine and Hygiene
1984;78:370-372.
20.
Vector Borne Disease Control
Programme. Annual Report 1993. Kuala
Lumpur, Malaysia.
21.
(not available).
22.
Technical Service Manual,
Department of Health, The Philippines.
23.
Dissanaike AS. Filariasis in Ceylon
then (1961) and in Sri Lanka now (1990) 30 years on. Annals of Tropical Medicine and
Parasitology 1991;85:123-129.
23
1
24.
Minjas JN and Kihamia, CM.
"Bancroftian filariasis". In Mwaluko GMP,
Ki lam a WL, Mandara MP, Murru M and
Macpherson CNL (eds) Health and Disease in
Tanzania. Harper Collins Academic, 1991,
London, pp 158-176.
25.
Suvannadabba S. Current status of
filariasis in Thailand. Southeast Asian Journal
of Tropical Medicine and Public Health
1993;24:5-7.
26.
Ottesen EA. Efficacy of diethyl
carbamazine in eradicating infection with
lymphatic-dwelling filariae in humans.
Reviews of Infectious Diseases, 1985;7:341356.
27.
WHO Expert Committee on
Onchocerciasis. Geneva, World Health
Organization 1995 (WHO Technical Report
Series) (in press).
28.
Ottesen EA and Campbell WC.
Ivermectin in human medicine. Journal of
Antimicrobial Chemotherapy 1994;34.T95203.
29.
Chodakewitz JA. Ivermectin and
lymphatic filariasis: clinical update.
Parasitology Today 1995 (in press).
30.
Pani SP, Krishnamoorthy K, Prathiba
J and Rao RS. Diethylcarbamazine and
supportive measures for the treatment of
Brugian filariasis. The National Medical
Journal of India 1989;2:260-263.
31.
Dreyer G, Pires ML, Andrade L,
Lopes E, Medeiros Z, Tenorio J, Coutinho A,
Noroes J, Figueredo-Silva J. Tolerance of
diethylcarbamazine by microfilaraemic and
amicrofilaraemic individuals in an endemic
area of Bancroftian filariasis, Recife, Brazil.
Transactions of the Royal Society of Tropical
Medicine and Hygiene 1994;88:232-236.
32.
Laigret J, Fagneaux G, & Tura E.
Chimiotherapie de masse par la
diethylcarbamazine en doses espacees: effets
obtenus a Tahiti sur la microfilaremie a
Wuchereria bancrofti, var. pacifica. Bulletin
de TOrganisation mondiale de la Sante
1980;58:779-783.
33.
Mataika JU, Kimura E, Koroivueta J,
Kaisuva JN, Broun M, Tuivaga J, Bikai S,
Govind SR. Comparison of the efficacy of
diethylcarbamazine between 5 rounds of
annual single-dose treatment and an intensive
28-dose treatment spread over 2 years against
diumally subperiodic Wuchereria bancrofti in
Fiji. Fiji Medical Journal 1993;19:2-6.
24
34.
Kimura E, Penaia L & Spears GF.
The efficacy of annual single-dose treatment
with diethylcarbamazine citrate against
diumally subperiodic bancroftian filariasis in
Samoa. Bulletin of the World Health
Organization 1985;63:1097-1106.
35.
Panicker KN, Krishnamoorthy K,
Sabesan S, Prathiba J and Abidha.
Comparison of effects of mass annual and
biannual single dose therapy with diethyl
carbamazine for the control of Malayan
filariasis. Southeast Asian Journal of Tropical
Medicine and Public Health 1991 ;22-402-411.
36.
Cartel JL, Spiegel, Nguyen Ngnoc L,
Cardines R, Plichart R, Martin PM, Roux JF,
Moulia-Pelat JP. Compared efficacy of
repeated annual and semi-annual doses of
ivermectin and diethylcarbamazine for
prevention of Wuchereria bancrofti filariasis
in French Polynesia. Final evaluation.
Tropical Medicine and Parasitology1,
1992;43:91-94.
37.
Shenoy RK, Kumaraswami
V,
Rajan K, Thankom S and Jalajakumari. A
comparative study of the efficacy and
tolerability of single and split doses of
ivermectin and diethylcarbamazine in periodic
brugian filariasis. Annals of Tropical Medicine
and Parasitology 1993;87:459-467.
38.
Dreyer G, Coutinho A, Miranda D,
Noroes J, Rizzo JA, Galdino E, Rocha A,
Medeiros Z, Andrade LD, Santos A,
Figueredo-Silva J & Ottesen EA. Treatment
of bancroftian filariasis in Recife, Brazil:
Comparison of ivermectin and
diethylcarbamazine in a long-term (two-year)
study. The American Journal of Tropical
Medicine and Hygiene, 1994;50:339-348.
39.
Moulia-Pelat Y, Glaziou P, Nguyen
LN, Chanteau S, Plichart R, Beylier I, Martin
PMV, Cartel JP. Ivermectin 400 pg/kg: Long
term suppression of microfilariae in
bancroftian filariasis. Transactions of the
Royal Society of Tropical Medicine and
Hygiene 1994;88:107-109.
40.
Richards FO, Eberhard ML, Bryan
RT, McNeeley DF, Lammie PJ, McNeeley
MB, Bernard Y, Hightower AW, Spencer HC.
Comparison of high dose ivermectin and
diethylcarbamazine for activity against
bancroftian filariasis in Haiti. The American
Journal of Tropical Medicine and Hygiene
1991;44:3-10.
41.
Addiss DG, Eberhard ML, Lammie
PJ, McNeeley MB, Lee SH, McNeeley DF
and Spencer HC. Comparative efficacy of
clearing-dose and single high-dose ivermectin
and diethylcarbamazine against Wuchereria
bancrofti microfilaremia. The American
Journal of Tropical Medicine and Hygiene
1993;48:178-185.
42.
Kazura J, Greenberg J, Perry R, Weil
G, Day K and Alpers M. Comparison of
single dose diethylcarbamazine and ivermectin
for treatment of bancroftian filariasis in Papua
New Guinea. The American Journal of
Tropical Medicine and Hygiene 1993;49:804811.
43.
Gelband H. Diethylcarbamazine salt in
the control of lymphatic filariasis. The
American Journal of Tropical Medicine and
Hygiene 1994;50:655-662.
44.
Jingyuan L, Zi C, Xiaohang H and
Zhaoping T. Mass treatment of filariasis using
DEC-medicated salt. Journal of Tropical
Medicine and Hygiene 1992;95:132-135.
45.
Ottesen EA. Description, mechanisms
and control of post-treatment reactions in
human filariasis. Ciba Foundation Symposium
1987;127:265-283.
46.
Huijun Z, Piessens WF, Zhenghou T,
Wenfang C, Shihai W, Shizhi C, Yangming
Y, Laifeng L, Xiaorui C and Genbao G.
Efficacy of ivermectin for control of
microfilaremia recurring after treatment with
diethylcarbamazine. I. Clinical and
parasitologic observations. The American
Journal of Tropical Medicine and Hygiene
1991;45:168-174.
47.
Weil GJ, Lammie PJ, Richards FO
and Eberhard ML. Changes in circulating
parasite antigen levels after treatment of
bancroftian filariasis with diethylcarbamazine
and ivermectin. The Journal of Infectious
Diseases 1991;164:814-816.
48.
Dreyer G, Amaral F, Noroes J,
Medeiros Z, Addiss D. A new tool to assess
the adulticidal efficacy in vivo of antifilarial
drugs for bancroftian filariasis. Transactions
of the Royal Society of Tropical Medicine and
Hygiene (in press).
49.
Ismail MM, Jayasinghe KSA,
Premaratne UN, Weil GJ, Abeyewickreme W,
Rajaratnam HN, Rezvi Sheriff MH, Selvie
Perera C. Prolonged clearance of
microfilaraemia and antigenaemia in patients
with bancroftian filariasis after multiple high
doses of ivermectin or DEC (manuscript in
preparation).
so.
rDreyer G, Noroes J, Amaral F,
Adauto N, Medeiros Z, Coutinho A & Addiss
D. Direct assessment of the adulticidal
efficacy of single-dose ivermectin in
bancroftian filariasis. Transactions of the
Royal Society of Tropical Medicine and
Hygiene (in press).
51.
Olzewski, WL, Jamal S, Dworozynski
A, Swoboda E, Pani SP, Monokaran G,
Kumaraswami V and Biyla P. Bacteriological
studies of skin, tissue fluid and lymph in
filarial lymphoedema. Lymphology
1994;27(SuppI):345-348.
52.
Addiss DG, Eberhard ML, Lammie
PJ. ‘Filarial’ adenolymphangitis without
filarial infection [letter]. Lancet 1994:343:597.
53.
Ottesen EA. Infection and disease in
lymphatic filariasis: An immunological
perspective. Parasitology 1992, 164:S71-79.
54.
Jamal S. Lymphovenous anastomosis
in filarial
lymphedema. Lymphology
1981;14:64-68.
55.
Hougard JM, Mbentengam R,
Lochouam L, Escaffre H, Darriet F, Barbazan
P, Quillevere D. Campaign against Culex
quinquefasciatus using Bacillus sphaericus'.
Result of a pilot project in a large urban area
of equatorial Africa. Bulletin of the World
Health Organization 1993;71:367-375.
56.
Cheong WC and Yap HH. Bioassay
of Bacillus sphaericus (strain 1953) against
mosquitoes of public health importance in
Malaysia. Southeast Asian Journal of Tropical
Medicine and Public Health 1985;16:54-58.
57.
Maxwell CA, Curtis CF, Haji H,
Kisumku S, Thalib Al, Yahya SA. Control of
bancroftian filariasis by integrating therapy
with vector control using polystyrene beads in
wet pit latrines. Transactions of the Royal
Society of Tropical Medicine and Hygiene
1990;84:709-714.
58.
Rozendaal JA. Impregnated mosquito
nets and curtains for self-protection and
vector control. Tropical Diseases Bulletin
1989;86:1-41.
59.
Vasuki V, Rajavel AR. Betacyfluthrin, a synthetic pyrethroid for mosquito
control. Southeast Asian Journal of Tropical
Medicine and Public Health 1992;23:318-323.
60.
Abu Hassn A, Narayanan V.
Effectiveness of a soap repellent against
Mansonia mosquitoes in a fresh water swamp
forest in Northwestern Malaysia. Bulletin of
the Society for Vector Ecology 1992;17:83-84.
25
61.
Panicker KN, Jayasree M, &
Krishnamoorthy K. A cost benefit analysis of
fish culture strategy towards the control of
mansonioides in Shertallai, Kerala state.
Indian Journal of Medical Research
1992;95:157-160
62.
Day KP, Spark R, Gamer P, Raiko A,
Wenger JD, Weiss N, Mitchell GF, Alpers
MP and Kazura JW. Serological evaluation of
the macrofilaricidal effects of
diethylcarbamazine treatment in bancroftian
filariasis. American Society of Tropical
Medicine and Hygiene 1991;44:528-535.
63.
Chanteau S, Moulia-Pelat JP, Glaziou
P, Nguyen NL, Luquiaud P, Plichart C,
Martin PMV and Cartel JL. Og4C3
circulating antigen: A marker of infection and
adult worm burden in Wuchereria bancrofti
filariasis. The Journal of Infectious Diseases
1994;170:247-250.
64.
Ramzy RMR, Hafez ON, Gad AM,
Faris R, Harb M, Buck AA and Weil GJ.
Efficient assessment of filariasis endemicity
by screening for filarial antigenaemia in a
sentinel population. Transactions of the Royal
Society of Tropical Medicine and Hygiene
1994;88:41-44.
65.
Lizotte MR, Supali T, Partono F,
Williams SA. A PCR assay for the detection
of Brugia malayi in blood. The American
Journal of Tropical Medicine and Hygiene,
1994 (in press).
26
Chanteau S, Luquiaud P, Failloux A,
66.
Williams SA. PCR-based detection of
Wuchereria bancrofti larvae in pools of
mosquitoes. Transactions of the Royal Society
of Tropical Medicine and Hygiene 1994 (in
press).
67.
Plaisier AP, van Oortmarssen GJ,
Habbema JDF, Remme J & Alley ES.
ONCHOSIM: A model and computer
simulation program for the transmission and
control of onchocerciasis. Computer Models
and Programs in Biomedicine 1990;31:43-56.
68.
Anderson RM, & May RM. Infectious
Diseases of Humans: Dynamics and Control.
Oxford University Press, Oxford, 1991,
pp 757.
69.
Bundy DAP. The need for modelling
for epidemiology and control of lymphatic
filariasis. Geneva, World Health Organization
1991 (unpublished document
FIL/EC/91/WP.26).
70.
Grenfell BT & Michael E. Infection
and disease in lymphatic filariasis - an
epidemiologic approach. Parasitology
1992;104:881-91.
71.
CDC. Recommendations of the
International Task Force for Disease
Eradication. Morbidity and Mortality Weekly
Report 1993;42:1-38.
WHO/CTD/TDR
LYMPHATIC FILARIASIS INFECTION & DISEASE:
CONTROL STRATEGIES
UNIVERSITI SAINS MALAYSIA, PENANG,
MALAYSIA, 22-24 AUGUST 1994
LIST
O F
PARTICIPANTS
Dr David Addiss
Division of Parasitic Diseases
Centers for Disease Control and
Prevention (CDC)
Mailstop F-22, Bldg. 102
4770 Buford Highway, N.E.
Atlanta, GA 30341-3724
USA
Fax: 404-488-7761
Tel: 404-488-7770
Dr Sun De-Jian
Chief, Department of Epidemiology
Institute of Parasitic Diseases
Chinese Academy of Preventive
Medicine
207 Rui Jin Er Lu
Shanghai 200025
People’s Republic of China
Fax: 862-143-76-308
Tel: 862-143-32-670
Dr Norbert Becker
Wissenschaftlicher Direktor
Kommunale Aktionsgemeinschaft zur
Bekampfung der Schnakenplage e.V.
Ludwigshafen am Rhein (KABS)
Postfach 210780
D-67165 Waldsee
Germany
Fax: 49-062-36-418-622
Tel: 49-062-36-418-60
Dr Gerusa Dreyer
Centro de Pesquisas Aggeu Magalhaes
FIOCRUZ
Universidade Federal de Pernambuco
Ave Moraes Rego s/n
Cidade Universitaria
50730 Recife
Brazil
Fax: 55-81-271-2302/453-2448
Tel: 55-81-271-4000
Dr D.A.P. Bundy
Department of Zoology
University of Oxford
South Parks Road
Oxford 0X1 3PS
United Kingdom
Fax: 44-865-281-245
Tel: 44-865-281-246
Professor Adel Gad
Research and Training on Vectors
of Diseases
Ain Shams University
Faculty of Science Building
Abbassia
Cairo
Egypt
Fax: 202-283-9622
f
Dr Jeffrey Chodakewitz
Director
Clinical Research (Infectious Diseases)
Merck Research Laboratories
West Point, PA 19486
USA
Fax: 1-215-834-7555
Tel: 1-215-834-2454
:■
l
I
f
t
I
...
«
-
>
0^
£■
V'
27
Dr Tore Godal
Director
Special Programme for Research and
Training in Tropical Diseases
World Health Organization
CH-1211 Geneva 27
Switzerland
Fax: 41-22-791-4854
Tel: 41-22-791-3802
E-mail: godal@who.ch
@umc@HQVAX 1
Professor Yap Han Heng
Vector Control Research Unit
Universiti Sains Malaysia
11800 Pulau Pinang
Malaysia
Fax: 604-657-7200
Tel: 604-654-4776
Dr Pushpa Herath
Malaria Control
Division of Control of Tropical
Diseases
World Health Organization
CH-1211 Geneva 27
Switzerland
Fax: 41-22-791-0746
Tel: 41-22-791-3746
E-mail: herath@who.ch
@umc@HQVAX1
Dr Leda M. Hernandez
Communicable Disease Control Service
Department of Health
San Lazaro Compound
Sta Cruz
Manila
The Philippines
Tel: 632-711-6804/6699
Professor M. Mahroof Ismail
Department of Parasitology
Faculty of Medicine
University of Colombo
Kynsey Road
Colombo 8
Sri Lanka
Fax: 94-1-691-581
Tel: 94-1-695-300
28
Dr T. Junghanss
Senior Registrar
Medical Department
Swiss Tropical Institute
Socinstrasse 57
CH-4002 Basel
Switzerland
Fax: 41-61-271-8654
Tel: 41-61-284-8111
Dr Mak Joon Wah
Filariasis Research Division
Institute for Medical Research
Jalan Pahang
50588 Kuala Lumpur
Malaysia
Fax: 603-292-0675
Tel: 603-298-6033
Professor J.W. Kazura
Case Western Reserve University
School of Medicine, W137
Division of Geographic Medicine
2109 Adelbert Road
Cleveland, OH 44106-4983
USA
Fax: 1-216-368-4825
Tel: 1-216-368-4818
Professor W.L. Kilama
Director General
National Institute for Medical
Research
P.O. Box 9653
Dar es Salaam
Tanzania
Fax: (255) 51-30660
Tel: (255) 51-30770
Dr A. Bruce Knudsen
Filariasis Control
Division of Control of Tropical
Diseases
World Health Organization
CH-1211 Geneva 27
Switzerland
Fax: 41-22-791-0746
Tel: 41-22-791-3830
E-mail: knudsen@who.ch
@umc@HQVAX 1
Dr V. Kumaraswami
Assistant Director
Tuberculosis Research Centre
Spur Tank Road
Chetput
Madras 600 031
India
Fax: 91-44-826-2137
Tel: 91-44-826-5425
Professor W.W. Macdonald
10 Headland Close
West Kirby
Wirral .
Merseyside, L48 3JP
United Kingdom
Tel: 44-151-625-7857
Dr Dan Meyrowitsch
Danish Bilharziasis Laboratory (DBL)
Jaegersborg A lie 1 D
2920 Charlottenlund
Denmark
Fax: 45-31-626-121
Tel: 45-31-626-168
Dr Edwin Michael
Department of Zoology
University of Cambridge
Downing Street
Cambridge CB2 3EJ
United Kingdom
Fax: 44-223-336-676
Tel: 44-223-334-430
E-mail: edwin@zoo.cam.ac.uk
Professor David H. Molyneux
Director
Tropical Health Sciences
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool L3 5QA
United Kingdom
Fax: 44-51-707-0155
Tel: 44-51-708-9393
Dr J.-P. Moulia-Pelat
Head, Clinical and Epidemiological
Research Department
Institut Territorial de Recherches
Medicales Louis Malarde
B.P. 30
Papeete, Tahiti
French Polynesia
Fax: 689-431-590
Tel: 689-416-464
Professor V. Navaratnam
Director
Drug Research Centre
Universiti Sains Malaysia
11800 USM, Pulau Pinang
Malaysia
Fax: 604-657-7957
Tel: 604-657-7888
Dr Eric A. Ottesen
Filariasis Control
Division of Control of Tropical
Diseases
World Health Organization
CH-1211 Geneva 27
Switzerland
Tel: 41-22-791-3225
Fax: 41-22-791-0746
E-mail: ottesen@who.ch
@umc@HQVAXl
!•
I
Dr S.P. Pani
Deputy Director
Vector Control Research Centre
Medical Complex
Indira Nagar
Pondicherry 605 006
India
Fax: 91-413-334-22
Tel: 91-413-373-96
Dr K.N. Panicker
Deputy Director
Vector Control Research Centre
Medical Complex
Indira Nagar
Pondicherry 605 006
India
Fax: 91-413-334-22
Tel: 91-413-234-373-96
I
I
Dr B.P. Patnaik
National Malaria Eradication
Programme
22 Sham Nath Marg
P.O. Box 8616
New Delhi 110054
India
Fax: 91-11-301-7924
Tel: 91-11-301-251-7745
29
>
Mrs Fiona Perreard
Special Programme for Research and
Training in Tropical Diseases
World Health Organization
CH-1211 Geneva 27
Switzerland
Fax: 41-22-791-4854
Tel: 41-22-791-3233
Dr C.P. Ramachandran
Chief
Filariasis Control
Division of Control of Tropical
Diseases
World Health Organization
CH-1211 Geneva^27
Switzerland
Fax: 41-22-791-4854
Tel: 41-22-791-3877
E-mail: ramachandran@who.ch
@umc@HQVAXl
Datin Dr (Mrs) S. Selvaraju
Deputy Director
Vector-Bome Disease Control
Programme
Ministry of Health
Kuala Lumpur 50590
Malaysia
Fax: 603-293-1590
Tel: 603-298-9222
Dr H.S. Sidhu
School of Biological Sciences
Universiti Sains Malaysia
11800 Pulau Pinang
Malaysia
Fax: 604-657-7200
Tel: 604-654-4776
Dr Paul E. Simonsen
Danish Bilharziasis Laboratory
(DBL)
Jaegersborg A lie 1 D
2920 Charlottenlund
Denmark
Fax: 45-31-626-121
Tel: 45-31-626-168
30
Dr S. Suvannadabba
Director of Filariasis Division
Department of Communicable Disease
Control
Ministry of Public Health
Devaves Palace
275 Samsen Road
Bangkok 10200
Thailand
Fax: 668-466-0140
Dr Paul Turner
Anton Breinl Centre for
Tropical Health & Medicine
James Cook University
of North Queensland
Townsville
Queensland 4811
Australia
Fax: 61-77-71-5032
Tel: 61-77-21-2281
Professor Walter H. Wemsdorfer
Cranachstrasse 8
Vienna
Austria 1130
Fax/Tel: 43-1-804-0764
Dr G. Wemsdorfer
Cranachstrasse 8
Vienna
Austria 1130
Fax/Tel: 43-1-804-0764
Dr Widarso
Chief
rub-Directorate of Filarial Control
Programme
Directorate of Vector Bome Diseases
Control
Ministry of Health
JI. H.R. Rasuna Said Kav. X 5
N° 4: 04 s/d 09
Jakarta
Indonesia
Fax: 62-21-420-7807
Dr Steven A. Williams
Department of Biological Sciences
Clark Science Center
Smith College
Northampton, MA 01063
USA
Fax: 1-413-585-3786
Tel: 1-413-585-3826
S’
REVISED STRATEGY FOR FILARIASIS CONTROL
IN INDIA
t.
-2^0
-r
A PILOT PROJECT
i.
■
NATIONAL MALARIA ERADICATION PROGRAMME
22 SHAMNATH MARG, DELHI - 110054
CD
0
0
Q
o o o fems
X
REVISED STRATEGY FOR FILARIASIS CONTROL IN IHDIA - A P!LO I PROJECT
IN I RODUCJ ION
Lymphatic Lilaiiasis caused by II uchcreria bancro/ti (baucioflian ziariasis) is a
wide spread public health problem in India and 1996 estimates indicate onr ahcul 428
million population is living in filariasis endemic areas spread oxer IS s:
>■ and ?:niim
i
I er r it or lies Of this. 1 13 millicm premia (ion is living in urban areas \\itlnn ’.’c-'e !
an estimated
i
'tales.
28 01 million population is harbouring the microfilaria and ’ us serve as
reservoir ol infection in the community Fuithen an estimated population '•
?:'our 21 23
million is sullcring from (he disease with peiceptible disease manifestations •
•esc areas
These estimates, though - include tdaiiasis caused bv Rrn^ia imi/uyi als>\ •
niter
.
—
-
*
accc'unts only for less than Oo per .cent of'the total estimates and is resrure-.’
' rural
areas in a lew pockets in coastal west Kerala and six ('(her stales Banc’rm’
transmitted through ( ul'e.x qiiimiiicfusciutus mosquitoes and largelx ex''-:
■a'C'-.n .nal
periodicilx except in Nicobar group of islands where the diurnal t\pe of
' ujcnnn :s
transmitted through mosquitoes belonging to Aedcs (Finlava) niveus grrmp
I ILARIASIS COX FROL IN INDIA
National Filaria Control Programme (NFCP) was initiated in |95;
objectives
(I)
(a)
(iii)
‘ollrwine
to delimit the problem
to undertake large scale control programme in endemic a-eas. .and
to (rain the professional and ancilliarv personnel require.: :?r the
programme
Initially (he programme was launched with the following strategy
mass DEC therapy at a dosage of4 mg/kg body weight Dr 5 d.avs
(luce rounds of'indoor dieldrin residual spraying in ruiai .’■eas. and
weekly antilarval operations in urban areas
I
REVISED STRATEGY FOR EtLARlASIS CONTROL IN INDIA - A P1UJTNWJECI
INTRODUCTION
Lymphatic Filariasis caused by Wuchereria bancrofti (bancrollian lilartasts) rs a
indicate that about 428
wide spread public health problem in india and 1996 estimates
million population is living
in filariasis endemic areas spread over 18 states and Union
Territorries Of this. 113 million population is living
in urban areas. Within these 18 states,
I
an estimated
28.01 million population is harbouring
the microfilaria and thus serve as
reservoir of infection in the community. Further, an estimated population of about 21.23
million is sullernig from the disease wid, pereepiible disease manileslations ir, these areas
These estimates, though include filariasis caused by Krugia
also, but the latter
of the total estimates and is restricted to rural
accounts only for less than 0 6 per cent
areas in a lew pockets in
coastal west Kerala and six other states
transmitted through Cule.'c quinqtief'ii.sciiititu mosquitoes
Bancrollian filariasis is
and laruelv exhibits nocturnal
periodicity‘except in Ni^bar group of islands where the diurnal type of
is
transmitted through mosquitoes belonging to Aedes (Hnlaya) nireus group
i
FILAIUAS1S CONTROL IN INDIA
National
Filaria Control Programme (NFCP)
was initiated in 1955. with Following
objectives:
(I)
to delimit the problem
(ii)
(iii)
,
...... ...
programme
Initially the programme was
launched with the following strategy:
„mss DEC .terap, »t a dosage ofd m,ftg bode wdglu f« 5 d»J
,l„ee rounds of indoor dieldrin residual spraying »> mral a.eas,
weekly antilarval operations in urban areas
The mass drug therapy for 5 consecutive days was withdrawn after initial
experiences because of mild side effects
ot the therapy and poor compliance. The
insecticidal spraying in rural areas had to be stopoed due to development of resistance
among vectors.
The strategy was then modified in
pursuance of the recommendations of Second
1CMR Assessment Committee and the revised
strategy included chemotherapy on
selective basis with a 12 day regimen of DEC @ 6 mg'.kg body weight per
cases and weekly antiiarval operations in endemic urban areas. The
day for positive
programme was
withdrawn from rural areas for operational and technical constraints as mentioned above.
However. a lew veers beck i„ 1994-95. selec.ive DEC rreermen. ,hrousl, PHC system has
•Use been introduced in rural areas. For delimitation of the problem. Filaria Su^y Units,
for diagnosis and treatment. Filaria Clinics and for antiia^al operations. Filaria Control
Units were established. At present, 206 NFCP Control Units, 199 Filaria Clinics and 27
Survey Units are operating in endemic urban areas under NFCP Though at present only
about 1 I per cent of the total population living in filaria endemic areas is provided
protection through NFCP, there has been a marked reduction in microfilaria rates in about
88 per cent of the towns covered uncfer NFCP control operations for more than five years.
Further. 69 per cent of these towns have also shown about 69 per cent decline in disease
rates.
A
Dishict(s)
Population
(1996 estimates)
1. Andhra Pradesh
East Godavari
Srikakulam
5.03 million
2 55 million
2 Bihar
Darbhanua
' 2 57 million
Si wan
2 SO million
I
3. Kerala
Alappuzha
Kozhikode
2 83 million
2 I () million
4. Orissa
Puri
Khurda
3 38 million
I 07 million
North Arcot
5 30 million
South Arcot*
4 99 million
0 Uttar Piadcsh
(.iorakhpur
Varanasi
I 45 million
5 43 million
7 West Bengal
Purulia
2 3 I milium
5 Tamil Nadu
.1
-12 29 million
* already observed Eilaria dav on 5.8 90 proposed lor momloiing
and continuance of revised strategy
\
Stiateg>
2.1.
I nrucl /\oc 2roiip
All md.udm.ls belommm lo all aucs exuep! mlanLs (cluid.cn below
the age of I
yeai & piemiani women) will be provided single dose llierapx
2.2.
Drug regimen
<
I
DEX' at the dosage ol
*
0 mg/kg body weight will be administered to all the
individuals withm the target group. As it is not possible to.calculate individual dose
on
body weight on the snot dm mg a mass therapy campaign, lulluwmg age based average
dose schedule will be adopted .
DIX" dose
No. of tablets
(50 mg)’
o
(100 mg)
I 7 \eais
300 mg
12 - I 7 yeais
0 - I I years
225 mg
I 50 mg
d 5
2-5 years
75 mg
. I 5
I year
0.06
30 f ng
0 00
0.33
2.3
Modalities ol Drug administration
2.3.1.
Observance of I II ARIA DA^
2.2’5
I 5
Ad Klennfiecl cline vmII be observed as FkL.\RI.\ DAY for adminisiralion of mass
drug therapy
I cntativcly. it is pioposcd to be observed
filaria day. all villages and schools
111 77/ 11'cck of iNoi'cniber. On the
etc. will be visited by identified workers to administer
DEC therapy to all individuals except children below the age of I year and pregnant
women.
:■
REV ISED S 11<A f EG^ FOR HLARfASIS CON I ROL
Studies carried out in various parts ot the World including India have indicated
that a single day dose schedule of DEC can effectively reduce microfilaria and disease
prevalence significantly if followed for either about 5 to 10 veais or initially for 2 years
supplemented by use of DEC medicated salt in following years This strategy has helped
Countries like lahiti and Fiji where single dose yearly DEC regimen in 4 oi 5 years
administration, resulted in decrease .in microfilaria prevalence (if 57 per cent and 86 pet
cent respectively, and a decrease in nucrolilarial density of 78 per cent and 97 per cent
respectively In India also, with 2 single dose administration of DEC in Brugian lilaitasis in
Kerala, a deci ease in microlilarial prevalence by 75 per cent and micro filarial density by 8 I
per cent could be achieved
|
i
I he global recent advances in filariasis research and control have been discussed at
length in Wl 10/C I D/1 DR Consultative Meeting held* at Unixersiti Sains Malaysia (22-24
;
August 1994) and t lie. one of the recommendations of the meeting nie.ntions
'Mass-distribution ' programmes should completely replace those based on a
'sclective-treiitnient’ strategy (Le. detection of ntieroJUajeojnics wlio are then treated
'selectively').
Various aspects of filariasis control in Indian context have been discussed, in a
Workshop on “ Revised Strategy for the Control of Lymphatic Filariasis In India" held at
Delhi (4-5 January 1996). The experts from 1CM1L, NMEP. NICD and some of the
endemic States including programme managers participated in the workshop
The
w orkshop recommended initiation of a revised NFCP strategy on pilot scale covering
endemic states and districts from 1996 and extension to all the endemic areas in the
I
country in phases by IW8 Hie
will be an additional input on
workshop tmther recommended that lhe revised strategy
lhe ex.stmg strategy to make il^hnically more precise and
cost elfective so as to achieve the desired msulls
The experiences clearly indicate a
technical and operational advantage in
single dose mass DEC therapy over conventional
adopting
12 days selective therapy.
rgargSAL FOR ADOn-INC REVISFU STARTE,;V
,
H view of the recomn.e„dalions ,rade », support of revised single day DEC mass
as a supple,™
cx,st„,„ Nm, sl,a|c„?. .,
L1
it to other areas based
„„ a pi.
wi,l, a view
extend
(he results of the pilot scale implementation
ibe revised strategy is. proposed to be implemented imdallv
for 5 vears in
idem it led areas.
methodology
L
Selection of Ai ea
Revised strategy will be itnplemented’m identdied ateas for live
option of continuing the strategy based on
years with an
lhe results of the pilot study. The study would
cover 42.29 ntilhon popmation (1995 estimates) in (3 highly endemic districts in 7 states
so that by the end of live years impact in quantitative terms can be evaluated.
F
•st
Vector Control
Existing level ol vector control operations through l ilaiia Contiol Units in uiban
areasol these distiicls will continue
Prcoaratorv Actixitics lor revised strategy
1.
Preparation of detailed plan of action at the district level
Prclnninarv prcpaiaiorv work has been done by the rdentilicd districts
The
onen’.ation ol Staic/dislricl level ollicers and finalization of microplans will be done in
September 1997
An ollicer from Directorate NMEP and a stale level ollicer will visit
the district lor progress monitoring during second/lhird week of October
I he action
plans .-.ill include idcnlilication ol mliastnicturc and the operative areas etc II is proposed
*
,
•
•
I*-’ uixoiVe NGOs. School teachers and-par Ocularly workers .ol Keyenue-depai iment like
t
Gram Scvaks etc- I his in\olvement. of other sectors and community
is proposed to be
achieved bv involving District Magistrates/ Collectors and Dixisional Comniisioners etc A
•• t.oie group, und.cr the yliairmansJiip of District-Magistrate would- be constituted with
C MO/Civil Surgeon, l ilaria ( ontrol Ollicer. DMO and other district level ollicers from
health and related departments as the members to oversee the observence of l ilaria Day
2
Procurement and supply of drugrf>
Antililaiia drugs are proposed to be supplied by Directorate NMEP directly to the
districts under intimation to Slate Programme Ollicerso as to ensure timely availability
»■ •
4
3.
s:
Infoi-inn(ion bjInciHiou ( <’iiiiiiiinic;Hi()ii
An intensive
campaign s|la|| |)e
lmm
|5 od()|)CI
IW)
with
be;
following major objecti\es
SUj
to educate public about the revised lilaiia control strategy, advantages of
SCI
single dose mass Iberapv. importance of
community inxolvemejit in such campaimis.
me
appeal to idcntilx xolnntccrs liom among (he community to help the
programme in mass
drug administration, appeal to co -operate by accepting mass therapy etc
5..
to oiicnt the opinion Icadcis
\vi
to orient the medical liatcrnitv in the area
6.
All probable approaches will be made use of wilh involvement of District media
I . ••
and publicity units Since it will be the first
attempt in limned aieas. state level icsouices
in
shall also be mobilized lor these purposes
4.
Orientation and (iainin<>
al
I he inliastiucluie identified for ding delixerv on l ilaiia dav will be trained bv last
gi
week of (9clober'97/liist week of No\ embci '^7 bv the distiicl and block lex cl medical and
health olliceis Die NM1-.P will also extend its seiviccs whcieevcr needed
Logistics
b5.1.
Drugs
st
lhenigh the main drug for mass therapy remains DEC. it is a well known fact that
admiinislialion of DEC may cause mild side effects in microlilarcamics particularly with
a:
high densities because ol release of antigens as a consequence to thcdcalh of microfilaria.
Il is Ihcrclbic suggested that availability withi some suppoitixe medicines like antipyretics
a'
and aiiliallcrgil’s may be ensured in these areas
5.2.
Vehicles
I
It is proposed to utilize vehicles available under NMLP and NI C'P and primary
th
heal Hi caic sei \ ices loi
picpaialory activities
lor l ilaiia day activities including
supervision, vehicles from other departiuents/district pool shall also be obtained along with
of
seiviccs ol other ollicials through District Magistrate POL piovisions arc pioposed Io be
is.
met out of NMI .P and NfCP budects bv the respective stales
I
ss
5.3.
Slalionaiy and other miscellaneous requirements will be met out of icgular funds
with the State7 District level
6.
la
?s
Monitoring and Snpen ision
I• ilai in ( out i ol ()I1 icci xxill be pumaiilv icsponsiblc C’f planning, moniloiing.
implementation and simcixision of the mass (hug .fhciapx undei the supci xision and
guidance ol ( M()/( i\il Smgcon State piogiammc otlicci shall re diiccth icsponsibfc for
-all activities connected xxith the implementation ol ievised sliateiiv I le w ill be piovided
st
id
guidance and assistance by the lespcctive Regional Directois and Diiccloiatc of NMLP
7.
Evaluation
Evaluation ol implementation oltrevised filaria control stra:egv shall be earned out
by Dircctoiate ol Health Services and Regional Olliccs for I Icahn and I'W of icspective
states along with NIC J) hianciics mentioned above Diicctoialc Wll’P will be the nodal
at
.h
a
:s
agency and shall pi ox ide standard evaluation parameters and formats hr ex aluating
agencies
In addition to concurrent evaluation, independent assessment teams shall be
'onslituted foi annual appiaisal liom thiid year onwaids
r
s.
< nlcndcr of Ac(i\ j(ics
a
Orientation of State/district
level officers by NMEP
by I si October ‘97
b
Dexeiopnicm & finalisation
of'niicroplans by districts
by 12th October '97
c
Identification of manpower/
infrastructure & orientation
by 18th October ‘97
ci
Development & replication of
IE( material
campaign
by I Stli October ‘97
c
Launcn ol ILO campaign
f
I Rev’ew ol progress bv
State .'cvel (feedback to NMEP)
g
II Review of progress
li
Logistics arrangements
Stocking of druus at
by 18th October '97
b\ 25th October '97
by Sth November '97
by l?th November '97
gtassroot level, monitorinu etc
i.
- Baseline data collection by
sun ey units
- Report to NMEP
-
Family enumeration
J
III Review of promess
k
I-liana Dav
I
Mopping up day
m
Report compilation and
submission to NMEP
by 15tii November l97
by 21 st November ’97
by 2 J st November ‘97
by 23rd November '97
28lh November '97
bill December ’97
'■ 21st December'97
A system of weekly progress monitoring upto 20th November ‘97
and Daily monitoring thereafter has
to be adopted for successful implementation.
I
i!
12/5*
iH^eai^UpdWr
TRENDS in Parasitology Vol.17 No. 10 October 2001
457
I Research News
Towards elimination of lymphatic filariasis in India
Pradeep K. Das, Kapa D. Ramaiah, Daniel J. Augustin and Ashok Kumar
The global initiatives to eliminate lymphatic
filariasis as a public health problem by the
year 2020 have generated a great deal of
a
debate in India, the largest endemic
country. This has led to a shift in the focus
(NFCP) in 1995*, and (2) eliminate an
age-old scourge. The conducive new
treatment strategies and the global
initiatives prompted India to begin a
campaign towards the elimination of LF.
from control to elimination of the disease.
Although the campaign to eliminate
filariasis has begun, much more needs to be
done. Several recent research studies have
provided an insight into various operational
issues and prospects of elimination of
lymphatic filariasis. In this article, the
current scenario, recent research results,
logistics and the prospects of eliminating
lymphatic filariasis in India will be
discussed.
I
I
»
Reassessment of prevalence of infection
To date, the LF burden estimates have
considered only microfilaria (Mf) carriers
and cases of chronic disease. However, the
immunochromatographic (ICT) card test"
and the ultrasound image of adult worms3
indicated infection in a considerable
proportion of the amicrofilaraemic and
asymptomatic endemic population.
Studies in Egypt9 and India10 revealed
that 17% of the endemic normals exhibit
blood antigenemia, an indication of adult
worm presence11. These results imply that
-68 million of the 400 million endemic
normal population in India might also be
infected with adult worms, in addition to
the 48.11 million people with an apparent
infection2. Thus, the size of the infected
population could be as high as
-116 million or 26% of the endemic
population. Therefore, mass treatment to
eliminate LF (Ref. 5) will benefit a large
proportion of the population because
amicrofilaraemic people with adult worms
also display dilated lymphatic vessels, a
symptom of LF (Ref. 8).
annually by the health personnel from all
634 Primary Health Centres (PHCs) to
26 million people living in 17 000 villages.
Evaluation of the programme from a
sample of three urban areas and 50 rural
villages across three districts revealed that
the PHC network distributed DEC in 98%
of the villages and to 75% of the rural
population12 (Table 1). The drug distribution
was found to be less effective in urban
areas12 (Table 1), where the personnel from
the urban health services implemented the
programme. Nevertheless, the Tamil Nadu
programme has provided some insights12
into the prospects of country-wide DEC
distribution including: (1) that the
distribution of DEC to the entire rural
population is possible through the PHC
network: (2) an annual single-dose of DEC
is acceptable to people; (3) specific
socioeconomic factors, manpower shortage
and the lack of an effective Information,
Education and Communication (IEC)
campaign regarding the programme
restrict drug distribution (Table 2); and
(4) behavioural and drug-related factors
(Table 2), and poorly perceived benefits in
the population as a result of a lack of an
apparent and immediate effect of
treatment limit the treatment compliance
to much below 80%, which is viewed as an
optimum level. There are plans to extend
the elimination programme to 100
districts over the next five years. Such
efforts are being complemented with the
introduction of albendazole, which yields
‘beyond-filariasis benefits’ including
enhanced nutritional benefits and effects
on intestinal helminth infections and other
parasites13. Results from a pilot study
involved in distributing albendazole and
DEC to seven districts in two states will
soon indicate the acceptability and impact
of the two-drug regimen in treated
communities. These results will assist in
extending the treatment regimen to other
districts.
Lymphatic filariasis (LF) remains a
significant health problem in India.
Approximately 45% of India’s one billion
population live in known endemic areas1
and 48 million are infected2, accounting
for 40% of the global LF burden. Although
the disease severely undermines the
socioeconomic progress of the affected
communities3, until recently, the control of
LF, let alone its elimination, has received
little attention in India. This might be due
to a lack of simple, cost-effective control
tools and little understanding of the social
and economic consequences of the disease.
More than financial constraints, the
inherent operational problems associated
with various control strategies, such as
Recent initiatives
vector control, multi-dose mass treatment, In the past five years, several steps have
selective chemotherapy and
been initiated in India to move from control
diethylcarbamazine (DEC)-fortified salt,
to elimination of LF. The most important of
frustrated the efforts of programme
. these steps is the introduction of annual
managers. Although these strategies are
single-dose mass treatment5 with the
effective in specific situations, their wider
traditional drug DEC, in 11 districts with a
application is not easy. Nevertheless,
population of 32 million across six states.
recent developments such as the
The logistics, feasibility and effectiveness
generation of evidence for immense
of the strategy are being studied by the
economic and social suffering3, the costNFCP, and the strategy is likely to be
effective annual single-dose treatment
expanded in a phased manner. The
strategies4-5 and the multi-sectoral
southern state ofTamil Nadu launched a
initiatives6 have instilled hope in all
fully pledged LF elimination programme in
concerned. These developments are of
1996 in all 12 endemic districts. Under this
great importance to India and provide an
programme, DEC is being distributed
Research
opportunity to: (1) protect the entire
Preparations
for the LF elimination
‘Sharma, R.S. et al., eds (1995) National Filaria
endemic population, which includes a
campaign are well supported by several
Control Programme, India. Operational Manual. ’
hitherto unprotected 89% reported by the * The Directorate, National Malaria Eradication
new research initiatives. Socioeconomic
National Filaria Control Programme
Programme, Delhi, India 110054.
studies showed that the annual economic
http://parasites.tr6nds.com
1471-4922/01/S-see front matter ©2001 Elsevier Science Ltd. All rights reserved. Pll: 31471-4922(01)02056-6
|ffegearchUpdata
458
TRENDS in Parasitology Vol.17 No.10 October 2001
Table 1. Results of evaluation of annual single dose DEC mass treatment in Tamil Nadu
state in India0
Rural areas
Urban areas
Number of communities sampled
50
3
Number of households sampled
396
300
Number of people in sampled households
4328
1554
Percentage of households that received DEC
80.4(801/996)
57.0(171/300)
Percentage of people who received DEC
75.3(3713/4928)
53.1 (825/1554)
i Percentage of people who consumed DEC
59.3 (2924/4928)
35.2(547/1554)
solutions include the substitution of the
currently used 50-mg tablet formulation
with 100-mg, 200-mg or 300-mg tablets to
minimize the number of tablets per
person, distribution of the drug at
appropriate times and mobilization of
additional manpower and IEC back-up to
the programme12.
Country-wide elimination
An estimated 450 million people living in
i Percentage of people who received but failed to consume DEC 21.2 (789/3713)
33.7 (278/825)
257 districts across 18 states and Union
^Abbreviation: DEC, diethylcarbamazine.
territories are at risk from infection.
However, three relatively less-developed
Table 2. Important reasons for people not receiving or complying with DEC treatment0 6
states (Uttar Pradesh. Bihar and Andhra
Pradesh) alone account for 52% of the
' Reasons for limiting distribution
Reasons for limiting compliance
endemic population and 62% of the infected
I Incomplete distribution
Poor awareness of the benefits of taking DEC
population (data provided by NFCP).
; Temporary migration
Concerted efforts are needed to introduce
Side-effects and adverse reactions
the programme to these states. A nationwide
; Travel
Too many tablets
elimination programme requires the
I Inadequate publicity for the programme
Misplaced drug
distribution of DEC to ~82 million
i Shortage of time or personnel
Forgot to take drug
households in 300 000 villages and
1 Inappropriate distribution time
Lacked confidence in drug distributor
1450 urban agglomerations. At the rate of
' Exclusion of some eligible people (e.g. elderly
Feeling healthy and not in need of drug
three drug distributors per village (mean
people, lactating mothers and some children)
population size of 1500), the programme
JAboreviation: DEC, diethylcarbamazine.
needs a million drug distributors. The PHC
“Data obtained from Ref. 12
network and the urban health services can
only provide one drug distributor per
loss caused by LF is close to a billion
1000 people, which is only half of the
The results from these studies provide
US dollars3, and that there is tremendous
some clues to the prospects of LF
requirement of two drug distributors per
hardship in adults and children1’15. These elimination (Box 1). The epidemiology of
1000 people. Therefore, the support of
data highlighted the significant public
LF has been modelled using a simulation
village-level government staff and volunteers
health importance of LF and low
is crucial for the success of the programme.
programme. LYMFASIM(Ref. 19). The
cost-benefit ratio of the elimination
user-friendly model has predicted the
Distribution of DEC at the dose of 6 mg kg"1
programme3. Prevalence and distribution
per person requires 2500 of 100-mg tablets,
effects of vector control satisfactorily and
data provided by the NFCP are available
is being further developed to facilitate
or 5000 of 50-mg tablets per 1000 people. For
for at least some urban areas16, but are
the entire endemic population, ~1.1 billion of
predictions on the effect of mass
very scanty for the rural areas. A
treatment-based control and elimination
100-mg tablets or 2.2 billion of 50-mg tablets
questionnaire has been developed for the
programmes.
are required. The current drug production
rural areas to assess this problem at
To develop an effective and sustainable capacity is approximately a third of the total
village level through well-informed
drug delivery mechanism, a communityrequirement and therefore drug production
community members17. A preliminary
directed treatment approach (in which
needs scaling up with assured quality. The
filariasis map of India with district level
communities alone decide the timing and
per capita cost of the annual DEC mass
endemicity has been prepared and
duration of drug distribution), the
treatment programme has been estimated
recently published16. This map highlights
mainstay of onchocerciasis control in
at Rs 1.32 ($US 0.028)2,1. This cost might
the Gangetic plain in northern-central
Africa, was tested in rural communities of
rise to Rs 2.00 ($US 0.043) because
India and the coastal belt as the hard core
Tamil Nadu and was found to be less
programme managers and researchers
endemic foci: 55% of the 466 surveyed
believe that to introduce and sustain an
acceptable. The health services were able
districts are endemic and 27% of these
to distribute DEC to 74% of the population intense IEC campaign, a higher financial
districts are at a relatively high
and the community leaders distributed
input is required. In addition, the health
endemicity level16 with a >10%
DEC to only 68% of the population.
workers and other drug distributors might
microfilaraemia prevalence rate.
have to be paid incentives to enlist their full
Qualitative data strongly indicated the
Following clinical trials on the efficacy
support to the programme. At the per capita
people’s preference for drug distribution
of the single-dose treatment with DEC or
through the health services rather than
cost of Rs. 2.00 ($US 0.043), a country-wide
ivermectin alone4-5 or in combination5,
programme could amount to Rs 900 million
through community leaders20. Possible
community-based studies have been
solutions to well-recognized operational
(SUS 19 million). The experience in
launched to evaluate the impact of repeated problems such as the poor treatment
. Tamil Nadu demonstrated that it is possible
annual treatment on mirofilaraemia
for programme managers to convince the
compliance rate (35%) in urban areas are
prevalence and transmission18.
central and state governments to bear the
being studied and implemented. These
I
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••• L
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Research Update
TRENDS in Parasitology Vol. 17 No. 10 October 2001
459
Box 1. Impact of repeated annual diethylcarbamazine mass treatment
The principal strategy planned to eliminate
(from 0.66 to 0.07). The biting-mosquito
lymphatic filariasis (LF) is to interrupt
The application of antigenemia detection
population based mean monthly
tests in communities might throw light on
transmission of infection for four to six
transmission potential (MTP) fell by 93%
years, which is equivalent to the fecundic
life-span of the parasite3-6. Clinical trialsc-d
parasite dynamics in humans and the
and the resting-mosquito population
prospects of eliminating LF using five or
based transmission intensity index (Til)
have demonstrated that single-dose
more rounds of treatment.
also decreased by 74% (P.K. Das,
treatment significantly suppresses blood
microfilaraemia and similar results are also
unpublished). These appreciable
expected at the community level. It is
postulated that four to six cycles of annual '
treatment and interruption in transmission
might facilitate elimination of LF. A six-year
treatment compliance rate ranged
between 54% and 75% of the eligibb
- le
population (with >15 kg body weight)
(equivalent to 48-66% of the total
study demonstrated that four cycles of
annual single-dose treatment with
diethylcarbamazine (DEC), the
one of the five annual treatments.
Therefore, an improvement in the
reductions occurred even when the
population) and when 15% received only
predominantly used drug in India,
treatment compliance rate with five to six
rounds of treatment might reduce the GMI
of Mf and transmission of infection beyond
significantly reduced the prevalence and
geometric mean intensity (GMI) of
microfilaraemia and the transmission of
89% and 74%-93%, respectively.
infectione(Fig. I). By the end of the first year
following the fifth cycle of DEC treatment,
dynamics and the management of residual
Now is the time to address the issue of
the microfilaria (Mf) prevalence declined
microfilaraemia because the disease can
from 13.2% to 3.0% (equivalent to 77%
show resurgence, even after a decade
reduction), and the GMI decreased by 89%
following a successful control campaign'.
(a)
(b)
120
120
£
.S’
S
I
References
a Ottesen. E.A. el al. (2000) The global
programme to eliminate lymphatic filariasis.
Trap. Med. hit. Health 5. 591-594
b Ottesen, E.A. el al. (1999) The role of albendazole
in programmes to eliminate lymphatic filariasis.
Parasitol. Today 15, 382-386
c Cao. W.C. el al. (1997) Ivermectin for the
chemotherapy of bancroftian filariasis: a meta
analysis of the effect of single treatment. Trap.
Med. Ini. Heallh 2. 393-403
d Ottesen, E.A. el al. (1997) Strategies and tools
for the control/elimination of lymphatic
filariasis. Bull. WHO 75, 491-503
e Das, P.K. el al. (2001) Placebo-controlled
community trial of four cycles of single dose
diethylcarbamazine or ivermectin against
Wuchereria bancrofti infection and transmission
in India. Trans. R. Sue. Trap. Med. Hyg.
95. 336-341
f Harb. M. el al. (1993) The resurgence of lymphatic
filariasis in the Nile delta. Bull. WHO 71.49-54
g
800)
§
E
S
1'7
P-'
40-
?<•
pi
f
Post III
treatment
Post IV
treatment
0
Base-line
Post I
treatment
Post II
treatment
6
40
III
Base-line
Observation period
Post I
treatment
Post II
treatment
Post III
treatment
Post IV
treatment
Observation period
TRENDS in Parasitology
essential costs of the programme that
include cost of drugs, transport and training.
However, the mobilization of more funds and
materials from non-governmental
organizations and other donors are required
for the IEC campaign and for incidental
expenditure during the drug distribution
programme.
Future perspective
The research outcomes suggest that the
logistical and operational12 aspects, and
parasite dynamics in humans in relation
to the number of annual treatments18 will
have significant implications for the LF
elimination programme. Although the
economic burden estimates3 and
distribution maps16 are being used to
gather the support of the policy makers
(i.e. the fund providers), the logistical and
operational12 aspects suggest that a
nationwide programme requires a
tremendous effort. The abilities and
presence of an extensive PHC network,
and a well-established NFCP indicate that
country-wide DEC distribution for LF
elimination is possible. However, the
dimension of the problem1-2-16, low
treatment compliance rates and the lack
of knowledge by the people and their
poor interest in treatment12 are serious
obstacles that need to be tackled on a
priority basis. Because of the extent of the
LF problem1-2-16 and lengthy decision
making process, further steps should be
initiated soon to: (1) plan and
http://parasites.trends.com
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Reapaix^iUpdatg
TRENDS in Parasitology Vol.17No.10 October 2001
systematically extend the DEC
distribution to the entire country within a
timeframe; (2) generate resources;
(3) involve the health sector more actively;
and (4) educate the communities about the
programme to accomplish elimination of
LF by 2020 (Ref. 6).
Poor treatment compliance rates12 and
the persistence of microfilaraemia after
four to five rounds of treatment (Box 1)
necessitates rethinking on the adequacy of
four to six rounds of treatment, which is
believed to be sufficient for eliminating
LF. These factors need to be modelled by
LYMFASIM (Ref. 19) to predict the
epidemiological trends and duration of the
elimination campaign, information that is
imperative for programme managers and
funding agencies. Although the annual
single-dose treatment is the best option at
present, the search for better tools such as
new treatment regimens and more
effective adulticidal drugs should continue.
3 Ramaiah, K.D. el al. (2000) The economic burden
of lymphatic filariasis in India. Parasilol. Ibday
16,251-253
4 Cao. W.C. et al. (1997) Ivermectin for the
chemotherapy of bancroftian filariasis: a meta
analysis of the effect of single treatment. Trop.
Med. hit. Health 2,393-403
5 .Ottesen, E.A. el al. (1997) Strategies and tools for
the contrcl/elimination of lymphatic filariasis.
Bull. WHO 75.491-503
6 Ottesen, E.A. el al. (2000) The global programme
to eliminate lymphatic filariasis. Trop. Med. hyl.
Health 5, 591—594
7 Weil, GJ. et al. (1997) The ICT filariasis test: a
rapid-format antigen test for diagnosis of
bancroftian filariasis. Parasilol. Tbday 13,401-404
8 Dreyer. G. et al. (1996) Amicrofilaraemic carriers
of adult Wuchereria bancrofli. TYans. Roy. Soc.
'Trop. Med. Hyg. 90.288-289
9 Weil. G.J. et al. (1996) Parasite antigenemia
without microfilaraemia in bancroftian filariasis.
Am. J. 'Trap. Med. Hyg. 55.333-337
10 Pani. S.P..e/ al. (2000) Evaluation of ICT whole
blood antigen card test to detect infection due to
noctumally periodic Wuchereria bancrofli in
south India. Trop. Med. hit. Health 5. 359-363
11 Chanteau. S. etal. (1994) Og4C3 circulating
antigen: a marker of infection and adult worm
burden in Wuchereria bancrofli filariasis.
■J. Infect. Dis. 170.247-250
12 Ramaiah. K.D. et al. (2000) A programme to
eliminate lymphatic filariasis in Tamil Nadu
state. India: compliance with annual single dose
mass treatment and some related operational
aspects. Trop. Med. Ini. Health 5. 842-847
13 Ottesen. E.A. et al. (1999) The role of albendazole
in programmes to eliminate lymphatic filariasis.
Parasilol. Tbday 15, 382-386
14 Ramaiah. K.D. et a/. (1997) Functional
impairment caused by lymphatic filariasis in
rural areas of south India. Trop. Med. hit. Health
2.832-838
15 Ramaiah. K.D. and Vijay Kumar, K.N. (2000)
Effect of lymphatic flariasis on school children.
Acta Trop. 76, 197-199
460
!
Acknowledgements
We would like to thank the UNDP/World
BankAVHO/TDR for their financial
support to various research studies.
References
1 World Health Organization <2000) Eliminate
Filariasis: Attack Poverty. The Global
Alliance Lymphatic Filariasis.
Proceedings of the First Meeting.
*
W H ()/C DS/C P1-VC E E/2000.5
2 Michael. E. et al. (1996) lie-assessing
the global prevalence and distribution
of lymphatic filariasis. Parasitology
112.109-428
http://parasites.ti-ends.com
II____ _ ______ - :--------- -..... - —.... .... .
16 Sabesan, S. et al. (2000) Mapping of lymphatic
filariasis in India. Ann. Trop. Med. Parasit.
94.591-606
17 Sri vidya, A. et al. (2000) Development of rapid
assessment procedures for the delimitation of
lymphatic filariasis-endemic areas. Trop. Med.
hit. Health 5, 64-71
18 Das. P.K. el al. (2001) Placebo-controlled
community trial of four cycles of single dose
Diethylcarbamazine or ivermectin against
Wuchereria bancrofli infection and transmission
in India. TYans. R. Sac. Trop. Med. Hyg. 95.336-341
19 Plaisier, A.P. et al. (1998) The LYMFAIM simulation
program for modeling lymphatic filariasis and its
control. Methods Inform. Med. 37.97-108
20 Ramaiah, K.D. et al. Effectiveness of community
and health services organized drug delivery
strategies for elimination of lymphatic filariasis in
rural areas ofTamil Nadu. India. Trop. Med. hit.
Health (in press)
21 Krishna moorthy, K. et al. (2000) Cost of mass
annual single dose diethylcarbamazine
distribution for the large scalecontrol of lymphatic
filariasis. Indian. J. Med. Res. Ill, 81—89
Pradeep K. Das*
Kapa D. Ramaiah
Vector Control Research Centre (Indian
Council of Medical Research), Medical
Complex, Indira Nagar, Pondicherry,
India 605 006.
*e-mail: mosquito@sancharnet.in
Daniel J. Augustin
Directorate of Public Health and Preventive
Medicine, 259 Anna Sa la i, Chennai,
India 600 006.
Ashok Kumar
National Anti Malaria Programme, 22 Sham
Nath Marg, Delhi, India 110 054.
Indian J Med Res 111, March 2000, pp 81-89
Cost of mass annual single dose diethylcarbamazine distribution for
the large scale control of lymphatic filariasis
K. Krishnamoorthy, K. Ramu, A. Srividya, N.C. Appavoo', N.B.L. Saxena”, Shiv Lal” & P.K. Das
Vector Control Research Centre, Pondicherry,-Directorate of Public Health, Govt, of Tamil Nadu, Chennai &
Directorate of National Anti Malaria Programme, Delhi
Accepted March 13,2000
Economic analysis of the revsed strategy to control lymphatic Glariasis with mass annual single dose diethylrbamazine (DEG) at 6 mg/kg body weight launched in one of the districts of Tamil Nadu in 1996 was carried
“U T1t1'S “P
S7dy’ proposed for five years in 13 districts under 7 states on a pilot scale through the
Departaient of Public Health is an additional input of the existing National Filaria Control Programme in
India. A retrospective costmg exercise was undertaken systematically from the provider’s perspective foliowin"
the completion of the first round of drug distribution. The major activities and cost components were identified
to the^ C“‘i7nU
prepared t0 estimate the direct (financial) and indirect (opportunity) cost related
to the mplementahon of the Programme. The total financial cost of this Programme to cover 22.7 lakh
popu afion m the district was Rs. 22.05 lakhs. The opportunity cost of labour and capital investment was
calculated to be Rs. 7.98 lakhs. The total per capita cost was Rs. 1.32, with Rs. 0.97 and Rs. 0.35 as financial and
'’'I3'' BaSed °n th“e estimates'the implementation cost of the Programme at Primary
Health Centre (PHQ level was calculated and projected for five years. The additional financial cost for the
existing health care system is estimated to be Rs.27,800 per PHC every year. DEC tablets (50 mg) was the major
cost component and sensitivity analysis showed that the cost of the Programme could be minimized by 20 per
cent by switching over to 100 mg tablets. The analysis indicates that this Programme is a low-cost option and
the results are discussed in view of its operational feasibility and epidemiological impact
Key words Costing - financial and opportunity costs - lymphatic filariasis - mass annual single dose DEC - PHC
i
It is essential to consider both operational and
standardized in recent years and are used to identify
economic feasibility of any intervention to control
cost-effective options to control parasitic diseases2'4.
parasitic diseases apart from its effectiveness so as to
However, their application in lymphatic filariasis is
make decisions more rationally. Health care sector in
limited and consequently information on the costs of
developing countries is constrained by limited resources
control strategies under operational settings are
and it is difficult to implement all possible worthwhile
. scanty5'7.
interventions. Still, considerable resources are allocated
towards prevention and control of diseases in many
Lymphatic filariasis is considered as the second
developing countries in view of their significant’,
leading cause of permanent,and long-term disability8
contribution to disease burden-; Economic evaluation world-wide. India alone contributes about 40 per cent
• techniques to assess health care interventions have been
.. of the global disease burden due to filariasis9-10 and the
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82
INDIAN J MED RES, MARCH 2000
National Filari.a Control Programme (NFCP) initiated
in 1955, covers only 46 million people essentially in
urban areas11. Antilarval measures and case detection
cum treatment of microfilaria carriers are the two
methods adopted to control filariasis in these areas. A
revised strategy using mass annual single dose
diethylcarbamazine (DEC) distribution12 had been
launched on a pilot scale by the NFCP in 1996 as
National Filariasis Day (NFD) programme. As an
exploratory approach, the operational feasibility of this
Programme through the existing health care system is
being assessed in 13 identified districts in 7 states
following its implementation. However, the extension
of this Programme requires information on not only
operational feasibility but also its cost and effectiveness.
In an effort to provide information on cost-effectiveness,
we determined the cost of the Programme by examining
retrospectively the financial and opportunity costs from
Cuddalore district in Tamil Nadu following the
completion of the first round of drug distribution. Cost
projections were also made for the implementation of
the Programme at Primary Health Centre (PHC) level.
The results of sensitivity analysis were used to provide
guidelines for cost saving in programme
implementation.
Material & Methods
Mass annual single dose DEC distribution, integrated
with the existing primary health care system was
initiated in 1996 in selected endemic districts. The
National Institute of Communicable Diseases (NICD),
Delhi and National Malaria Eradication Programme
(NMEP) are the nodal agencies responsible for
procurement of drugs and developing strategy for
information, education and communication (IEC)
including arrangements of necessary funds for the same.
The Directorate of Public Health and Preventive
Medicine, Government of Tamil Nadu and Vector
Control Research Centre, Pondicherry are the state level
nodal agencies of the programme in Tamil Nadu. The
Deputy Director of Health Services is looking after the
Progfamme at the district level. Medical Officers of the
PHCs through their public health staff are involved in
actual implementation of NFD programme. A ■
' committee of independent experts has been identified <
for monitoring and evaluation of the programme.
Planning, preparation and implementation are the
different phases of this programme. The key activities
encompassed by this intervention included planning,
sensitization, family enumeration, drug distribution and
supervision. An age related dosage schedule is followed
with 50mg for age class 1-2 yr, 100 mg for 2+ to 4,
150 mg for 4+ to 8, 200 mg for 8+ to 11, 250 mg for
11+ to 14 and 300 mg for more than 14 yr of age.
Pregnant women, infants and-chronically sick
individuals are exempted.
Study area : Among the 13 districts selected, this pilot
programme could be launched only in Cuddalore
district in Tamil Nadu during the first year. All data
related to costing were from Cuddalore district follow
ing the first round of drug distribution which was
carried out between August 4-7, 1996. The population
of this district is 22,69,477 (as per family enumeration
prior to drug distribution). Male to female ratio is 1:0.98.
Only about half of the population had formal educa
tion. The total surface area is about 4,283 km2 with a
population density of 530/km2. About 5.3 lakhs popu
lation is living in urban areas, which include five
municipalities and 16 town panchayats. There are 1,518
villages governed by 13 administrative blocks with a
rural population of 17.4 lakhs. Health care facilities are
extended to the urban and semi-urban population
through 27 Government Hospitals and 16 dispensa
ries. A network of 51 PHCs with 319 Health Subcentres
(HSCs) is pro viding health care to the rural popula
tion. Delimitation surveys conducted during 1955-59
under the NFCP had shown that the prevalence of
microfilaraemia ranged from 3.0 to 15*7 per cent in
different localities of this district (erstwhile Southarcot
district)13. It was relatively higher in urban areas (12.9%)
than in rural areas (5.4%),The overall microfilaria (mf)
and disease rates were 8.38 and 2.62 per cent
respectively14. Subsequent surveys during 1988-89
(NFCP unpublished data) showed the persistence of
filariasis with mf prevalence ranging from 2.50 to 10.06
in different areas of this district.
Assessment ofcost: Functional organization of the NFD
. programme was used as the basis for identification and
^ distribution of cost-components. The present costing
^exercise13,16 considers the resource inputs from
provider’s perspective only. District was the level of
fcosting.as the entire district was covered under this
i '
.
- —•
A?--*'-’ -■'7’'■'v1
-
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83
KRISHNAMOORTHY et al: COST OF MASS ANNUAL SINGLE DOSE DEC DISTRIBUTION
Programme and all activities as well as resources were
channeled vertically from the district headquarters.
Itemized cost menu17 was used to determine direct
(financial) and indirect (opportunity) costs. Identifica
tion of component items, recognition of the units of each
item and derivation of a cost profile in relation to vari
ous input and activity categories were the main ap
proaches followed. Actual cost incurred under differ
ent inputs of the Programme was used to determine unit
cost. Actual number of vehicles used and the distance
covered were used to assess the cost on transport. A
unit cost of Rs. 1.95/km, including Rs. 1.15 for fuel and
Rs.0.80 for maintenance, was used to calculate running
cost on transport.
The opportunity cost of the diverted services of per
sonnel was calculated using official wage rates. The time
allocated by different personnel for programme imple
mentation was used to assess the total cost on labour.
Vehicle was the only capital item used for this pro
gramme, the economic cost of which was calculated by
annualization factor11* using current market rate. Annual
economic cost of the vehicle was converted into cost
per kilometer run, considering the life span of the
vehicle in terms of fixed target distance to cover (2 lakhs
km).
!
Evaluation of mass DEC programme is being car
ried out in this district both for its process and impact.
Process indicators such as coverage, compliance, side
reactions and record keeping are being monitored. Ef
fectiveness indicators such as microfilaria prevalence
and intensity are also monitored for impact assessment.
Present analysis on impact assessment for effectiveness
was restricted to data from 28 villages, 3 town
panchayats and 2 municipal towns for want of parallel
data from the rest of the areas.
Based on district level costing, cost at PHC level
was estimated and presented in 1996 price. Estimates
were made by assuming a population of 25,000 cov
ered by. 5 HSCs, eligible population of 97 per cent and
total coverage of eligible population. The time alloca
tion for drug distribution was assumed to be five days
while for the rest of activities one day each. As all the
PHC staff will be engaged in'actual drug distribution
-only-the MedicaLOfficer,.will be.left’for,supervision.
Market rate of Rs.0.20/50mg DEC tablet was used as
unit cost on drug. Actual requirement of drug was
calculated separately for 50 and 100 mg and combina
tion using the general distribution pattern of different
age classes from the census record with additional 10
per cent on wastage and overhead expenditure. The
average distance of HSC from the PHC was assumed to
be 10 km.
Sensitivity analysis was carried out for cost mini
mization. Drug price was the only parameter with un
certainty in relation, to the strength of the drug (50 mg/
100 mg) and a unit cost of Rs.0.31 per 100 mg DEC
tablet was used for comparison. Cost saving by switch
ing over from 50 to 100 mg was determined by using
sensitivity analysis. Cost projection for five years was
also done using present value calculation on future cost
for subsequent rounds of mass drug distribution at an
nual discount rate of 5 per cent4. The per capita cost
derived from this analysis was used to estimate total
cost of this Programme, at the national level to cover
the entire population at risk. The per capita cost reported
from earlier studies was converted into present value
(1996) and the cost per 1 percent reduction of microfilaraemia was used as cost-effectiveness ratio for com
parison.
Results
Information on age-specific population, drug
requirement and coverage achieved in rural and urban ’
areas are given in Table I. The coverage in drug
distribution (excluding infants) reported by the drug
distributors ranged between 80.9 and 99.4 per cent in
different PHCs with an average of 92.07 per cent. In
urban areas the coverage was 92.39 per cent, ranging
from 77.95 to 98.97 per cent in different towns. The
coverage was relatively higher in urban areas when
Table I. Population, drug distributed and reported coverage in rural
and urban areas of Cuddalore district
Rural
Total population
Eligible population
DEC (50mg) distributed
Population covered
Coverage (%)
1735602 .
1700890
8284548
1.597897
92.07
Urban
Total
533875
1690213
2577977
493251
92.39
2269477
3391103
10862525
2091148
92.14
.
i
—
•.
84
INDIAN J MED RES, MARCH 2000
compared to rural areas. As many as 1,08,62,525 DEC
tablets were distributed covering a population of
20,91,148 (92.14%). The proportion of population
considered as not eligible (infants, pregnant women and
sick persons) was 2.02 per cent.
The coverage (the percentage of people contacted)
and compliance (the percentage of people who actually
consumed the drug of those who. were contacted) were
also assessed through sample surveys using pre-tested
questionnaire in 30 PHCs covering 3,936 individuals
by external agencies following the second round. The
proportion of people reported to have consumed DEC
under direct supervision was 26.55 per cent. The
estimated coverage was 90.04 per cent and compliance
. was 82.13 per cent. Among those who did not take the
drug, about 27 per cent reported that they were not
present at the time of drug distribution and 5 per cent
did not receive the drug from the family members with
whom the drug was left. Perceived side reactions was
reported by 22.08 per cent of the respondents. On
classification it was found that most of the side reactions
were non-specific which included giddiness (53.59%),
vomiting (10.69%) and nausea (1.40%). Side reactions,
considered specific to infection were fever (14.49%)
and headache (19.83%).
A series of meetings was held at the district
headquarters to plan various activities of the programme.
I
Sensitization was carried out using various IEC tools
(Table II). These IEC tools were designed at the
Directorate of Public Health and the materials were
supplied to district headquarters. Health personnel, staff
from other government sectors (Table III) and NGOs
'were involved in sensitization. Orientation camp for
medical officers was held at district level in carrying
out this awareness programme. Village health nurses in
their respective areas, over five days carried out
enumeration of household members in the family
register. As many as 2,552 personnel from health and
other departments were engaged in drug distribution.
There were 1,276 teams, .each with one provider and
one assistant. During the first round of DEC distribution,
the entire population was covered in two days and
therefore the total person days required was 5,104.
Students were treated in their respective schools while
the rest of the population by door-to-door visits. Medical
officers of the respective PHC area did the supervision.
Vehicles from the Public Health Department were
engaged and the total distance travelled was 47.659 km
for different activities of this Programme. Process
evaluation showed that all the villages and towns were
covered and record keeping by the PHC staff was good
in terms of proper entries of new additions of population
and administration of correct dosages. This shows the
commitment and competence of the health personnel
in drug distribution. Cross sectional parasitological
Table II. Itemised cost menu and direct financial cost (Rs) by inputs and activity at district level
Cate- Cost
gory item
Unit of
measure
Unit
cost
Total cost
______ Activity
Planning
Cost
Units
IEnumeration
Cost Units>
Cost
Sensitization
Units
Supervision
Drug distribution
Units
Cost
Units
Cost
24000
46800.00
12000
23400.00
92935.05
Transport
Running cost
km
1.95
Supplies
DEC tablets (50mg) Per tablet 0.18
3659 7135.05
0
r
0.00
0
0.00
0.00
0
0.00 10900000 1962000.00
0
0.00
1962000.00
Posters
Piece
5.57
0
0.00
4400 24508.00
0
0.00
00
0.00
0
’ 0.00
24’508 00
Wall stencils
Piece
100.00
0
0.00
100 10000.00
0
0.00
o0 -
0.00
0
• 0.00
10000.00
Rubber stamp
Piece
40.00
0
0.00
100
4000.00
0
0.00
00
0.00
0
0.00
4000.00
Cine slide
Piece
75.00
. 0
0.00
150 11250.00
0
0.00
0 ’■
O
0.00
0
0.00
11250.00
100
0
0
Banner
Piece
. 75.00.
0
0.00
0.00
00
0.00
0
0.00
7500.00
Pamphlet
Piece
0.20
0
00
0.00
0
0.00
22500.00
Registers
Placards
Piece
Piece
10.00
6.00
0
0.00
0.00 112500 22500.00
0 .
0.00 5500 55000.00
o.oo
o
0
0
0
0.00
0.00
55000.00
2400.00
Filaria model
Piece. 500.00
0
0
0.00
1000.00
Slickers
Piece
0
o.oo
o.oo
o.oo
0
0.00
12000.00
2205093.05
3.00
0
7135.05
■ 0.32
Total
% out of total
|
8000 15600.00
7500.00
2400.00
0
o.oo’
1000.00
0
0.00
0
0.00
0.00
0.00
4000 12000.00
0
0.00
0
0.00
400
2
0
■_ ii0758.00
, 55000.00
2008800.00
23400.00
5.02
2.49
91.10
1.06
’ £ ■- .■
.
-
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r
.
.-
■ ■.;
.•
KRISHNAMOORTHY et al: COST OF MASS ANNUAL SINGLE DOSE DEC DISTRIBUTION
I
85
Table HI. Opportunity cost (Rs) of personnel and capital of the Programme at District level
Cate Cost
gory item
Unit of
measure
Unit
cost
_________
Planning
Units
Capital
Vehicle
Recurring
Personnel
km
Cost
2.25 3659 8232.75
Activity
1Enumeration
Sensitization .
Cost Units;
Units
8000* 18000.00
Total cost
Drug distribution
Supervision
Units
Cost
Cost
Units
Cost
0
0.00
24000
54000.00
12000
27000.00
107232.75
0
0.00
0
0.00
2
600.00
5100.00
0
0.00
0
0.00
0
0
0
178
356
0.00
0.00
0.00
35600.00
71200.00
638
78474.00
1420.00
Dy.Director of
Health Services
per day
300
10 3000.00
per day
per day.
per day
per day
per day
200
242
265
200
200
15 3000.00
17 4114.00
102 27030.00
0
0.00
0
0.00
5
1500.00
District Malaria
Officer
Filaria Officer
Medical Officer
Health Supervisors
Health Inspectors
Village Health
Nurses
per day
Lab Assistants
per day
Field Assistants
per day
Social Welfare Staff per day
Drivers
per day
Total
% out of total
123
0l
142
0I
83
20
' 144
0.00
0.00
0
0.00
0.00
0
0.00
45376.75
0
5.68
5 1000.00
3
726.00
51 13515.00
89 17800.00
178 35600.00
0
0.00
0
0.00
0
0.00
319 39237.00 1595 196185.00
0
0.00
0I
0.00
0
0.00
0
0.00
1916 38320.00
0
0.00
20 2880.00
0
0.00
168578.00
196185.00
21.11
24.57
surveys,
j , carried
uiniru out
vul in
ui selected
octccicu areas showed
snowed 0.32
U.3Z pt
per
cent microfilaria prevalence during, the pre control
(baseline) period and 0.30 per cent after two rounds of
mass drug distribution.
The total resources (financial cost) spent for the
implementation of the first round of NFD Programme
covering 22.05 lakhs population are summarized as
itemized cost menu in Table II. The per capita cost was
Rs. 0.97. Among the resource-input categories, supplies ’
were the major cost component, contributing to about
96 per cent of the total cost. Cost on drug (DEC 50 mo-)
alone was Rs. 19.62 lakhs (89%), the per capita cost on
drug being Rs. 0.87. Government vehicles were used to
cover a total of 47,659 km and the per capita running
cost on transport was Rs.0.04 and the cost on
sensitization materials and family enumeration register
was Rs.0.06.
10
30
3832
60
2490.00
76640.00
8640.00
328464.00
41.14
2
400.00
2
484.00
102
27030.00
0.00
0.00
4400.00
5324.00
67575.00
53400.00
106800.00
0.00
0.00
313896.00 •
1420.00
0.00
0.00
4320.00
59834.00
2490.00
114960.00
15840.00
798437.75
0
0
0
0
0
0
30
' 7.49
the per capita cost being Rs. 0.35. Cost on personnel
was the major cost component (Rs.6.91 lakhs)
accounting for about 87 percent of the total opponunity
cost. The share of capital cost on vehicle, which was
estimated in relation to distance run (km), was only 13
per cent. Comparison of cost between the activities
showed that drug distribution required relatively a higher
labour force accounting for about 40 per cent of total
opportunity cost. Planning and supervi.sion required
allocation of minimum-personnel time. The total
economic (financial ^-opportunity) cost of the
Programme at district level was Rs.30.04 lakhs with a
per capita cost of Rs. 1.32.
Estimation of Programme cost at the PHC level with
the existing infrastructure showed that the additional
cost required for each round of mass drug distribution
was Rs.27,824 (Table IV) to cover 24,250 individuals
Drug distribution was the most expensive activity
eligible for treatment (97%). The opportunity cost was
of the Programme, demanding about 91 per cent of the
estimated to be Rs. 16,947 (Table V). When this is
■ I
total financial cost. The remaining cost was shared by
extrapolated to cover the entire population of4,280 lakhs
sensitization (5.02%), enumeration (2.49%),
at risk of filarial infection in India, it will require
supervision (1.06%) and planning (0.32%). Drug and
financial allocation of about Rs. 5,365 lakhs for the
transport costs were the only cost component under the
entire programme, every year. The cost on diverted
functional category of drug distribution.
labour and capital item will amount to Rs.3,267 lakhs.
’ .r^ie opportunity cost on diverted labour and capital
Estimation of present value of future cost of the
......... inPut’under different activities:is shown in Table1 ID,7‘ —Programme ,-.for subsequent • roundsl-of drug
i
. f
,;s
rife..;
J
86
INDIAN J MED RES, MARCH 2000
administration for five years showed that each PHC
would require an additional financial*allocation of Rs.
1.7 lakhs for this Programme when 50 mg tablets are
used..
to protect 460 lakh population under the National
Programme'through anti-larval measures and detectioncum-treatment of microfilaria carriers in urban
areas9,11. The per capita recurring cost of this Programme
is Rs.2.60 per year (estimated cost of Rs. 14.37 for five
Sensitivity analysis of drug price showed that
- years). Analysis of costs of current mass annual single
• switching over from 50 mg tablet to 100 mg could
dose DEC Programme showed that the per capita cost
reduce the cost by 20 per cent (Fig.). This will result in
for five annual rounds would be only Rs. 7.29. This
saving Rs. 31,400 at PHC level in financial cost for five - * covers the entire operation of the programme including
annual rounds of mass DEC. When combination of 50
the cost on personnel.
and 100 mg is used, cost saving will be about 19 per
Analysis of the per capita cost of different
cent.
intervention"strategies
of a pilot study19, carried out
Discussion
between 1966-1975 to control brugian filariasis showed
that one round of selective DEC treatment was low cost
The burden of filarial disease in terms of disability
option (Rs. 11.70) when compared to one round of
adjusted life years (DALYs) lost in India has been
weekly doses of mass DEC treatment for 12 wk
estimated to be 2.8 and 1.6 lakhs for men and women
(Rs. 13.34), 36 rounds of HCH residual spray (Rs.83.34),
respectively1. Annually about Rs. 12 crores are spent"
I
Table IV. Estimated financial cost (Rs) for mass drug distribution at PHC level
Cate
gory
Cost
item
Unit of
measure
Unit
cost
km
1.95
______________________ Activity
Sensitization_______ Enumeration
Units
Cost Units
Cost
Planning
Units
Cost
Total cost
Drug distribution
Supervision
Units
Cost
Units
Cost
Transport
Running cost •
0
0.00
100
195.00
0
0
100
2000
0
0.00
557.00
400.00
0.00
1152.00
4.14
0.00
0
0.00
0
0.00
0
0
0.00
0.00
126410
0
0
0
1000.00
25282.00
0.00
. 0.00
0.00
25282.00
3.59
90.86
200
390.00
585.00
0
0.00
0
0
0.00
0.00
25282.00
557.00
400.00
Supplies
DEC tablets (50mg)
per tablet 0.20
0
0.00
Posters
Pamphlet .
piece
piece
5.57
0.20
0
0
0.00
0.00
•Registers
Total
piece
10.00
0
0.00
0.00
% out of total
100
1000.00
1000.00
27824.00
0.00
0
390.00
1.40
Table V. Estimated opportunity cost (Rs) of personnel and capital of the Programme at PHC level
Cate
gory
Cost
item*
Capital
Vehicle
Recurring
Personnel
Unit of
measure
Km
Social Welfare
Staff (18)
Drivers (1).
Total
% out of total
Total cost
______________________ Activity
Sensitization______ Enumeration
Planning
Units
Cost
Units
Cost Units
2.25
0
0.00
100
225.00
265
200
200
I
1
265.00
600.0Q
200.00
1
3
3
1
123
5
615.00
per day
20
per day ■ 144
0
0
per day
Health Supervisors (3) per day
Health Inspectors (1) per day
Village Health
per day
Nurses (5)
Medical Officer (1)
Unit
cost
Cost
Supervision
Drug distribution
Units
Cost
Units
Cost
200
450.00
675.00
2
530.00
0.00
1000.00
0
0
0.00
1060.00
4200.00
1400.00
25
3075.00
0
'0.00
7380.00
90
1800.00
0.00
8875.00
52.37
0
0.00
288.00 ■
1268.00
7.48
1800.00
432.00
16947.00
0
0.00
265.00
0
0.00
0
0.00'
600.00
0
0.00
15
3000.00
200.00
0
0.00
5
5
615.00
25
3075.00
0.00
' 0
1
0.00
144.00
0
0.00
2049.00
0.00
0.00
3075.00
12.09
18.14
1680
.9.91
.
0
■
0
0
0.00
•
2.
!
•Figures in parenthesis denote staff position
■
x',
!i
■
■ > ;
87
KRISHNAMOORTHY et al: COST OF MASS ANNUAL SINGLE DOSE DEC DISTRIBUTION
I
Fjnancial cost -e- Economic cost
10.00
8.00
co
o
ra
r
i
■f 6.00
o
<5
Q.
4.00
50 mg
50mg+100mg
100 mg
Tablet strength
•
1
Fig. Projected per capita cost for 5 years in relation to variation in
drug price.
its supplementation with selective treatment (Rs. 86.47),
and its supplementation with mass chemotherapy
(Rs.89.03) . Another study showed that the per capita
cost of DEC medicated salt programme to control
bancroftian filariasis in Lakshadweep20 was Rs. 7.43
(present value). The cost to screen an individual for
selective DEC treatment was reported to be Rs. 3.00
(present value)21. Cost effectiveness analysis of those
interventions for which effectiveness data are available
shows that the DEC medicated salt programme is more
cost effective as the cost (present value) per 1 per cent
reduction in microfilaraemia prevalence was the lowest •
(Rs. 0.09) when compared to the rest. The intervention
with 36 rounds of HCH spray was the least cost-effective
intervention (Rs. 1.10). However, this analysis has some
limitations such as no uniformity in costing and
implementation at different points of time. In view of
these difficulties, the costing of the present mass single
dose DEC programme has been carried out
systematically. Though information on effectiveness is
available" after two founds of mass treatment, it will be
too early to.assess the impact of the programme in terms
of change in microfilaraemia prevalence. With the
revised sampling design in epidemiological evaluation
of the programme-for impact assessment of this
programme, it will be possible to carry out cost
effectiveness analysis after subsequentrounds. Yet, mass
annual single dose DEC distribution remains to be
cheaper with a per capita economic cost of Rs. 1.32 at
district level for each round, including the time cost on
personneLwhich accounts for only 27 per cent of the
total cost when compared with all other strategies.
I
I.
Cost saving to an extent of 20 per cent by switching
over to 100 mg tablets of DEC can be considered while
planning large scale control programmes. Operationally
it may be possible to use only 100 mg tablet by giving
1/2 tablet for 50 mg dosage or rounding the dosage to
the nearest 100. Palatable syrup may be operationally
convenient with high compliance to cover children
below five years of age. Considering the cost of syrup
(100 ml^Rs. 12.65), the additional cost would be only
1.7 per cent of the total cost when tablets are replaced
with syrup for the age class 1-4 yr. However, its
operational feasibility needs to be assessed.
Estimates of both direct and indirect costs due to
filariasis are available for different communities22. The
estimated number qf days lost due to acute attacks of
filariasis respectively for Wuchereria bancrofti and
Brugia malayi was 23.4 and 26.5 days23. Based on this,
the economic loss due to lymphatic filariasis in India
was estimated to be Rs.6,300 crores (USS 1.5 billion)
per year24. This can be considered as minimum as there
appears to be underestimates on costs due to some
uncertainties. With the estimated per capita financial
cost of Rs. 1.14 at PHC level, the revised strategy would
cost.Rs.48.79 crores per annum to cover the entire
population at risk in India. This is only less than 1 per
cent of the annual economic loss due to filariasis.
Though this Programme is integrated with the PHC
system with no additional resources for personnel,
distribution of DEC drug is an added work, burden to
the existing public health workers. Therefore, the
opportunity cost of the diverted services of health
personnel to distribute drug to control filariasis should
not be neglected while planning large scale control
operations.
The efficacy of mass single dose DEC treatment has
been studied extensively9-25'28 and this strategy has been
recommended for the control/elimination of filariasiS29.
The present study shows that mass single dose DEC
distribution is operationally feasible in terms of good
coverage reflecting the commitment of the PHC staff
and compliance (community acceptance as the side
reactions are minimal). Thus this revised strategy differs
from our earlier experience with mass single dose DEC
continuously for five days during 1955-6014 which was
abandoned due to poor coverage and- precipitation of
drug reactions provoking public resistance. Another
i
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88
INDIAN J MED RES. MARCH 2000
study of mass treatment with 12 weekly doses of single
dose DEC also showed a very low coverage30: Therefore ‘
With a good coverage and compliance with minimal side
reactions as observed in the present study, mass annual
single dose DEC can be considered operationally
feasible and a low cost option for large scale control of
lymphatic fiIariasis in India. The Ongoing exploratory
study on pilot scale is also expected to resolve some of
the issues such as the duration of programme
implementation, the level below which the transmission
ceases spontaneously and the minimum coverage to be
achieved. It is also essential to collect data on various
resource inputs utilized for the implementation of the
present pilot programme in different operational settings
so as to optimize the inputs in maximizing the
effectiveness in view of uncertainties in some cost
components. The present economic analysis can be used
as a guideline for planning and implementing the revised
ilariasis control strategy with mass annual single dose
DEC distribution at different levels.
Acknowledgment
The authors are grateful to Dr R.T. Porkaipondian. Deputy
rvic=s-Dr K^enthantizhselvi. District MaJana
Officer Cuddalore distnet and Dr R. Meera. Filaria Officer. Filaria
Control Unit for providing some details of programme
implementation in Cuddalore district.
References
/'^°rl^ank' W°rld DeveioPmm‘ ReP°T. Investing in health
P^1993 f2^
NCW
OXf°rd Un,VCrSi^'
■2
Foster S. Phillips M. Economics and its contribution to the
right against malaria. Ann Trap Med Parasitol 1998; 92:
391-8.
3
Haddix AC. Shaffer PA. Cost effectiveness analysis. In: Haddix
AC. Teutsch SM. Shaffer PA. Dunet DO, editors. Prevention
effectiveness. A guide to decision analysis and economic
evaluation. Oxford: Oxford University Press; 1996 p. 103-29.
'4.
Drummond M. O’Brien B. Sloddart G. Torrance G. Methods
for the economic evaluation of health care programmes.
London. Oxford University Press; 1987 p. 39-167.
5.
Evans DB. Gelband H. Vlassoff C. Social and economic factors
and the control of lymphatic filariasis: a review. Acta Trap 1993;
53: 1-^6.
6.
Michael E. Meyrowitsch DW, Simonsen PE. Cost and cost
effectiveness of mass diethylcarbamazine chemotherapy for the
control of bancroftian filariasis: comparison of four strategies
in Tanzania. Trap Med Int Health 1996; 1: 414-26.
• •
7.
Barlow R. Grober LM. Cost and benefits ofcontrolling parasitic
diseases, PHN Technical Note 85-17. Washington DC.
Population. Health and Nutrition Department, The World Bank;
p.
8.
World Health Organisation. The World Health Report 1996
righting diseasefostering
w development.
----- - ------- Geneva: World Health
Organisation; 1996 p. 1-137.
World Health Organisation. Lymphaticfilariasis infection and
a^ase: Control strategies. Report of a WHO Consultative
jeting held at the Universiti Sains Malaysia. Penang
Malaysia. Document TDR/CTD/FIUPENANG/94. ] Geneva.’
World Health Organisation; 1994 p. ] -30.
9.
10. Michael E. Bundy DAP. Grenfell BT. Re-assessing the global
?9%^TAe-7ol|d^bUn0n Oflymphalic fiIariasis- Parasitology
11. Sharma RS. Biswas H. S.iaxena NBL. National FUaria Control
Programme. Operational manual. Delhi: National Malaria
eradication Programme; 1995 p.6.
12. Biswas G. Rama VK. Rao CK. A revised strategyfor the control
of lymphatic filariasis in India. Repon and recommendations
of the WHO Sponsored Workshop. Delhi: National Malaria
eradication Programme; 1996 p. 1-43.
13. Basu PC. Raghavan NGS. Gaur MP. FiIariasis i.. I.,,
in India - facts
and figures. Part X - Tamil Nadu. J Commun.. Dis 1971;
11 d_25.
14. Ramakrishnan SP. Raghavan, ?'22,
v
i. NGS. Krishnaswamy AK. Nair
CP, Basu PC, Singh D. et al. National Filaria Control
rogramme in India; a review. Indian J Malaria! I960’ !4457-94.
15. Creese A. Parker D. Cost analysis in primary health care. A
training manual for programme managers. Geneva: World
Health Organization; 1994 p. LI47.
16. Phillips M. Mills A. Dye C. Guidelines for cost-effectiveness
analysis of vector control. Panel of Experts on Environmental
Management for Vector Control. PEEM Guidelines senes Nd.
J. Geneva: World Health Organisation; 1993 p. 1-19'2.
17. Guyatt H. Evans D. Lengeler C. Tanner M. Controlling
schistosomiasis: the cost - effectiveness of alternative delivery
strategies. Health Policy Planning 1994; 9: 385-95
18. Clemmer B. Haddix AC. Cost benefit analysis. In: Haddix AC
Teutsch SM. Shaffer PA. Dunet DO. editors. Prevenuon
effectiveness. A guide to decision analysis and economic
evaluation. Oxford: Oxford University Press; 1996 p. 85-102.
19. Rao CK, Chandrasekharan A. Kaul SM, Narasimham M WL,
Sharma SR Relative effectiveness of different methods of
control of Brugian filariasis in India. Indian J Med Res 1980;
72. 194-202.
20. Rao CK. Rao PP. Russel S. Hamzakoya KK. Chandrasekharan
A. Roychowdhury SP. et al. Control of bancroftian filariasis
with common salt medicated with diethylcarbamazine in
Lakshadweep.. Indian J Med Res 1981; 73: 365-73.
21. Sharma SP, Kosaie GJ, Biswas H, Das M, Trivedi GK. Sharma
OK. Control of Bancroftian filariasis in rural areas throueh
selected treatment with diethylcarbamazine. J Commun Dis
1986; 18: 283-6.
/
i
KRISHNAMOORTHY et al: COST OF MASS ANNUAL SINGLE DOSE DEC DISTRIBUTION
I
I
22. Ramaiah KD. Ramu K. Guyatt H. Vijar Kumar KN. Pani SP.
Direct and indirect costs of the acute form of lymphatic filariasis
to households in rural areas of Tamil Nadu, south India. Trap
Med Im Health 1998; 5: 108-15.
23. Sabesan S. Krishnamoorthy K. Pani SP. Panicker KN. Man
days lost due to repeated acute attacks of Ivmphatic filariasis.
Trends Life Sci 1992; 7; 5-7.
24. World Health Organization. Lymphatic filariasis: Reasons for
hope. WHO/CTD/FIL/97.4 Geneva: World Health
Organization; 1997 p. 1-20.
25. Kimura E. Spears GFS. Singh KI. Samarawickrema WA. Penaia
L. Sone PF. et al. Long-term efficacy of single-dose mass
treatment with diethylcarbamazine citrate against diurnally
subperiodic Wuchereria bancrofti: eight years’ experience in
Samoa. Bull World Health Organ 1992; 70\ 769-76.
26. Kimura E. Mataika JU. Control of lymphatic fiiahasis by annual
single-dose diethylcarbamazine treatments. Parasitol Today
1996; 12: 240-4. ’
Reprint requests :
89
27. Addiss DG. Eberhard ML. Lammie PJ, McNeeley MB. Lee
SH. McNeeley DF. et al. Comparative efficacy of clearing dose
and single high dose ivermectin and diethylcarbamazine against
Wuchereria bancrofti microfilaraemia. Am J Trap Med Hyg
1993; 48\ 178-85.
28. Kazura J. Greenberg J. Perry R, Weil G. Day K. Alpers M.
Comparison of single-dose diethylcarbamazine and ivermectin
for treatment of bancroftian filariasis in Papua New Guinea.
Am J Trap Med Hyg 1993: 48\ 804-11.
29. Ottesen EA. Duke BOL. Karam M, Behbehani K. Strategies
and tools for the control/elimination of lymphatic filariasis. Bid!
World Health Organ 1997; 75: 491-503.
30. Rao CK. Sen T. Roychowdhury SP. Datta KK. Das M. Krishna
Rao Ch. et al. Rural filariasis control with diethylcarbamazine.
J Comrnun Dis 1978; 10: 194-6.
The Director, Vector Control Research Centre. Indira Nagar. Pondicherry 605006
I
T
Operational feasibility and impact of co
administration of Albendazole and DEC
in controlling lymphatic filariasis
Nodal Agencies
NAMP
ICMR
Implementation
Evaluation
(
INSTITUTIONS
Vector Control Research Centre
Pondicherry
Tuberculosis Research Centre
Chennai
!
Regional Medical Research Centre
Bhubaneswar
National Institute of Communicable Diseases
New Delhi
Department of Public Health
Tamil Nadu, Orissa & Kerala
VECTOR CONTROL RESEARCH CENTRE
WHO Collaborating Centre for Research & Training in Integrated Methods of Vector Control
INDIRA NAGAR, PONDICHERRY - 605 006. INDIA.
Fax: 9M13-372041 Tel: 372422,372396 & 372397
E-mail: mosquito@md5.vsnl.com
w
MESSAGES FOR MANAGERS
India is a signatory to the World Health Assembly resolution towards filariasis elimination
(WHA 50.20. 1997). Therefore it is mandatory to extend filariasis control actively to all the
endemic areas towards achieving the goal of elimination.
According to the constitution of India, health is a “state” subject. States themselves can take the
leadership role in implementing various health programmes. Tamil Nadu is a pioneer in so far as
implementing filariasis elimination / control programme is concerned as 12 districts have already
been brought under this programme.
Filariasis is the second leading cause of permanent and long-term disability in humans. Disability
and morbidity due to this disease result in considerable productivity loss. Therefore filariasis
elimination is an essential component of efforts towards poverty alleviation, and requires co
operative involvement of the Government, NGOs and the people at large.
The elimination programme has two strategies: disease transmission control and morbidity
control in individual patients afflicted with the disease. Transmission control can be achieved
through reducing the parasite load in the community using drugs (such as DEC or DEC plus
albendazole) or through appropriate vector control or both. The major difficulty in ensuring the
consumption of the drug(s) is the lack of knowledge among the people about the disease. For
example, most people are unaware that hydrocele is due to filariasis. People also need to be
educated about the possible side reaction of the drug. Morbidity control can be achieved through
prevention and treatment of cases.
There are three components in filariasis elimination programme: Science, commitment and
partnership. Science or knowledge is not sufficient unless the other two are mobilized.
There are four aspects through which the programme has to proceed.
• Mapping (identifying endemic areas)
• Implementation of intervention strategy
• Monitoring and evaluation
• Certification of elimination
I
Filariasis elimination can only be achieved through right motivation at all levels in order to
implement the programme effectively through partnership approach.
Vector Control Research Centre, a permanent Institute of the Indian Council of Medical
Research provides global, national and local technical guidelines to implement and evaluate
programmes scientifically and to help train programme personnel.
ICMR Cell towards elimination of filariasis in India
Vector Control Research Centre
Indira Nagar, Pondicherry 605 006
E-mail: mosquito@sancharnet.in
Website:www. pondicherry. nic. in. fil-free
D:\alben\common protocol.com
RESEARCH PROTOCOL
1. Title of the Research Project: Operational feasibility and impact of co-administration of
albendazole and DEC in controlling lymphatic filariasis.
2. Name and Designation of Project Co-ordinator:
Dr.P.K.Das, Director, VCRC,
Pondicherry
3. Nodal agencies of the project:
a. National Anti-malaria Programme - Dr. Ashok Kumar
b. Indian Council of Medical Research - Dr.Lalit Kant
4. Investigators:
(a) Investigators from VCRC, Pondicherry:
^c^JPpflcipal Investigator : Dr.S.P.Pani, Deputy Director (Sr. Gr), Vector Control
/
Research Centre, Pondicherry.
•
Co-Investigators
: Dr. D.J. Augustin, Joint Director, Directorate of Public
Health and Preventive Medicine, Govt, of-Tamil Nadu,
. Chennai
Dr. K.Krishnamoorthy, Dr. B.Nanda, Dr. Shanti
Anathakrishnan, Mrs A.Lakshmi, Vector Control Research
_Centre, Pondicherry
(b) Investigators from TRC, Chennai:
Principal Investigator
: Dr .V. Kumaraswami, Deputy Director (Sr. Gr), TRC,
Chennai
Co-Investigators
: Dr. D.J. Augustin, Joint Director, Directorate of Public
Health and Preventive Medicine, Govt, of Tamil Nadu,
Chennai
(c) Investigators from RMRC, Bhubaneswar:
Principal Investigator
: Dr. G.P. Chhotray, Deputy Director (Sr. Gr), RMRC,
Bhubaneswar
Co-Investigators
: Dr. R.N. Nanda, Director, Health Services, Govt, of Orissa
Dr. S.S.Mahapatra, Asstt. Director, RMRC, Bhubaneswar
Dr. M.R. Ranjit, S.R.O., RMRC, Bhubanesv/ar
Consultants
: Dr. Chittaranjan Pattanayak, Director, Medical Education
& Training, Govt, of Orissa
Dr. R.N. Rath, Prof, of Medicine (Retd.)
c3$sW’r
rBclhr:
: Dr. R.C.Sharma, NICD, Delhi
: Dr. S.M. Koya, NICD, Calicut, Kerala
Director of Health Services, Govt, of Kerala
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
D:\Alben_proj\COMMON PROTOCOL final.DOC
Page 2
3/7/01
‘
5. Background:
Lymphatic filariasis has been identified as one of the six major tropical diseases that can be
potentially eradicable (Ottesen and Ramachandran, 1995). It is the second leading cause of
permanent and long-term disability in human (WHO, World Health Report, 1995), in
addition to causing social stigmatization, psychosocial and economic burden to individual
and community. Consequently, filariasis is one of the diseases that cause poverty. Therefore,
elimination of filariasis is linked with poverty alleviation.
I
India is a signatory to the WHA (1997) resolution on lymphatic filariasis elimination where
about 412 million people are at the risk of this infection. Towards meeting this goal, mass
annual single dose DEC treatment is being carried out on a pilot scale in 13 districts in India.
Experience during the last three rounds of drug distribution showed that even though the
coverage was reported to be above 90%, the compliance (drug consumption) was estimated
to be below 60%. Mathematical model predictions suggest that with this level of compliance
5-6 rounds of mass treatment will not be sufficient to achieve zero probability of infection.
Therefore, it is essential to enhance community compliance.
Community compliance can be improved if the community perceives the benefit. Co
administration of .albendazole could be a potential proposition by which community
compliance can be enhanced through perceived benefit. The current study proposes to
compare the operational feasibility and impact of co-administration of DEC and albendazole
with that of DEC alone at district level. It is also proposed to develop a monitoring and
evaluation strategy for large-scale control of filariasis.
♦
This multicentric study will be carried out in Tamil Nadu, Orissa and Kerala. Research
institutes such as VCRC and TRC will be involved in Tamil Nadu, RMRC in Orissa and
NICD in Kerala for evaluation and providing technical support.
The findings and recommendations will be useful in developing'national strategic plan for
large-scale control of lymphatic filariasis, moving towards the ultimate goal of filariasis
elimination.
6. Duration of Research Project: 5 years (2000-2005)
7. Research institutions responsible for programme evaluation and co-ordination (please
also see Table 1 on page 5)
a. Vector Control Research Centre
(Indian Council of Medical Research)
Medical Complex, Indira Nagar
PONDICHERRY - 605 006
b. Tuberculosis Research Centre
(Indian Council of Medical Research)
Spur Tank Road, Chetput, Chennai - 600 031
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
D:\Alben_proj\COMMON PROTOCOL fmal.DOC
Page 3
3/7/01
c. Regional Medical Research Centre
(Indian Council of Medical Research)
Chandrasekharpur
Bhubaneswar-751 023
Orissa
d. National Institute of Communicable diseases
New Delhi
8. Objectives:
1. Compare mass annual single dose DEC alone with co-administration of albendazole and
DEC for filariasis control/elimination - district as a unit with reference to:
•
•
•
•
•
•
Coverage
Compliance
Perceived benefit
Impact in terms of mf prevalence and intensity, antigenaemia prevalence,
transmission and geo-helminth prevalence
Adverse reaction, and
Cost
2. Training of local health authorities (state and district) for implementation, monitoring and
evaluation
9. Hypotheses:
•
•
•
•
Co-administration of DEC and albendazole improve^ community compliance
through perceived benefits than DEC administration alone
Co-administration of DEC and albendazole has better impact than DEC
administration alone
Co-administration of DEC .and albendazole is as operationally feasible as
administration of DEC alone
Adverse reactions due to co-administration of DEC and albendazole are similar to
administration of DEC alone
9. Present knowledge on control options
More recently it has been demonstrated that combination of albendazole with DEC or
ivermectin can effectively clear microfilaraemia of bancroftian infections (WHO, 1998).
Single dose co-administration of albendazole with either DEC or Ivermectin is superior in
efficacy to single drug treatment for decreasing microfilaraemia in lymphatic filariasis.
Albendazole alone has shown to possess killing or sterilizing activity on adult filarial parasite
(Denham ct al., 1980; Mak et al., 1984). Albendazole plus DEC/ivermectin co-administration
offers “beyond filariasis” benefits in terms of comprehensive health development and
cognitive function in children. Also, addition of Albendazole to DEC did not appear to
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
D:\Alben_proj\COMMON PROTOCOL fmal.DOC
Page 4
3/7/01
increase the frequency or intensity of adverse events when compared to DEC when given
alone (WHO, 1999). However, the usefulness of this approach needs to be evaluated on large
scale before it’s up scaling to cover the entire population at the risk of filarial infection.
j
10. Detailed Research Plan:
The two components of the programme include, implementation and evaluation, and the
latter includes both process and impact. This study will be carried out in 13 districts, with 8
districts in Tamil Nadu, 3 districts in Orissa and 2 districts in Kerala respectively. The two
arms of this study include co-administration of DEC with albendazole and administration of
DEC alone. A population of 20.54 million in 9 districts will receive both albendazole and
DEC while 9.0 million people in 4 districts will be distributed with DEC alone (Table 1).
Comparisons will be made between these two arms using appropriate indicators.
F
!•:
■
Table 1. District wise population, strategy and institutions responsible for
evaluation
Centre
I
i
Institut
ion
State
District
Drug
!
Endemicity rate
(%)
Bhubaneswar
RMRC
Orissa
Puri#
Balesore
Ganjam #
DEC 50
DEC 50+Alb
DEC 50+Alb
1.57
1.80
2.90
10.6
4.5
24.9
Chennai
TRC
Tamil
Nadu
Trichy #
Kanchipuram^
Vellore
ThiruvallurS/
DEC 100
DEC 100+Alb
DEC 100+Alb
DEC 100+Alb
2.44
2.72
3.33
2.73
2.7
19.3
15.7
19.2
Pondicherry
VCRC
Tamil
Nadu
Thiruvanamalai
DEC 50
DEC 50+Alb
DEC 100+Alb
DEC 100+Alb
2.19
2.14
1.18 1.54
15.6
15.9
15.9
15.9
DEC 50
DEC 50+Alb
2.80
2.20
7.1
21.3
I
I
Populat
ion (in
(millions)
#
Thanjore #
Thiruvarur
Nagapattinam
&
Delhi
NICD
Kerala
Kozhikode #
Alleppey #
# Districts for intensive studies by the research institutions. In other districts the
State/district authorities will be trained and monitoring and evaluation will be done by
regular supervision.
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
D:\Alben_proj\COMMON PROTOCOL fmal.DOC
Page 5
10.1. Implementation:
National Anti-malaria Programme (NAMP) is the nodal agency for the implementation of
mass annual single dose programme. As an active partner, continued involvement is
identified as its role in the present trial. NAMP will co-ordinate activities of drug
distribution through state level programme managers. (Technical Advisory Group
recommendation, 12.9.2000). Department of Public Health, Government of Tamil Nadu,
Orissa and Kerala has .already launched filariasis control programme using mass annual
single dose DEC (6 mg/kg body weight) in 2 districts each. Tamil Nadu has extended this
programme to 10 more districts subsequently. Addition of albendazole (400 mg) to the
existing single drug (DEC) regimen will be carried out by the Department of Public Health
of the respective state Governments. Implementation of this programme will be carried out
under the programme mode with active collaboration of the research institutions.
The key activities of programme implementation include, sensitization of providers and
partners, preparation of implementation plan, Training, Family enumeration, preparation of
community through awareness campaign using appropriate IEC tools, drug distribution
through house visits, active surveillance for adverse reaction and passive surveillance for
serious adverse experience. An action plan will be prepared with appropriate time schedule
for programme implementation.
DEC tablets will be supplied by the NAME (except for 6 districts in Tamil Nadu for which
the State Government will be responsible for drug supply). WHO has supplied the required
20 million albendazole tablets (400 mg) for the first round with a commitment for
subsequent rounds at free of cost. No separate fund is requested for the implementation of
this programme with two-drug co-administration of albendazole and DEC. This will be
carried out with the existing infrastructure with the Department of Public Health of the
respective State governments.
10.2.
Evaluation:
Being an operational research study, it is aimed to collect information to monitor the
progress of both programmatic activities (process evaluation) and overall programme
effectiveness (impact evaluation), in addition to providing remedial measures into the
problems that arise in programme implementation. Appropriate process and impact
indicators will be used to compare operational feasibility, safety, perceived benefits, impact
and cost to compare between the interventions. As the programme is implemented at district
level, district is considered as evaluation unit. Intensive studies will be carried out in 8
districts, with one district under each arm per evaluating institution (Table 1). Changes in
these parameters over a given period of time in relation to base line will also be analyzed.
During the first year all the necessary baseline information will be generated.
Coverage, reported by the drug distributor will be used as one of the indicators of
implementation process. Details on drug receipt and supply, and coverage of drug
distribution will be collected from the drug distributors for all the villages/wards through
return forms.
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Safety of the drug(s) will be determined from the adverse reactions, which will be assessed
through active surveillance and Serious Adverse Experience reports. Active surveillance
will be carried out by monitoring 2000 persons in each district covering all PHCs and
Municipalities on 5-7 days post intervention, using consumer-monitoring form. Perceived
benefit in terms of deworming will also be assessed through this method apart from
questionnaire method. These process parameters will be monitored following each round of
drug distribution.
I
Monitoring of population for the rest of the evaluation parameters will be carried out in
sentinel sites. This is because lymphatic filariasis is clustered in distribution and monitoring
of the entire population in a district is neither feasible nor necessary. Also, the impact can be
realized only in areas where the problem exists. Sentinel sites are those sites, which will be
monitored through out the evaluation period. However to have a wider representation and to
minimize the bias due to possible focus of attention in sentinel sites, equal number of sites
will be selected randomly every time i.e. selecting different sites for every subsequent
survey as spot check sites.
Rural and urban areas will be treated separately in view of difference in risk factors and
health care delivery. Rural population is covered under PHC services and urban population
is covered under municipalities. Villages are the subunits of PHC and wards are that of
municipalities. Villages/wards are considered as the lowest evaluation sites.
1
I
To select sentinel sites (villages/wards), a list of sites that are positive for microfilaria
carriers will be prepared. Identification of positive sites will be done rapidly microfilaraemia
(mf) prevalence in the peak age class as a proxy indicator. Initial screening for mf will be
carried out from 10 villages/wards in 50% of the PHCs and Municipalities selected at
random. Villages/wards in each PHC/Municipality will be selected by using cyclic
systematic sampling procedure after arranges the sites in ascending order of population. In
each village/ward a total of 30 households will be selectecTusing systematic sampling
procedure. A cross sectional survey will be carried out by screening all the individuals in the
age class 15-30 years for microfilaraemia in the selected households and drawing 20 pl
blood following finger prick method between 8.00 PM and 11.00 PM. A village/ward with
at least one microfilaria carrier will be considered as positive village/ward. A list of
minimum of 5.0 such positive villages and 10 positive wards will be prepared for selecting
sentinel villages/wards. These positive villages will be stratified into 3 categories (low,
medium and high) based on mf prevalence in a given district following cluster analysis.
From each category, 2 villages will be selected at random as sentinel villages. The rest of
the villages will be considered for selecting spot-check villages. From this list, equal
number of villages will be selected randomly as spot-check villages while collecting data on
different parameters during the pre-intervention survey and subsequent surveys. In the urban
area, only two wards that are positive for microfilaraemia will be selected as sentinel wards
randomly irrespective of mf rate, with two more positive wards as spot-check wards.
♦
Community acceptance will be assessed using compliance (drug consumption) rate through
interviews with semi-structured questionnaire. This will be collected from all the sentinel
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
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Page 7
villages/wards and from equal number of spot check villages/wards. From each village/ward
20 households will be selected and information will be collected from all the available
individuals, in case of children from their parents. This will be monitored following each
round of drug distribution.
Impact evaluation will be carried out using outcome indicators such as mf prevalence, mf
intensity, antigenaemia prevalence, transmission parameters, and prevalence and intensity of
geo-helminths. Base line data on mf prevalence and intensity will be collected from all the
sentinel villages and wards. In addition, equal number of spot check villages from each
category of positive villages as well as wards will be selected for the survey. A cross
sectional survey will be carried out by screening individuals in 10% of the households in
each of the selected village/ward for microfilaraemia. Households will be considered as the
sampling unit and all the individuals available at the time of the survey will be screened for
• microfilaraemia using finger prick method and collecting 20 pl blood between 8.00 PM to
11.00 PM. Subsequent surveys will be carried out in all the sentinel and spot-check
villages/wards before 2nd, 4th rounds of drug distribution and after 5th round.
Antigenaemia prevalence will be assessed prior to the intervention in all the sentinel and
spot check villages/wards, by screening 75 individuals from each village/ward following
simple random procedure with 25 from each of the age classes 1-5, 6-10 and 20-25 years
respectively using ICT. Post intervention evaluation will be carried out following the same
procedure to observe the change in acquisition of antigenaemia, for elimination certification
and loss rate in the peak age class. Follow up surveys will be carried out before 4th round
and after 5th round of drug administration. A total of 1200 individuals will be screened every
time for antigenaemia from each district under intensive studies.
Base line survey on geo-helminths will be carried out from sentinel and spot-check
villages/wards by screening at least 25 children in the age class 9-10 years in each
village/ward. Kato Katz technique will be followed to assess the prevalence of geo
helminths, species profile and intensity. This cross sectional survey will be repeated every
year prior to the drug distribution.
r
I
1
Entomological survey will be carried out by collecting indoor resting vector mosquitoes
from all the sentinel villages/wards. Collections will be made at fortnightly interval, by
spending 6 man-hours and searching 24 (12 fixed and 12 random) houses for a period of two
months during the peak transmission season (November to January). All the collected vector
mosquitoes with a maximum of 100 per collection from each village/ward will be dissected
for parasite infection. Details on the number dissected, number infected (any stage) and
number infective (infective stage larva) along with stage-specific density will be generated.
Follow-up collections will be carried out every year prior to each round of drug distribution.
Costing of the programme will be carried out by following itemized cost menu procedure.
Cost components, their unit cost and magnitude will be identified and quantified. Both
financial cost and opportunity cost towards diverted time will be considered. Cost profile in
terms of input and activity category will be prepared and per capita cost of the programme
will be determined.
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
I
D:\Albcn_proj\COMMON PROTOCOL final.DOC
Page 8
References
1. Ottesen, E.A. and Ramachandran, C.P. Lymphatic filariasis Infection and Disease: Control
Strategies. Parasitology Today, 1995; 11:129-31.
2. World Health Organization. 1998. Report from informal consultation on albendazole
research findings in lymphatic filariasis. WHO, Geneva.
4
3. World Health Organization. 1999. Initiative to global elimination of lymphatic filariasis
(LF) - 1999 a year of achievements. WHO, Geneva.
4. Mak JW, Sim BICL, Yen PKF. 1984. Filaricidal effect of albendazole against subperiodic
Brugia malayi infection in the leaf monkey Presbytis melalophos. Tropical Biomedicine
1: 121-23
5. Denham DA. 1980. The antihelminthic effects of albendazole on Brugia pahangi. J
Helminthology, 54:199-200
I
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^^^LlST OF VI1.LAGES / WARDS SELECTED FOR EVALUATION IN TANJORE DISTRICT
.ass
NADUCAUVERY
Mssagi
NADUCAUVERY
5374
Spotcheck
2 THIRUVALAMPOLIL
AKKINATHAPURAM
AKKINATHAPURAM
660
Sentinel
Medium
3 KABISTHALAM
KABISTHALAM
KABISTHALAM
5520
Sentinel
High
4 VEERAMANGUDI
ELANGARKUDI
UMBALAPPADI
1587
Spotcheck
Medium
5 AYYAMPETTAI
CHAKKARAPALLI
CHAKKARAPALLI
6254
Spotcheck
Medium
6 PATTESWARAM
UDAIYALUR
UDAIYALUR
2358
Sentinel
Low
7 S.P.KOVIL
S.P.KOVIL
S.P.KOVIL
5809
Sentinel
High
8 THUGILI
THUGILI
THUGILI
2326
Sentinel
Low
9 VEPPATHUR
VEPPATHUR
VEPPATHUR
3080
Spotcheck
Low
10 AMMAPETTAI
AMAPETTAI-III
PUTHUR
3484
Spotcheck
High
11 BUDALUR
KOODANANAL
THIRUKKATTUPALLI
5157
Sentinel
Medium
12 VALLAM
PILLAIYARPATTI
PILLAYARPATTI
2213
Spotcheck
High
13 MUNICIPALITY
KUMBAKONAM
25
3014
Spotcheck
14 MUNICIPALITY
KUMBAKONAM
34
3295
Sentinel
15 MUNICIPALITY
TANJORE
7
4164
Sentinel
16 MUNICIPALITY
TANJORE
41
6189
Spotcheck
NADUCAUVERY
Low
1
LIST OF VILLAGES / WARDS SELECTED FOR EVALUATION IN CHEYYAR DISTRICT
y ^L^gtlONg; gCLLIjSTERg
HSC
1 KOVILUR
ANAKAVOOR
ANAKAVOOR
3952
2 VEMBAKKAM
THIRUPANAMOOR
THIRUPANAMOOR
1690
3 THELLAR
NERKUNAM
1725
4 MELSEESAMANGALAM
PENNATHAGARAM
THIRUMANI
THIRUMANI
3162
5 VEMBAKKAM
THIRUPANAMOOR
VENKATARAYANPETTAI
547
6 KOLAPPALUR
NAMATHODU
NAMATHODU
1968
7 NASAL
VELAPADI
VELAPADI
1078
8 MULLANDRAM
SEVOOR
SEVOOR
4464
9
10 PERUNGATTUR
BRAMADESAM
VADAMANAPAKKAM
HASANAMPET
2104
VELLARI .
MULLIPATTU
ATMANUR
1336
MULLIPATTU
2616
13 CHEYYAR
WARD 13
565
14 VANDAVASl
WARD 21
1772
15ARANI •
WARD 12
2036
16 ARANI
WARDS
1830
11 SV NAGARAM
12 MALAYAMPATTI
1
<*•
LIST OF VILLAGES / WARDS SELECTED FOR EVALUATION
IN THIRUVANNAMALAI DISTRICT
iC
1 THIRUSSURPETTAI
MAMBATTU
21 ANANADAL
THANDARAI
JADATHARIKUPPAM
THANDARAI
~
3 MALAMANJANUR
4 KILPENNATHUR
5 CHETPET
6 KALASAPAKKAM
~
7 KOMMANANDAL
8 MELVILVARAYANALLUR
9 PUDUPALAYAM
THANIPADDI- II
THANIPADDI
KARUNKALIKUPPAM
MARUTHUVAMBADI
KARUNKALIKUPPAM
ULAGAMPET
~~
KILVENNIYANUR
POONDI
KARIKATHUR
THIRUMALAI
MELA RANI
VILVARAN I
PUDUPALAYAM
G.N.PALAYAM
W SU.VALAVETTI
VERAIYUR
11 PALAYANUR
SU.VALAVETTI
THATCHAMBADI
12 VETTAVALAM
ANUKKUMALAI
DEVANUR
INEIVANATHAM
13 ~
~~~~
~
WARD 7
14
15
16
WARD 1
WARD 24
WARD 14
~~
411
1915
4862
3772
1001
1144
1964
1500
2723
1775
1235
854
280
450
158
333
Spot check
MEDIUM
Spot check
HIGH
Sentinel
HIGH
'Sentinel
Spot check
LOW
HIGH
Spot check
MEDIUM
Spot check
LOW
Sentinel
MEDIUM
Sentinel
HIGH
Spot check
LOW
Sentinel
MEDIUM
Sentinel
LOW
Sentinel
Sentinel
Spotcheck
Spotcheck
. D:\Alben_proj\COMMON PROTOCOL final.DOC
Page 9
3/7/01
Table 2: Activities and time schedule
SI.
No.
Activity
1.
Sensitization and ,
advocacy
• State level
• District level
• PHC level______
Micro-plan
(implementation)
preparation at district
level_________________
Training/orientation
(health staff)
• NBS
• Stool examination
• Entomological .
2.
3.
4.
5.
r
6.
7.
I
|
8.
I
9.
Training/orientation
(Other sectors)
• IEC
• Drug
distribution
Identification of
villages/wards positive
for microfilaraemia
Selection of sentinel
villages/wards_________
Collection of baseline
data on mf prevalence
and intensity, and
antigeneamia prevalence
in sentinel and spotcheck villages/wards
Collection of baseline
data on entomological
parameters in sentinel
villages/wards_________
Collection of baseline
data on geo-helminth
prevalence in sentinel
and spot-check villages
Responsible agency
Time schedule
From
To
November 2000
December 2000
December 2000
December 2000
15 12.2000
20.12.2000
Programme manager at
district level in
collaboration with
Research Institution
4.12.2000
11.12.2000
4.12.2000
15.12.2000
20.12.2000
15.12.2000
Research institution
FIRST WEEK
OF
FEBRUARY
2000
SECOND
WEEK OF
FEBRUARY
2000
20.12.2000
15.1.2001
15.1.2001
20.1.2001
Programme manager at
district level in
collaboration with
Research Institution
Programme manager at
district level in
collaboration with
Research Institution
VCRC
20.1.2001
15.2.2001
Research Institution in
collaboration with
Programme manager
15.1.2001
20.2.2001
Programme manager/
Research Institution
10.2.2001
Research Institution
20.1.2001
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
Programme Manager in
collaboration with
Research Institution
D:\Alben_proj\COMMON PROTOCOL
3/7/01
10.
!
11.
12.
13.
14.
15.
16.
17.
18.
Family Enumeration/
updating and morbidity
survey
____________
Drug request from
PHC/district__________
Drug procurement and
supply_____ _________
Community preparation
(IEC campaign
including planning)
Drug distribution
Active surveillance for
adverse reaction_____
Serious Adverse
Experience report
Compliance survey >
Consolidation and
reporting of drug
distribution and
coverage
1.1.2001
10.1.2001
Programme manager
10.1.2001
15.1.2001
15.1.2001
15.2.2001
1.2.2001
15.2.2001
19.3.2001
23.3.2001
23.3.2001
28.3.2001
Programme manager at
PHCZ district level_____
Programme manager at
state / district level
Programme manager at
state/district/PHC level •
in collaboration with
Research Institution
Programme manager
Programme manager
19.3.12001
28.3.2001
Programme manager
1.3.2001
10.3.2001
Research Institution
26.3.2001
1.4.2001
Programme manager
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
■
VJ
Activity
^DAAlb^^rojACOMMONTRDTOCX^L’finaroOC^^
Report on
To be reported by
Documenting the process
Reporting
Format No.
1
Summary sheet on activities at district level
Documenting the process
2
Summary sheet on activities at PHC level
Drug inventory
3
Drug receipt and supply at district level
Family enumeration and drug
distribution________________
Sample survey for coverage and
compliance
4
Demographic profile and coverage at village
level________________________________
Compliance survey - questionnaire_______
Summary on estimated coverage and
compliance at district level
___________
Drug consumer monitoring form
District Level Programme
Managers______________
Medical / Health Officer of
the PHC / Municipality
District Level Programme
Managers______________
Medical / Health Officer of
the PHC / Municipality
Research organization
Research organization
5
6
7
Active surveillance for adverse
reaction
Passive surveillance for serious
adverse reaction_____________
Entomological survey for vector
infection and infectivity
Sample survey for prevalence of
mf carriers
9
Active surveillance on adverse reaction and
perceived benefit_____________________
Serious adverse experience report
10
Entomological dissection results
11
Entomological dissection summary
12
Sample blood survey - field form
13
Sample blood survey summary at PHC level
14
Sample blood survey summary at district
level
8
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
Medical / Health Officer of
the PHC / Municipality
Medical / Health Officer of
the PHC / Municipality
Medical / Health Officer of
the PHC / Municipality
District Level Programme
Managers______________
District Level Programme
Managers______________
Medical / Health Officer of
the PHC / Municipality
& Research organization
Medical / Health Officer of
the PHC / Municipality
District Level Programme
Managers & Research
organization
MT
Page 12
Sample survey for prevalence of
geo-helminths
Survey for disease prevalence
while family enumeration
Sample survey for the
prevalence of antigenaemia
15
16
17
18
19
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
Sample geo-helminth survey - field form
Sample geo-helminth survey summary at
district level_____
Summary on morbidity at district level
Sample Antigenaemia survey - field form
Sample antigenaemia survey summary at
district level
trial.'
I
Research organization
Research organization
District Level Programme
Managers
_________
Research organization
Research organization
L
D:\Alben_proj\COMMON PROTOCOL fmal.DOC
Page 13
3/7/01
IDENTIFICATION OF FILARIA ENDEMIC VILLAGES/WARDS
DISTRICT
RURAL
URBAN
Existence of information on mf prevalence
r
ZL
YES
NO
SELECT 50 ENDEMIC VILLAGES
AND 30 ENDEMIC WARDS
SELECT 50 % PHCS/
MUNICIPALITIES AT RANDOM
SELECT 10 VILLAGES/WARDS OR 10% OF THE TOTAL VILLAGES/WARDS WHICHEVER IS
HIGHER PER PHC/MUNICIPALITY ,BY USING CYCLIC SYSTEMATIC SAMPLING AFTER
ARRANGING THEM IN ASCENDING ORDER OF POPULATION
SELECT 30 HOUSEHOLDS IN EACH VILLAGE/WARD FOLLOWING SYSTEMATIC SAMPLING
PROCEDURE
-------------------------------- ----------- 1
I
________ PM
VILLAGE/WARD WITH AT LEAST ONE MF CARRIER
r
YES
NO
mF+VE
VILLAGE/
WARD
mF-VE
VILLAGE/
WARD
£
I
F
I
ft- '
K?'.'
I
—I-----------------------
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
D:\Alben_proj\COMMON PROTOCOL fmal.DOC
Page 14
3/7/01
SELECTION OF SENTINEL SITES AND COLLECTION OF BASE
LINE DATA ON MICROFILARAEMIA AND TRANSMISSION
mF +VE VILLAGES
mF+VE WARDS
STRATIFY BASED ON MF
PREVALENCE
(PERCENTILE)
LOW
MEDIUM
HIGH
SELECT BY CYCLIC
SYSTEMATIC SAMPLING
WITH WEIGHTAGE TO
POPULATION SIZE
!
3 VILLAGES FROM EACH AS
SENTINEL SITES BY SIMPLE
RANDOM - WEIGHED TO
POPULATION SIZE
2 WARD AS SENTINEL SITES
BY SIMPLE RANDOM WEIGHED TO POPULATION
SIZE
SELECT SENTINEL VILLAGESAVARDS AND EQUAL NUMBER OF...
SITES AS SPOTCHECK SITES ANDGENERATE BASE LITQE DATA ON
MICROFILARIA
PREVALENCE WITH A
MINIMUM 10% SAMPLING
FRACTION FROM EACH SITE
TRANSMISSION PARAMETER FOR
TWO MONTHS AT FORTNIGHTLY
INTERVALS - 6 MAN HOURS PER
COLLECTION - SENTINEL SITES
ANTIGENAEMIA PREVALENCE IN
THE AGE CLASS 1-5, 6-10 & 20-25
YEARS WITH 25 FROM EACH AGE
CLASS FROM EACH SITE
GEO-HELMINTH PREVALENCE IN
THE AGE CLASS 9-10 YEARS - 25
CHILDREN FROM EACH SITE
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
i
D:\Alben_proj\COMMON PROTOCOL final.DOC
Page 15
3/7/01
IDENTIFICATION OF FILARIA POSITIVE VILLAGES IN A DISTRICT
FOR SELECTING SENTINEL VILLAGES FOR IMPACT ASSESSMENT
•3
Purpose: To identify 50 villages and 10 wards that are positive
[ ’ ’ for mf prevalence for
forming the universe from which sentinel villages could be selected to assess the
impact using microfilaria prevalence and intensity as the indicators
Steps:
I. Selection of endemic PHCs
II. Screening of villages/wards for positive villages/wards
III. Categorization of positive villages based on local (district) prevalence
IV. Selection of sentinel villages and spot-check villages
l
Steps II and I will be carried out by the programme personnel at state/district level in close
co-ordination with the respective research institutes. Step III will be carried out by the
VCRC, Pondicherry. The respective research institutes should carry out step IV.
I.
I
Selection of endemic PHCs: (use one the following options depending upon the local
situation)
a. If village (rural)/ward (urban) wise information on microfilaria prevalence is available in
a district, list out all the positive villages/wards. A minimum of 50 villages and 10 wards
should be identified. If the required number of villages and wards are identified from the
existing records, furnish the details in the following format and send it to “The Director,
Vector Control Research Centre, Indiranagar, Pondicherry - 605 006”, with a copy
to District level Health administrator. The VCRC will determine the sentinel villages
based on this data.
Name of the PHC:
E
K
Kk;
I
Bg:.;-
Sl.N
o.__
_1__
2
Name of the
village
Name of the district:
No. persons
examined
No. persons
found positive
(%)
Population of
the village
(OR)
b. If the number of positive villages/wards based on earlier records is less than 50 and
10 respectively, conduct microfilaria surveys in more villages from
PHCs/Municipalities that have recorded mf positivity in the past so as to reach the
target of 50 positive villages and 10 positive wards.
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
I-
Mf rate
1
D:\Alben_proj\COMMON PROTOCOL final.DOC
Page 16
3/7/01
(OR)
c. Randomly select 50% of the total PHCs/municipalities in a given district. From each
PHC/municipality, select 10 villages/wards or 10% of the total villages/wards which ever
is more by following cyclic systematic sampling. Conduct night blood survey for
SO^ear^13
SCreening 60 individuals (include both sexes) in the age class 15-
Vllla8e.s/wards for scr^enit,g: (*f you have selected options lb or Ic, please
proceed as under till the end of this document. This does not apply if you have selected the
option la)
SI.No
Village Population Selected
•
•
!
•
Prepare list of villages/wards
with population for each
PHC/municipality
Arrange the villages in
ascending order of population
size
Work out the class interval
by dividing the total number
of villages by ten
E.g. If there are 33 villages in a
PHC, the class interval is equal to
33/10=3.3. This figure should be
rounded to the nearest whole
number - in this case 3.
From the list of villages the
first village will be selected
by using the random number
between 01 and 'the total
number of villages (say the
random number 11 and the
first village will be lllh
village
• The second village will be
this random number i.e. 11
plus the class interval i.e. 3
here. So the second village
will be 14lh village in the list.
Similarly the third village
will be 14+3=17th village and
so on.
• In case of reaching the last
village in the list before 10
villages are identified, the
•
i
Name
1lxxx
2 xxx
3 xxx
4 xxx
5 xxx
6 xxx
7 xxx
8 xxx
9 xxx___
10 xxx
11 xxx
12lxxx
13 xxx___
14 xxx
15 xxx
16 xxx____
17 xxx____
j8w(____
19 xxx____
20 (xxx
21 xxx
22 xxx
23 xxx
24 xxx
25 xxx
26 xxx
27 xxx
28 xxx
29 xxx
30 xxx
31 xxx
32 xxx
33]xxx
VECTOR CONTROL RESEARCH CENTRE, PONDICHER.RY
villages
223
324,
400
454
509
565
622
680
739
799'
860'
922'
985
1049 ~
1114
1180~
1247
1315"
1384
1454
1525
1597
1670
1744
1819
1895
1972
2050
2129
2209
2290
2372
2455
9
10
2
z.
5
6
7
8
J
l
&
I
•c
¥
r
D:\Alben_proj\COMMON PROTOCOL fmal.DOC
Page 17
3/7/01
selection of next village will continue from the beginning of the list again. For e.g. in this
case, the selected villages are 11, 14, 17, 20, 23, 26, 29, 32, 2 and 5. In this example
villages of serial number 2 and 5 are selected by adding the class interval 3 with 32. Here
the cycle continued to the beginning of the list to complete the required 10 villages.
-
1. From each of the selected village/ward, identify 30 households in the selected villages,
spreading over to the entire village.
This can be achieved by systematic sampling procedure with household as the sampling unit.
Identify the first household by a random start. The subsequent households can be identified
by adding the class interval to the first household. Class interval can be determined by
dividing the total number of households by 30.
In case, the selected household is locked or people are not available, sample the people in the
adjacent household.
Collect blood smear from all the available individuals in the age class (include both sexes)
15-30 years from the selected households using finger prick methods and( collecting 20 pl
blood (3-4 drops approximately) between 8.00 PM and 11.00 PM.
2. A village is declared positive even if one mf carrier is detected.
I
3.• Furnish the details in the following format and send it to “The Director, Vector Control
Research Centre, Indiranagar, Pondicherry - 605 006”, with a copy to District level
Health administrator. The VCRC will determine the sentinel villages based on this data.
Name of the PHC:
SI.
No.
1
2
Name of the
village
Name of the district:
No. persons
examined
No. persons
found positive
I'
VECTOR CONTROL RESEARCH CENTRE, PONDICHERRY
I
Mf rate
(%)
Population of
the village
FORM:ENT
FORMAT: 11
ENTOMOLOGICAL DISSECTION - SUMMARY *
NAME OF THE DISTRICT:
DATE:
REPORTED BY *:
VILLAGE
NAME
Dissected
1
2
3
4
5
6
7
8
9
il
No. parasites detected
Infected Infective Any stage
L3
NUMBER OF MOSQUITOES________
collected
10
TOTAL
WARD
1
2
TOTAL
GRAND TOTAL
* : TO BE FILLED IN BY THE DISTRICT LEVEL OFFICERS
FORM:SBS
FORMAT 12
SAMPLE BLOOD SURVEY - FIELD FORM
DISTRICT:
■
K.
VILLAGE/WARD
PHC/MUNICIPALITY:
Street Name :
Date:
Collected by:.
Examined by:
Id No.
Door
Name
Relationship
Age
Sex
No.
I
I
cI
*:: Enter the actual count after examination
Samples should be drawn after 8.00 PM anf for each street start at a new page
Slide
No.
Mfc*
FORM:SBS SUMMARY
FORMAT: 13
SAMPLE BLOOD SURVEY SUMMARY AT PHC LEVEL*
NAME OF THE PHC:
REPORTED BY * :
SI.No.
VILLAGE
DATE:
POPULATION
No. SMEARS
COLLECTED
No, WE
FOR MF
1
2
3
4
5
6
7
8
9
I
10
11
12
i*'
13
Ul
15
16
17
18
19
L
201
* : TO BE FILLED IN BY THE MEDICAL / HEALTH OFFICERS OF PHC/MUNICIPALITY
TOTAL
MF
FORM:SBS SUMMARY
FORMAT: 14
SAMPLE BLOOD SURVEY SUMMARY AT DISTRICT LEVEL*
!
NAME OF THE DISTRICT:
DATE:
REPORTED BY * :
SI.No.
VILLAGE
PHC
POPULA-
No. SMEARS
No. +VE
TOTAL
TION
COLLECTED
FOR MF
MF
1
2
3
4
5
6
U'
7
8
9
10
*
11
12
13
14
15
16
17
18
19
20
*: TO BE FILLED IN BY THE DISTRICT LEVEL OFFICERS
fI
I
ronuvi.v-Ji—o
i oiaivimi; io
SAMPLE GEO-HELMINTH SURVEY - FIELD FORM*
NAME OF THE DISTRICT:
DATE:
NAME OF THE VILLAGE/WARD
NAME OF THE PHO:
REPORTED BY * :
SI.No.
NAME
FATHER’S
DOOR
NAME
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
T(^be filled by research organisation
eps : egg per smear
------epg#: egg per gram
AGE
SEX
EGG COUNT
ROUND WORM
HOOK WORM
WHIPWORM
eps
eps
eps
epg#
epg#
epg#
FORM:SBS SUMMARY
FORMAT: 16
SAMPLE GEO-HELMINTH SURVEY SUMMARY
AT DISTRICT LEVEL
I
NAME OF THE DISTRICT:
REPORTED BY * :
Sl.No.
VILLAGE
DATE:
PHC
NO. SAMPLES
COLLECTED
POSITIVE
1
2
3
4
5
6
7
8
9
I
10
11
12
13
14
15
16
1
17
18
19
20
21
22
23
!
24
25
26
27
28
*: TO BE FILLED IN BY RESEARCH ORGANISATION
I
No.
SPECIES
DENSITY
FORM:DISEASE
SUMMARY ON MORBIDTY AT DISTRICT LEVEL
NAME OF THE DISTRICT:
FORMAT: 17
_ REPORTED BY *:
DATE:
ISI.No.
VILLAGE
PHC
POPULATION
HYDRO)
MALE I FEMALE I TOTAI
CELE
1
2
3
4
5
6
7
8
9
10
I
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
*1
26
27
28
29
30
: TO BE FILLED IN BY THE DISTRICT LEVEL OFFICERS
LYMPHOEDEMA
MALE | FEMALE
TO1
FORMJCT
FORMAT 18
SAMPLE ANTIGENEAMIA SURVEY - FIELD FORM*
- DISTRICT:
VILLAGE/WARD
PHC/MUNICIPALITY:
Street Name :
Collected and examined by:
Id No.
Door
Date:
Name
No.
r
I
1
* TO BE FILLED BY RESEARCH ORGANISATION
Father’s
Name
Age
Sex
ICT
Result
No.
+ve/-ve
FORMAT: 19
FORM:SBS SUMMARY
SAMPLE ANTIGENAEMSA SURVEY SUMMARY AT DISTRICT LEVEL*
DATE:
NAME OF THE DISTRICT:
REPORTED BY *:
SI.No.
VILLAGE
PHC
POPULA-
TION
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
‘ TO BE FILLED BY RESEARCH ORGANISATION
Ii
No. SCREENED
No. +VE
FOR Ag
information leaflet on albendazole in hie elimination of
FILARIASIS FOR PROVIDERS
(If you are helping someone else to take albendazole,
read this leaflet before
administering treatment)
What is albendazole?
Albendazole is a broad-spectrum anti-helminthic drug effective against
roundworms, hookworms, whipworms, pinworms, strongyloidosis, tapeworms
ncurocysticcrcosis, larva migrans (visceral and cutaneous) and hydatid disease It
is also effective against a common intestinal infection, giardiasis. Coa ministration of albendazole with DEC has marginally better effectiveness on
lymphatic filanasis.
How is it available?
It is available as chewable tablets (200mg & 400mg). For children, it is also
available as a suspension (2% & 4%)
What is the dose of albendazole?
The dose depends on the infection to be treated. The table below gives the dosage
schedule for different infections
°
_______ Infections
Intestinal worms
Strongyloidosis
Giardiasis
Hydatid disease
Tapewonn_____
Neurocysticercosis
_ ________ DOSE
A single dose of 400 mg
400 mg per day X 3 days
400 mg per day X 5 days.,
15 mg / kg / day X 4 weeks
400 mg / day
X 3 days
15 mg / kg / day X 2 - 4
weeks
What are the advantages of giving albendazole?
•
•
•
1
It has a single dosage schedule.
Mild discomfort if you are having worms.
Effective against large number of intestinal worms.(wide spectrum) '
What should be considered before taking albendazole?
You must not take albendazole if you are allergic to albendazole or any similar
type of medicine used to clear parasites
2. If you have ever had an allergic reaction (such as a rash) when taking another
worming preparation, you should tell persons responsible for drug administration
before you take albendazole
3. Albendazole should not be taken during pregnancy (Before taking albendazole,
you should tell the person responsible for drug administration if you think you
may be pregnant).
4. Albendazole is not recommended for lactating mothers and children under 2 years
of age (There is no evidence to suggest that single dose albendazole therapy
presents a risk to the development of breast-fed babies, but please exercise
caution and if you or the baby experience unusual effects tell the person
responsible for administering treatment or your doctor at once)
5. Albendazole should not be given to people who have fever, liver and kidney
disorders.( You must tell the person responsible for drug administration if you are
taking any other treatment)
1.
How and when should albendazole be given?
Albendazole tablets can be chewed or swallowed. It can be taken anytime during
the day and preferably after food to minimize the side reactions. No special
fasting or purgative is required with albendazole treatment
What are the side reactions to albendazole?
Side reactions following administration of a single dose as for worm infections
are minimal. Some of the side reactions that may be observed are epigastric pain,
nausea, vomiting, headache and dizziness. If the symptoms become severe or if
the person develops rashes or itching, the health worker should be informed and
the doctor consulted at once.
Are there serious side reactions to giving a higher dose of albendazole or its
prolonged use?
I
Yes. High dose of albendazole or its prolonged use can cause abnormalities in the
liver function, bone marrow depression and alopecia. However, these reactions do
not occur with a single dose as is given for intestinal worms.
Has albendazole any action on filarial parasite ?
♦
*
Albendazole, when given in high dosages (400 mg / per day for 3 weeks) has
been shown to kill the adult filarial parasites.
In a single dose, it is likely to damage the adult parasite, but inadequate to
clear parasitaemia by itself.
3
•
i
•
•
I
Therefore, single dose albendazole alone is not indicated for treatment of
parasite carriers.
Co-administration of DEC and albendazole is comparable to DEC alone in
terms of tolerability.
The co-administration of the two drugs has similar or marginally better
effectiveness compared to DEC.
Why to give albendazole together with DEC for controlling filariasis?
r
There are several reasons for using albendazole in filariasis control programs such
as:♦ When albendazole is co-administered with DEC, the deworming effect of
albendazole is likely to be perceived and appreciated by the community and
hence might increase the compliance. DEC will thus be taking a piggy ride on
albendazole
♦ The community and particularly children will benefit indirectly by the
deworming effect of albendazole resulting in an improvement in growth and
nutritional status
♦ It will be cost-effective to have a single program to control two infections of
public health importance namely filariasis and geohelminths
♦ Albendazole also has some anti-filarial action and hence the co-administration
of DEC and albendazole will have a sustainable effect against filariasis than
DEC alone
Donor of albendazole
For the filariasis elimination program, albendazole is donated by GSK for under
the auspices of WHO Lymphatic Filariasis elimination .
I
(
!
D:\Alben\ALB-INF.doc
Issued by Vector Control Research Centre, Pondicherry, Tuberculosis Research Centre, Chennai and
Department of Public Health, Tamil Nadu
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FILARIAL LYMPHOEDEMA REDUCTION BY SURGERY IMMEDIATE AND LATE RESULTS
S. Jamal and S. P. Pani
City Hospital (formerly Medical College), Thanjavur (S.J), and Vector Control Research
Centre, ICMR (S.P.P) Pondicherry. INDIA
INTRODUCTION:
For the last three decades for filarial lymphedema of the legs the first author has been doing
lymph Nodo Venous Shunt (NVS) (1) and if needed staged excision. In this paper
immediate and late results of 82 cases are presents.
MATERIAL AND METHOD:
All patients with filarial lymphedema were managed by as per our protocol (2). Those who
desired to have the lymphedema reduced further were subjected to NVS at groin (1) and if
needed staged excision in one to five stages at 10 to 12 days interval. Only unilateral
filarial lymph edema cases examined by the same author repeatedly were selected for this
study, and those who had acute inflammation within the past two months were excluded.
There were 82 patients with unilateral lymphedema, equal number of males and females,
their ages ranged from 10 to 73 years. NVS alone was done in 29 cases and additional
staged excision numbering up to five were done in 53. The follow up period was 2 to 10
years. For evaluating the edema, circumference measurements from fixed points (1,3,4,)
was done prior to surgery, at the time of discharge form the hospital, and at each follow up
visit. The edema is calculated as the difference in the sum of circumferences of the affected
to the normal limb, and the reduction of edema from pre to post operation and in the follow
up period. Twenty-nine patients had only NVS and their hospital stay ranged form 7 to 10
days (average 8 days) and the follow up period 2 to 9 years (mean 4.3 years). Fifty nine
patients had in addition to NVS, staged Excisional surgery, their hospital stay ranged from
21 to 90 days (average 36 days) and their follow up period 2 to 10 years (mean 5.4 years)
RESULTS:
In those cases were NVS alone was done (N: 29) the reduction of edema volume at the
time of hospital discharge (immediate) was 85.4% in an average period of 8 days hospital
stay. In those cases were additional Excisional surgery was done (N: 53) the reduction was
84.4% in an average period 36 days of hospital stay Table l, Fig 1. For the late results the
follow up period for NVS alone (2 - 9 years) the mean duration was 4.3 years, and the
reduction 78.3%, and for those who had additional excision the follow up period (2- 10
years) the mean duration was 5.4 years, and the reduction 76.3%. Table 2, Fig.2 and 3.
Unlike in conservative management, there was decrease in edema volume in the presence
of septic foci in both the groups but to a lesser degree.(2) In the late results for both groups
the change in the percentage of edema were not statistically significant with regard to age
and gender or with respect to the presence or absence of septic foci.
i
I
1
148
DISCUSSION:
In the Indian scenario conservative management of filarial edema gives some reduction in
grade II but much less reduction in grade III but both these are negated in the presence of
recurrence of septic foci (2). On the contrary daily administration of Coumarin showed
sustained reduction (5) but has to be given for a long time. For faster and sustained results
we resorted to surgery. NVS at groin provides a by pass for the lymph to drain into venous
system at the lower most lymph node level. This works well if the limb is elevated while
sleeping. The surgery has to be advocated only to those who showed reduction or maintain
the same level of edema with medical treatment and request for further reduction. The NVS
remains patent for a long time provided there has been no acute secondary inflammatory
attack. This evidenced by keeping the lymph elevated overnight and noting the extent of
edema reduction Fig 4.
J
I
Tabled
Surgery for filarial edema initial results
NVS Alone average 8 days stay
NVS + Excision average 38 davs
Gender
No.
%reduction
SEM
No.
%reduction
SEM
Female
14
88.1
13.6
27
80.5
3.7
Male
15
82.8
8.1
26
88.1
10.6
All cases
29
85.4
4.8
53
84.4
5.2
Table 2
Surgery for filarial edema late results
NVS Alone mean follow up 4.3 years
NVS + Excision mean 5.3 years
Gender
No.
% reduction
SEM
No.
% reduction
SEM
Female
14
71.5
6.3
27
70.1
6.3
Male
15
84.6
6.6
26
82.0
9.5
All cases
29
78.3
4.6
53
76.3
5.4
Absent
25
80.7
4.6
28
80.0
8.8
Present
4
63.0
2.6
25
65.9
8.8
Septic foci
I
1:
B
1
In grade III cases (circumference difference between normal and edematous leg more than
5 cm at one or more sites) (3) additional staged excision is required to remove the baggy
skin, fibro- fatty subcutaneous tissue and to correct the folds and bulges in the leg. To
preserve the vascularity of the flaps and to get an acceptable size and shape of the leg the
excisional surgery has to be staged at 10-12 day's interval. The immediate result shows
greatest edema reduction at the shortest time. As with other methods of treatment for
edema, the reduction in edema can be maintained only by continued supportive measures
like wearing bandage/stocking, foot care and prevention/treatment of secondary infection.
However in the Indian scenario due to socio- economic, climatic, and cultural reasons the
■i
1
I
149
I ' patients more often abandon the supportive methods iin the long run. Even then the late
I
i:
results in our study shows that edema reduction is sustained for a long time.
CONCLUSION:
For filanai Lymphedema NVS and Excisional surgery provide high degree of edema
reduction at the shortest time. The late results show the reduction is sustained for a long
time and is the best for Grade III edema which otherwise will progressively increase.
Fig 1. a. Pre-op b. 8 days after NVS. c. After first stage excision, d. After three excisions
I
Fig 2. a. Pre op. b. After five staged excision, c. After six years. D. After ten years
150
-
■
C
[3 >
£
i
.
If ! th
i
I
Fig 3: a. Pre - op. b. After four stages for left and three stages for right leg excision.
c. After eight years follow up
Fig 4\ a. Pre-op. b. After three stage excision, c. After 7 years - recurrence, d. Reduction
after overnight elevation showing the NVS is functioning
References:
1.
Jamal,S., Lymph Nodo Venous Shunt in the Treatment of filarial Elephantiasis: In
Progress in Lymphology VII - Eds. Horst Weissleder. Valdimir bartos, Leo Clodius et
el. Avicenum. Czechoslovak Medical Press. Prague 1981 p 250 -51
2.
Jamal,S., S.P.Pani: Long term follow up of Filarial Edema with Conservative
Management. In this XVII International Congress of Lymphology under Filariasis.
3.
Jamal.S. Grading of chronic lymphedema further refinement proposed - In Progress i
Lymphology XI - Ed H.Partsch . Excerpta medica. Amsterdam 1988,p 505 - 8
4.
Jamal,S: Failure in Lymphoedema Treatment - The patient factor - Lymphologv
3 1 (suppl): 1998 ,p 403-6
5.
Casley Smith JR., S.Jamal.. Judith Casley Smith: Reduction in filaritic lymphedema
and elephantiasis by Coumarin and the effects of DEC. Ann.Trop.med.parasitiol 1993;
87 p247 -58
^15 -^3’17
Tropical Medicine and Internationa! Health
VOLUME 8 NO I PP 56-59 JANUARY 2.00}
Treatment seeking behaviour and costs due to acute and
chronic forms of lymphatic filariasis in urban areas in south India
B. Nanda and K. Krishnamoorthy
Vector Control Research Centre, Pondicherry, India
Summary
•
Previous estimates on the economic burden of lymphatic filariasis (LF) in India and elsewhere were
primarily based on studies in rural areas. We investigated the treatment costs due to acute and chronic
forms of LF in urban areas, where nearly one-third of the affected people live. Almost 98% of the
patients with acute <episodes of adenolymphangitis (ADL) underwent treatment and 49% of chronic
patients also received treatment.
The- average treatment cost per ADL episode (n = 108) was
.........
Rs 22.21 ± 53.84 (USS 0.46 * 1.12). The overall (n = 200) treatment costs incurred by a chronic
patient per visit were Rs 16.71 — 62.36 (USS 0.35 x I.jO); for those who paid (n — 98) they were
Rs 34.10 ± 85.90 (USS 0.71 ± 1.79). These costs are considerably higher than-in rural areas.
Government health centres and private practitioners were important sources of treatment. Treatments
received from private practitioners were considerably more expensive than those from government
health facilities. The cost of medicine accounted for 44% and 50% of the total expenditure on treatment
for acute ;and' chronic
’
disease patients, respectively. The medical personnel from these treatment sources
need to be-------------------trained on the
new
morbidity
management
methods,
which
new
morbidity
management
methods,
which
are likely to be more effective
than the current methods of treatment.
keywords lymphatic filariasis, treatment costs, acute disease, chronic disease, urban areas, India
correspondence B. Nanda, Vector Control Research Centre (Indian Council of Medical Research),
Medical Complex, Indira Nagar, Pondicherry 605 006, India. Tel.: +91 413 272 396;
Fax: +91 413 272 041; E-mail: vcrcC^vsnl.com
Introduction
Lymphatic filariasis (LF) is widely prevalent in developing
countries andJ approximately 120 million people living in
BO countries :are infected. Globally, LF is the second
leading cause: of permanent and long-term disability
(WHO 1995). India is a major endemic country for LF.
About half of its population is exposed to the risk of
infection and an estimated 48.11 million people are infec
ted (WHO 1994). Recent estimates, based on the immu
nochromatography card test, suggest that the infected
population could be 116 million in India (Das ei al. 2001).
Quantification of the social and economic burden of LF has
been identified as a priority research area in view of the
ongoing LF elimination programme.
Studies in India (Ramaiah et al. 2000) and Ghana
(Gyapong et al. 1996) showed that LF inflicts considerable
social and economic burden on the affected communities.
The annual economic loss in India alone was’estimated at
close to. I billion USS. These estimates have also helped to
show that rhe benefits of control/elimination of LF through
annual mass treatments are much higher than the costs
(Ramaiah et al. 2000). So far, the estimates of labour loss
and treatment costs have primarily been based on the data
collected from rural areas. However, a considerable
proportion of LF patients live in urban areas and infor- •
mation on costs incurred by them on treatment is scarce.
Therefore, we undertook this study, in the urban region of
Pondicherry in s.outh India to assess the LF-related treat
ment costs of various treatment, sources and the factors
determining their choice. We also studied treatment
seeking behaviour, which will be useful in developing
morbidity management strategy towards elimination of LF.
Study area
The study was conducted in three urban areas - Cuddalore,
Villupuram and Pondicherry located about 160-180 km
south of Chennai in south India. Cuddalore and Villupuram
are the district headquarter towns and Pondicherry is the
headquarter town of the union territory of Pondicherry. All
three study areas - Cuddalore, Villupuram and Pondicherry
56
2003 Blaocwell Puunsning Lid
i'
VOLUME 8 NO I PP 56-59 JANUARY XOO?
.nd International Health_________ _________
Tropical Medicine ai
Treatment costs of lymphatic filarias is
B. Nanda &C K. Krishnamoorthy
4
1 991 The disease rate was j-6 /o.
census data of 1991.
inclucje
The health-care facilities in
hospitals
government run general ”Sp^cS?sively for the treatment
.
run by private practition ^ational Filaria
„f LF. all rhe three
run by the state
COntrOmentgThmeXwces offered by filarial clinics include
X for tnicrofilana (mf) and treatment of
ation of lymphoedema and hydrocoele among
respondents was 12 and 6 years.
rap„a.™ («.!*!
? s0/ were
“'Xi"— ”>
< "«■ *• ’”%
■hi
""
<25 US$ per month.
Treatment seeking for acute episodes of ADL
mf carriers and chronic patients.
Methods
A total of 110 (55%) chronic patients reported occ"r“ce
of ADL episodes during the 1-year period prior to thl
of ADL episoa
g
a
nt 309
A list of chronic panents-in all localises of Cuddalore and
Villupuram is kept by local
panents) were selected ustng systemanc random sampl ng
P Asemi-structured interview schedule was used to col lee
the mformation on treatment seeking behavour an1 costs
treatment The interview schedule was initially prepared i
English and translated mto Tamil. The Tamil verston of the
ql.e.n.,nnn.re was pre-tested on a few pat.enn’
neC”S^
tnodifkatmm. were made and used in the study. Two teams
of two members each administered the questionnaires to the
patients. The study was conducted during 1999-2000.
For each respondent, information on sex, age, occupa
•
tion. educational qualification and income level was
collected. The questionnaire included the following ques
tions: (1) Did he/she undergo treatment for the disease
condition (acute or chronic disease)?. (2) If yes, what were
the sources of treatment? (3) What was the type of
treatment received? (4) Why did he/she choose a particular
source of treatment? and (5) How much expenditure was
incurred on treatment in terms of doctor s fee, medicines,
investigations, travel, etc?
To assess the costs due to chronic disease, all 200
patients were visited once during the study period and
expenditures noted in detail. We also explained the char
acteristics of acute adenolymphangitis (ADD (Ramaiah
et al. 1 996) and asked patients if they had suffered any
episodes in the past year. If so, the details on treatment for
the most recent ADL episode were documented.Data were analysed using the SPSS program.
Results
Of the 200 chronic patients interviewed, 87 (43.5%) were
male; 158 (45 males and 113 females) had lymphoedema
“Snw
goveramen.
im <’«c«
se|(.,Ita[ed m.h medicine
-irr^-XKlTK.pm
Pn™n.,ISd.seeking treatment from government-sources was 47 Am
Pondicherrv compared with 34% in Cuddalore and 30 Am
Villupuram. About 6.5% of the patients sought treatment
from the NFCP clinics. Self-treatment was more common
in patients with lower levels of income. Affordability was
the reason for 30-47% of the respondents to seek care
from public health care facilities and for 35.2% from drug
sellers, while credibility or confidence in the provider
prompted some patients to seek treatment from private
clinics.
108)
The average treatment cost per ADL episode (n
was Rs 22.21 ± 53.84 (USS 0.46 = 1.12). It was
5.66 = 19.03 (USS 0.12 = 0.40) for males and
17.23 = 64.88 (USS 0.36 = 1.35) for females. The mean
treatment costs per ADL episode in different studv areas
and with different treatment sources are given in Table 1.
Thev were in the range of Rs 20.68 = 27;74 (USS
0.43 = 0.57) to 24.09 = 27.05 (USS 0.50 = 0.56). How
ever, treatment costs were much higher at private medical
practitioners: 77.28 = 91.07 (USS 1.61 = 1.89) (Table 1). •
Nearly 44% of the total expenditure was incurred for
. .
medicine (Table 2).
Treatment seeking for chronic disease
Of 200 patients interviewed, 98 (49%) underwent treat
ment for chronic disease manifestations at least once
during the 1-year period preceding the interview and all
had incurred expenditure. Fifty-eight per cent of the
57
& 2003 Riao-well Publishing Ltd
VOLUME 8 NO I PP 56-59 JANUARY 2.OO3
Tropical Medicine and International Health
B. Nanda &£ K. Krishnamoorthy Treatment costs of lymphatic filariasis
Table I Costs (in rupees) of treatment for ADL episodes in
different study towns and with sources of treatment
Mean treatment costs (SO)
Category'
Discussion
Previous estimates on the economic burden of LF were
based on studies conducted in rural areas. Similar infor
mation from urban'areas is necessary because nearly one-
Study area
Cuddalore
Viilupuram
Pondicherry
24.09 (27.05)
20.68 (27.74)
22.18 (67.84)
Treatment source
Government run clinics/hospitals
Private practitioners
Self-treatment
10.08 (11.10)
77.28 (91.07)
2.40 (2.74)
third of the LF burden in India originates in urban areas
(Rao & Sharma 1986). Our study showed that treatment is
considerably more expensive in urban areas. For example,
while 98% of the patients affected with ADL episodes
underwent treatment and incurred expenditure in urban
areas, only 62.84% of the patients underwent treatment
and 51% spent on treatment’in rural areas. Only 26.8% of
the ADL patients consulted either qualified or registered
medical practitioners whereas in urban areas for nearly
64.8% of the episodes, patients consulted the medical
Table 2 Disrrihudon of treatment costs (in rupees) for ADL epi
sodes (w = 108) and chronic disease (n = 98) with respect to input
ADL patients
Chronic patients
personnel. On average, per ADL episode, the patients spent
Rs 2.35 (USS 0.05) in rural areas (Ramaiah ct al. 1998)
compared with Rs 22.21 (USS 0.46) in urban areas. While
75% of the chronic patients in rural areas consulted the
Input
Costs
Proportion
of total (%)
Medicine
Travel
Doctor tee
Clinical rests
1069
750
’ 370
210
44.6
31.3
15.4
8.8
Costs
1684
633
700
325
Proportion
of total (%)
50.4
18.9
21.0
9-7.
hydrocoele patients underwent treatment compared with
45.6% of rhe lymphoedema patients. The proportion of
male and female patients who underwent treatment was
54.2% and 46.9%, respectively. Seventy-one per cent of
doctor, about 49% did so in urban areas. Fifty-two per
cent of the rural and 49% of the urban patients incurred
expenditure on treatment. On average, each chronic
patient spent Rs 16.71 (USS 0.35) in urban areas compared
with Rs 8.32 (USS 0.17) in rural areas (Ramaiah et al.
1999).
The above data suggest that LF patients in urban areas
spend more on treatment than patients in rural areas.
Hence, the overall economic burden must be higher than
the current estimates, which are based on only rural areas.
’ However, in the total economic burden imposed by LF
treatment costs account for 3.9% and the remaining
the chronic patients (n = 98) preferred treatment from
burden is due to the loss of labour (Ramaiah ct al. 2000).
public health facilities, 26% from private practitioners and
Therefore, updating the economic burden estimates
requires data on treatment costs and also labour loss from
3% underwent self-treatment. Seventy-one per cent
sought treatment from government sources: 48% from the
NFCP clinics and 23% from other government health
sources. Affordability was the main reason for treatment
at public health facilities and self-treatment from drug
sellers, whereas accessibility was the major reason for
seeking care from private clinics.
urban areas. While our study provides information on the
treatment costs in urban areas, further studies are necessary
to understand the labour loss due to LF.
Government health facilities are the major sources of
.
treatment for LF patients. Credibility (confidence) and
satisfaction with the attitude of the provider and perceived
The overall (n = 200) treatment cost incurred by a
benefits of the treatment as well as accessibility of clinics
chronic patient per visit was Rs 16.71 = 62.36
(USS 0.35 = 1.30); for those who paid (n = 98) it was
are the factors that prompted patients to seek treatment for
Rs 34.10 = 85.90 (USS 0.71 ± 1.79). Among those who
ADL from private clinics. Affordability is the major cause
for seeking treatment from public health care facilities and
(USS 1.38 = 2.28); for lymphoedema, 26.91 * 78.79 (USS
drug sellers. Morbidity management and alleviating the
suffering of chronic patients is an important component of
0.56 * 1.64). Males paid 36.97 ± 75.59 (USS 0.77 ± 1.57)
the LF elimination programme (Siem et al. 1999).
and females 31.66 ± 94.42 (USS 0.66 * 1.96). Nearly 70%
Recently, new and effective strategies that focus on leg
of the costs were incurred on medicine and doctors fee
hygiene, elevation, exercise and other palliative care have
paid, the costs for hydrocoele were Rs 66.06 * 109.21
(Table 2). Private treatment was more expensive at Rs
been developed (Dreyer et al. 2000). The medical and
120.96 (USS 2.52), in contrast with the cost of self
paramedical personnel in the government health facilities
treatment. which was Rs 2.88 (US$0.06).
and also private practitioners should be trained in these’
58
(ci 2003 BlacKwell 'Ruousnmg Ltd
■
Tropical Medicine and International Health
B. Nanda
K. Krishnamoorthy
VOLUME 8 NO I PP 56-59 JANUARY ZOO3
Treatment costs of lymphatic filariasis
measures, which are likely to provide better relief to the LF
patients.
Acknowledgements
The authors thank Dr P. K. Das; Director, Vector Control
Research Centre, Pondicherry for his support. We are
grateful to Dr K. D. Ramaiah for his suggestions on the
manuscript. Thanks are aiso due to all the participants of
the study for their honesty and openness in providing
information.
References
Das PK. Ramaiah KD, Augusun DJ it Ashok K (2001) Towards
elimination of lymphatic filariasis tn India. Trends in Para
sitology 10. 457—460.
Drever G, Addiss D. Bettinger J, Dreyer P. Noroes J & Rio F
(2000a) Lymphedema Staff Manual. Part I. Learner s Guide.
WH(), (ieneva.
GyapongJO, Gyapong M, Evans DB. Aikins MK & Adjei S (1 ^96)
’ The economic burden of lymphatic filariasis in northern Ghana.
Annals 0/ Tropical Medicine and Parasitology 90, 39—48.
Ramaiah KD, Ramu K. Vijay Kumar KN
Guyatt H (.1996)
Epidemiology of acute filarial episodes caused by Wuchercna
hancrofti infection in two rural villages in Tamil Nadu, south
India. Transactions of the Royal Society of Tropical Medicine
and Hygiene 90, 639-643.
Ramaiah KD, Ramu K, Guyatt H, Vijay Kumar KN &C Pani SP
(1998) Direct and indirect costs of the acute form of lymphatic
filariasis to households in rural areas of Tamil Nadu, south
India. Tropical Medicine and International Health 3, 108-115.
Ramaiah KD, Guyatt H, Ramu K, Vanamail P, Pani SP
Das PK
(1999) Treatment costs and loss of work time to individuals
with chronic lymphatic filariasis in rural commumties in south
India. Tropical Medicine and International Health 4, 19-25.
Ramaiah KD, Das PK, Edwin M & Guyatt H (2000) The
economic burden of lymphatic filariasis in India. Parasitology
Today 16, 251-253.
Rao CK & Sharma SP. (1986) Control of bancroftian filariasis in
India. Journal of Communicahle Diseases 18. 276-282.
Siem AR. Dreyer G & Addiss DG (1999) Controlling morbidity
and interrupting transmission: twin pillars of lymphatic filariasis
elimination. Revista Da Socicdade Brasileira de Medicina
Tropical 32, 325-328.
World Health Organization (1994) Lymphatic Filariasis Infection
and Disease: Control Strategies. Report of rhe Consultative
Meeting held ar the Univirsiti Sams Malaysia, Penang, Malaysia.
WHO, Geneva.
World Health Organization (1995) World Health Report I99.S'.
WHO, Geneva.
I
(c> 2003 Biackwell Publishing Ltd
59
J. Commun. Dis. 33(3)2001: 198
Community Perception of Malayan Filariasis in the Rural Areas
of Cherthala Taluk of Kerala State, South India
contrc
diseas
B. Nanda*
(Receivedfor publication : Oct. 2000)
ABSTRACT
Lymphatic filariasis, one of the major public health problems can
be controlled with the active participation of the community. The
human factors involved in the disease transmission are important.
The knowledge on the community perception and practice is essential
to develop community oriented control programmes. A descriptive
study was conducted in the filariasis endemic area of Cherthala,
Kerala State, India, to identify the level of people's perception on
Malayan filariasis. Two methods namely, interviews and uncontrolled
observation were used in the study. A total of 450 respondents (150
microfilaria carriers, 150 chronic patients and 150 normals) were
interviewed. The study results showed that majority of the
respondents (86.7%) were aware that the disease was caused by a
parasite and 93.6% had awareness on transmission of the disease
through mosquito bite. The knowledge on the preventive measures
against filariasis was also high (78.2 %) among the sampled
respondents. The strategy for community mobilization in filariasis
control programme is discussed in view of high awareness.
INTRODUCTION
Malayan filariasis with an estimated 8.6
million infected persons is known to be
endemic in many parts of Asia and is
causing increasing concern to the Public
Health experts.1 India accounts for 20.2%
of the global burden ofmalayan filariasis2
with 3 million people at risk, along the west
coast of Kerala.3 Cherthala Taluk in
Alleppey district is recognized as the hot
bed of filariasis since 1855.4 The disease
has gained a strong foothold in Cherthala
due to its unique topographic, ecological
and socio-economic factors. This disease
is caused by Brugia malayi parasite and
transmitted by Mansonia mosquitoes
which breed in close association with
aquatic weeds that grow abundantly in the
natural as well as man made water-bodies
in this area. Control of this type of filariasis
depends mainly on two measures (1)
destruction of breeding sites and thereby
controlling the emergence of mosquitoes
which transmit this disease and (2) mass
chemotherapy. The sustainability of any
control programme needs people's
involvement. For proper utilization of the
existing facilities and participation in the
* Vector Control Research Centre, Pondicherry-605 006
I
1
Medic
Natior
Contrc
started
the co
health
implerr
Contrc
integrz
progra
partici
implem
Vector
study aj
ensure
Malayai
The stu(
taluk, A
area of
Cherthal
econom
househo?
of 4,77,8
locality is
is 2,79,4'
concentn
Literacy
82.96%.6
administr
one muni(
the peop
agricultur
and fishin
coir is the
are over 7
number of
Community pera.'eption ofMalayan filariasis
eas
nd
>es
ith
he
es
sis
1)
es
ss
iy
's
ie
e
199
control programme, awareness on the
disease is a prerequisite.
of seasonal water collections providing a
total surface area of about 16.50 sq. kms
In January 1986, Indian Council of
for vector (mosquito) breeding.7 The ponds
Medical Research, through one of its
and channels are mainly used for irrigating
National Institutes (ICMR), the Vector
the sandy terrain. They are also used for
Control Research Centre, Pondicherry,
retting coconut husk for coir making. Apart
started a 'Technology Mission Project' for
from this, ponds are used for domestic
the containment of filariasis. Intensive
purposes like bathing, washing, drinking,
health education programmes were
etc. These water bodies are heavily infested
implemented in this area by the Vector
with floating weeds such as Pistia
Control Research Centre,’ through
stratiotes, Eichhornia crassipes and
integrated disease/vector control
Salvima molesta. Mansonia mosquitoes
programmes with active community
lay their eggs in clusters in the under
<
participation. After ten years of
surface of fronds of these plants.8 The
implementation of these programmes by
larvae of this mosquito attach to the roots
Vector Control Research Centre5 in the
of the waterweeds for their oxygen
study area, this study was carried out to
requirement. The proliferation of
ensure the awareness of the people on
mosquitoes is related to the presence of the
Malayan filariasis.
weeds and the control of mosquitoes is
possible only through the destruction of
STUDY AREA
these weeds.
The study was carried out in Cherthala
taluk, Alleppey district, Kerala. The total
materials and methods
area of the taluk is 304 sq. km. Rural
A total of 450 respondents were selected
Cherthala is mhabited^by
i ‘
middle and low
for the study from 6 of the 18 panchayats
-----------economic groups. There are 95,875
using simple random method,
households in this area with a population
panchayats thus selected were
of 4 77,819. The urban population in this
Kadakkarapally,
Pattanakkad,
locality is i1’9---??-42~ and the ruraI P°Puiation Kuthiathode, Kodumthuruth, Tl..
----- 1, Thuravoor
is 2,79,477. Majority of the population is
and Kanjikuzhi. The endemicity
------- J rate in
concentrated in rural areas of this taluk.
thes^panchayats ranged between 3.5% and
i
I
15.5%. Population varied ----from1 2500°f the area is as hiSh as
6%. This taluk is divided into 18
3000. From the saitmpled
’ * panchayats, 25
administrative units called panchayats and
respondents were selected from each of the
i
one municipality. The major occupation of
three categories of respondents
.
___.3 namely
the people in this locality includes
microfilaria positive cases, chronic cases
agriculture, toddy tapping, coir industry
of elephantiasis and normal individuals. A
an ishing. Coconut is the major crop and
semi-structured questionnaire was
coir is the notable cottage industry. There
designed to collect information on
are over 75,000 domestic ponds besides a
perception of the community on the cause,
i
i number of canals/channels and vast areas
transmission and control of the disease.’
|.i________
i
j
i
•
1
t
200
The schedules were pre-tested before the
actual study was undertaken. The questions
were in the order of demographic and
socio-economic particulars of the
respondent, knowledge on the term
filariasis, cause of the disease as filarial
worm, role of mosquito in the transmission,
symptoms of the disease, diagnostic
procedures, knowledge on the treatment
procedures, course of medicine and
frequency of treatment, knowledge on the
preventive measures and on breeding sites
of the disease transmitting mosquitoes. The
data were organized and analyzed using
epi-info statistical package.
RESULTS
All the respondents irrespective of
infection were aware of the prevalence of
the disease in the community and the local
term for lymphoedema of the upper/lower
limbs as "Manihurogam". Majority of the
respondents were also aware that the
disease was century old in this area.
Knowledge on the cause and
transmission of the disease: The analysis
of the data showed that a vast majority of
the people (86.7%) was aware that filarial
parasite was the cause of the disease. Only
13.4% of the respondents had
misconceptions regarding the cause, as to
drinking polluted water and due to the
sandy terrain of the area. The percentage
of people with misconceptions on the cause
were comparatively high among the
chronic patients than the other two
categories. Regarding the transmission of
the disease, 93.6% reported that the disease
was transmitted from one individual to
another through mosquito bite (Table 1).
Awareness on the symptoms of the
disease: Fever with chills, body ache,
swelling of the groins and recurrent
oedema were reported to be the major acute
symptoms by majority (76.7%). of the
respondents. It was interesting to note that
there was no notable difference in the
knowledge on symptoms of the disease
among the categories. This supports the
fact that awareness among the people was
very high in this area irrespective of
infection in total, 78% of the respondents
felt that without external manifestations a
person could harbour the disease parasite.
It is also interesting to note that
significantly (p<0.05), higher proportion
of the
of thi
indivi
Knov
of fil
methc
of fil
respo.
or m<
filaria
49.8°Z
assoc
mosq
vectoi
measi
on the
high
protec
measi
Tab
res
Pre
Table 1: Knowledge on the transmission of fiiariasis in terms of number of
respondents in relation to means of transmission under different respondent
Clei
categories
Pe
Means of transmission
I
i
5. Nunda
Inherited
Sleeping habits
Mosquito bite
Mf carriers
No. (%)
N= 150
Chronic
No. (%)
N= 150
Normal
No. (%)
N=150
2 (1.3)
7
(4.7)
1 (0.7)
7 (4.7)
142 (94.6)
4 ^(2.7)
144 (96.0)
8 (5-3)
135 (90,0)
Figures in parentheses denote percentage out of'n'
Total
No. (%)
N=450
10 (2.2)
19 (4.2)
421 (93.6)
Blooc
_5
Avoi
Pre
(
#Figu
■■
J
Only
had
as to
3 the
itage
:ause
the
two
n of
ease
1 to
1).
the
he,
ent
ute
he
lat
he
se
he
as
3f
ts
a
5.
t
-n
Community pera'eption ofMalayan filariasis
of the microfilaria carriers (76.6%) were
of this opinion when compared to normal
individuals.
I
Knowledge on the preventive measures
of filariasis: When asked about the
methods ofprevention from the contraction
of filariasis, as many as 78.2% of the
respondents could correctly mention one
or more preventive measures against
filanasis. From the vector point of view
49.8% of the respondents kiiew about the
association between weeds and vector
mosquitoes and suggested clearing of
vector breeding habitats as a preventive
measure (Table 2).
This shows that general awareness
on tthe role of mosquito breeding sites is
high among the respondents,
— Personal
protection was reported to be <-a preventive
measure by 18.4% of the people. Selective
201
therapy was suggested by 4.9% of the
people and preventive treatment was
suggested by 0.9% of the respondents.
Even though avoiding persons with the
disease is a misbelief, 4.2% of the
respondents reported that this had to be
followed as a preventive measure.
Knowledge on the diagnosis and
treatment: Regarding the perception on
treatment, among the acute and chronic
patients, it was found that 96.7% of them
had the knowledge on the drug given and
the course of treatment and 55.4% felt that
the drug had to be taken at regular intervals
to prevent further development of the
disease. Among those who did not have
proper knowledge on the treatment
procedure, normafs constituted higher
percentage 9/15 (60%) than the others. All
the microfilaria carriers were aware of the
Table 2: Knowledge on preventive measures of filariasis in tei
rms of number of
lespondents in relation to means of transmission under different
-----: respondent
categories
Preventive measure
Mf carriers
Chronic
Normal
Total
N= 150
N= 150
N= 150
N=450
No. (%)#
No. (%)# - No. (%)#
No.
(%)#
X > Clear breeding site of
80 (53.3)
59 (39.3)
1
85 (56.7)
224 (49.8)
______mosuitoes
Personal protection
31 (20.7)
36 (24,0)
15 (.10,7)
83 (18.4)
Blood test and treatment
5
(3.3)
2
(1.3)
15 (10.0)
22 (4.9)
~ Selective therapy
Avoid persons with the | 7
(4.7)
1 (0.7)
11 (7.3)
19 (4.2)
_ _____ disease
Preventive treatment
2
(1.3)
0
(Mass therapy)
—
Do not know
25
16.7
52 (34,7)
Figurs in parentheses denote
percentage out of'n'
2
(1.3)
4 (0.9).
21
14.0)
98 (21.8
$
■
202
B. Nanda
blood examination as a diagnostic
procedure for filariasis. This is because,
all of them had undergone the procedure
at least once. Among the chronic
respondents, 86% of them could tell blood
examination as a diagnostic procedure
while it was 68.7% among the normals.
All the microfilaria carriers and chronic
cases reported that blood examination was
to be done at night. Among the normals
74 A were aware that blood smear should
be checked at night hours while 2.5% did
not respond to the question.
Source of information: Among the source
of information regarding the etiology of
the filarial infection, majority of the
chronic patients got the information from
others. About 54% of the microfilaria
carriers also had known from others.
Lessons learned from own experience were
am°ng the chron,c
(43.3/o) as expected. However, readinn
materials were found to be the major
source for dissemination of information,
particularly among the normals (80%)’
When this was analyzed irrespective of the
infection, 50% of the respondents reported
to have gathered information from others
and this followed by print media.
DISCUSSION
A vast majority of the people in the study
area were aware of the disease and its
cause, mode of transmission and methods
o prevention. As observed in other
peases like onchocerciasis,9 dengue1'1 and
AIDS, the respondents recognized the
clinical symptoms and the cause. While
different studies concluded that people's
knowledge on transmission of filarias was
poor in different endemic areas,12-17 the
!
present study revealed majority of the
i
respondents had the right perception on
filanasis. A similar study on dengue, also
showed that very high proportion of the
community was aware ot the disease and
its transmission.10 The reason was to the
high literacy rate of the study population
as observed in other studies'5-1718 as well
as the impact of the decade long filariasis
control efforts of Vector Control Resear
Centre, Pondicherry, in this area. A study
conducted prior to health education
campaigns among school children in the f
same study area, showed that 70% of the ~
students had misconceptions regarding the
cause of filariasis.19
Majority of the respondents were
aware that the disease-causing parasite
could be present in humans without
showing external clinical manifestation
1 his was supported by the view that the
microfilaria carriers who had taken
treatment did not show any clinical
manifestation.20 Among the categories,
microfilaria carriers were found to support
this view more than the others. This could
be related to their experience since all the
microfilaria carriers were normally
asymptomatic.21 Knowledge was not found f
to be related to infection. The uninfected
were found to be more informed on the
disease than the patients with chronic
clinical manifestations^ '
1
r
c
i
s
F
g
c
c
k
P
fe
cc
Majority of the respondents were
aware of the preventive method of
deweeding the domestic water bodies for
preventing vector mosquito breeding.
Awareness of persona] protective methods
was found to be low. More efforts to
popularize the various personal protective
Sl
av
kr
be
.1
a
Community perception of Malayan filariasis
the
on
also
the
and
the
ion
veil
isis
rch
.idy
ion
the
the
the
ere
site
aut
ion
the
:en
cal
es,
ort
aid
the
lly
methods to prevent vector mosquito bites
are needed.
c
■
I
lnd dJ
led
die
lie
?re
of
for
ig-
>ds
to
ve
i
The high levels of knowledge on the
treatment procedure for filariasis is an
added advantage, as majority of the
patients may undergo treatment, and thus
facilitate interruption of transmission from
the sick. As chronic patients were found
to have misbeliefs when compared to the
other two categories, more attention should
be paid in creating awareness among them
regarding the transmission of the disease.
Similarly the perception on the diagnostic
procedure for filariasis was found to be low
among the normals. So more efforts are to
be made on the need of night blood
examination and treatment.
As many of the respondents have
gathered information on the disease
through reading materials, it clearly shows
that dissemination of information on
prevention of disease will be effective if
spread through press, which can get further
channeled through exchange between
individuals. Kerala being a highly literate
state, educational programmes through
print media will be successful.
Even though the community has
good perception on the preventive and
curative aspects of filariasis, disease
control will be possible only if the
knowledge they have acquired is put into
practice. An effective component or a
feeling about it and a behavioral
component or a tendency to take action
should follow a cognitive component or
awareness on the disease.22 There can be
knowledge without right attitude and
behaviour.
203
The presence of awareness on
disease control will be fruitful in planning
and implementing vector/disease,control
programmes for the target group. The
requirements for the three different
categories in relation to filariasis control
vary considerably. The kind of appropriate
information to be given to each group is
different. So efforts should be made to
prepare separate information package to
address the different categories.
ACKNOWLEDGEMENTS
The author is deeply grateful to Dr. Mary
Joseph of the Cochin University of Science
and Technology, Cochin for guidance and
helpful comments. Dr.P.K.Das, Director,
Vector Control Research Centre is
gratefully acknowledged for his support.
Acknowledgements are due to Dr. K.
Krishnamoorthy of the Centre for valuable
suggestions.
REFERENCES
1.
2.
3.
4.
5.
6.
Jain DC. Epidemiology of brugian
filariasis in a rural community of Kerala
State. J Cow Dis 1989; 21 (1): 27-33.
World Health Organization report,
WHO, 1997.
Rajagopalan PK, Panicker KN, Sabesan
S, Krishnamoorthy K and Rao AS.
Control of Brugia filariasis in Cherthala,
South
India.
Pie-control
epidemiological observation. Misc Publ
Vector Control Res Centre 1988; 7: 118.
Iyengar MOT. Studies on the
epidemiology of filariasis in
Travancore. Indian Med Res Memoir
1938; 30 : 33-8.
Miscellaneous Publication, Vector
Control Research Centre. (18) 1989.
Anonymous. Census of India series. 12
Kerala. Paper 3 of final population total
204
7.
8.
9.
10.
11.
12.
13.
14.
B. Nanda
1991. Director of Census Operations,
Kerala.
Vector Control Research Centre Control
of Brugian filariasis- A Community
Approach. Misc Publ PCRC 1992; 19,
15.
Chandrasekharan A. Biology and
Control of Mansoma Mosquitoes. Proc
Sym Vectors and Vector Borne Diseases
1982.
Richards F, Klein RE, Gonzales-Peralta
C, Flores RZ and Florez JC. Knowledge,
attitudes and perceptions (KAP) of
onchocerciasis: A survey among
residents in an endemic area in
Gutamela targeted for mass
chemotherapy with ivermectin. Social
Science and Medicine 1991; 32, (11):
1275-81.
Gupta P, Kumar P and Agarwal OP.
Knowledge, attitude and practices
related to dengue in rural and slum areas
of Delhi after the dengue epidemic of
1996. Journal of Communicable
Diseases 1998; 30 (2): 107-12.
Tuchinda S, Chotpitayasunondh T and
Teeraratkul A. Knowledge, attitudes and
practices of senior high school students
regarding human immunodeficiency
vims infection. Journal of Medical
Association Thai 1998; 81 (2): 130-5.
Koirala S, Parija SC, Karki P and Das
ML. Knowledge, attitudes and practices
about Kala-azar and its sandfly vector
in rural communities of Nepal 1998.
Organ, 76 (5): 485-90.
Ramaiah KD, Vijayakumar KN and
Ramu K. Knowledge and beliefs about
transmission, prevention and control of
lymphatic filariasis in rural areas of
South India. Tropical Medicine and
International Health 1996; 1: 433-438.
Crame B, Uthahia A, Tuira E and et al.
Filarial elephantiasis in French
Polynesia: A study concerning the
'beliefs of 127 patients about the origin
of their disease. Transactions of the
15.
16.
17.
18.
19.
20.
21.
22.
Royal Society of Tropical Medicine and
Hygiene 1979; 73 : 424-426.
Muhondwa
EPY.
Community
participation in filariasis control: The
Tanzania experiment. TDR/SER/SWG
(4)/WP/83.13. WHO 1983; Geneva.
Haliza Bte Mohd Riji. Comparison of
knowledge on filariasis and
)
epidemiologic factors between infected ;
1
and uninfected respondents in a malayi
community. Southeast Asian Journal of
.Tropical Medicine and Public Health
1986; 17: 457-463.
Lu AG, Valencia LB, Llagas L and et
al. Filariasis: A study of knowledge,
attitudes and practices of the people of*
Sorsogon. Social and Economic
Research Project Reports No. 1, TDR/
SER/PRS/1, WHO 1988: Geneva.
Dhamija S. Sehgal A, Luthra UK and
Sehgal K. Factors associated with
awareness and knowledge of cervical
cancer in a community: implication for
health education programmes in
developing countries. J R Soc Health
1993; 113(4): 184-6.
Nanda B, Sabesan S and Panicker KN.
Students' Community - A potential force
for filariasis control CAP ART Peoples
Action, 1991; 6(3): 9-11.
Pani SP, Krishnamoorthy K, Rao AS
and Prathiba J. Clinical manifestations
in Malayan filariasis infection with
special reference to lymphoedema*" |
grading. Indian J Med Res 1990; 9:200-'" j
207.
Pam SP, Srividya A and Rajagopalan
PK. Clearance of microfilaraemia
following Diethyl carbamazine Citrate
(DEC) therapy in periodic Wuchereria
bancrofti infection in relation with age,
sex, microfilaria count and clinical
status. Tropical Biomedicine 1991:8:
59-65.
Ramachandran and Dharmalingam,. T.
Health Education: A new approach.
Vikas Publishing House Pvt. Ltd. New
Delhi 1976; 278.
pis- >6^ 3
200
Update______
TRENDS in Parasitology Vol.19 No.5 May 2003
that they do not invalidate the working hypothesis
outlined in our original article [1].
Ginsburg feels that we have been selective in our use of
the literature. However, there are good reasons for citing
the work of Slomianny et al. (apart from the fact that we
agree with them). Slomianny et al. have published five of
the most recent papers on the ultrastructure of the
hemoglobin (Hb) digestion apparatus in several Plasmo
dium spp. This is a large body of work, considerably more
than any other group, and must position Slomianny et al.
as leaders in the field.
We disagree with the assertion that there is no other
direct evidence in favour of our hypothesis. At least two
papers from other groups suggest that pigment can be seen
in small cytoplasmic vesicles, as well as in the digestive
vacuole (DV) [2,3]. For example, in Fig. 2 of Ref. [3], three
small vesicles containing hemozoin (HZ) can be clearly
seen adjacent to the DV. Neither do we agree that the
ap irance of vesicles containing undigested Hb inside
th. >V suggests that Hb digestion is confined to the DV.
This occurs only after the parasites have been treated with
high concentrations of chloroquine or ammonium chloride
[4,5], suggesting, instead, that the drugs have inhibited
Hb digestion in the transport vesicles (TV) and not in
the DV.
Ginsburg raises some other interesting issues on the
activation of proteolytic enzymes, possible osmotic effects
resulting from Hb digestion and possible high local
concentrations of ferriprotoporphyrin IX (FP) within the
TVs. These are intriguing questions that demand further
investigation. Nonetheless, it is clear that none of these
issues poses a problem to Plasmodium berghei, which
lacks a central DV and has no choice but to digest all of the
Hb within its cytostomal vesicles [6].
What is lacking in Ginsburg’s otherwise eloquent
critique is any credible explanation of how the HZ crystals
are initiated or how the DV membrane is protected from
the damaging effects of FP. We believe that our membrane
sacrifice mechanism provides an interesting and plausible
hypothesis that lends itself to experimental testing.
References
1 Hempelmann, E. et al. (2003) Plasmodium falciparum-, sacrificing
membrane to grow crystals? Trends Parasitol. 19, 23—26
2 Smith, D.H. et al. (1969) The ultrastructure of Plasmodium falciparum
in splenectomized Aotus triuirgatus monkeys. Ann. Trap. Med. Para
sitol. 63, 433-438
3 Langreth, S.G. et al. (1978) Fine structure of human malaria in vitro.
J. Protozoal. 25, 443—452
4 Yayon, A. et al. (1984) Effects of chloroquine on the feeding mechanism
of the intraerythrocytic human malarial parasite Plasmodium falci
parum. J. Protozoal. 31, 367—372
5 Zhang, Y. and Just, W.W. (1987) A comparative effect of chloroquine and
ammonium chloride on the feeding process of Plasmodium falciparum
in vitro. Parasitol. Res. 73, 475-478
6 Slomianny, C. et al. (1990) Three-dimensional reconstruction of the
feeding process of the malarial parasite. Blood Cells 16, 369—378
1471-4922/03/S - see front matter © 2003 Elsevier Science Ltd. All rights reserved,
doi: 10.1016/S1471-4922(03)00058-8
Strategic options for global lymphatic filariasis
elimination
Sbanmugavelu Sabesan
Vector Control Research Centre, Medical Complex, Indira Nagar, Pondicherry, 605 006, India
The global elimination of lymphatic filariasis (LF) pro
gramme has been launched in many countries. Their
strategy is to adopt mass, annual single dose (6 mg kg-1
of body weight) of diethylcarbamazine (DEG) adminis
tration, with or without albendazole (ALB), irrespective of
the level of endemicity. Recently, it has been reported that
mass treatment with a single dose of DEC (6 mg kg 1 of
body weight) alone could be sufficient to interrupt LF
transmission in areas with low intensities of infection and
low prevalence in Egypt [1]. Mass screening of night blood
smears and selective treatment of infected individuals
(standard course of DEC, 6 mg kg-1 of body weight, for
12 days) has been in practice in the Nile Delta region of
Egypt for many years before launching the mass annual
single dose of DEC. However, Reda et al. had not realized
that the end result was a cumulative effect of selective
therapy of infected individuals, followed by a mass annual
single dose for the community, and they had assumed
that these conditions apply to many other endemic areas
around the world.
India alone accounts for ~38% of the total disease
burden worldwide [2]. The facilities for detecting parasite
carriers (microfilaraemics) and treating them with a
standard dose of DEC are available in highly endemic
areas and in urban areas covered by the National Filaria
Control Programme (NFCP) (~ 10% of the total population
at risk). Selective treatment is recommended for infected
individuals [3]. For the majority of individuals in rural
areas and low-endemic areas (which contributes to more
than two-thirds of the total population at risk), DEC is
intended to the community for the first time. This situation
is also likely to occur in most other endemic countries.
One round of mass treatment with a single dose of DEC
fhn rrnn-rrvfil ovi on flVT-A nrovalfinpa anrl ai+xr
!
Update
TRENDS in Parasitology Vol.19 No.5 May 2003
by 31% and 70%, respectively, in Papua New Guinea [4],
whereas two rounds of DEC reduced prevalence and
intensity by 34% and 59%, respectively, in Tanzania [5]
and four rounds by 62% and 74% [6], respectively, in South
Arcot district of Tamil Nadu, India, and 48% and 65%,
respectively, in Villupuram district of Tamil Nadu, India
[7]. These studies all reveal that the mass annual single
dose of DEC has a more dramatic impact on reducing
parasite intensities than on parasite prevalence.
For the global LF elimination programme, a repeated
mass annual single dose of DEC was recommended because
this would lead to a reduction in the community microfilaraemiae load (CMFL), which would then facilitate
interruption of transmission. The biggest challenge is to
overcome the lack of community comphance, a problem in
areas of low endemicity. To enhance compliance, ALB has
also been added to the programme. However, in the real
world, neither the programme managers nor the commu
nity in areas of low endemicity give priority to LF control
and/or elimination and, as a result, DEC coverage, and
consumption is very poor under the mass annual single
dose DEC programme. If we continue to depend on this
strategy, the areas of low endemicity will continue to
remain as low-grade transmission foci and, once this
programme has stopped, resurgence of LF is likely.
Ideally, before it is too late, it would be wise to take stock
of information on the impact of mass annual single dose
DEC in all endemic areas where the LF elimination
programme is implemented. Once these areas reached a
low level of transmission, a small-spaced dose of DEC,
perhaps in a medicated salt formulation, in addition to
201
vector control, could be considered for complete cessation
of transmission. This has to be worked out independently
for different community settings, considering socio-econ
omic characteristics and other logistics. This approach
would help to reduce the CMFL and enhance community
compliance because it also addresses the nuisance caused
by mosquito biting. If planned properly, the global LF
elimination could be achieved much earlier than the
original target of 2020.
References
1 Reda, M. et al. (2002) The impact of single-dose diethyl carbamazine
treatment of bancroftian filariasis in a low endemicity setting in Egypt.
Am. J. Trop. Med. Hyg. 67, 196-200
2 Michael, E. et al. (1996) Re-assessing the global prevalence and
distribution of lymphatic filariasis. Parasitol 112, 409-428
3 World Health Organization, (1992) Lymphatic filariasis: the disease and
its control. Tech. Rep. Series 821, 45-46
4 Bockarie, M.J. et al. (1998) Randomised community-based trial of
annual single-dose DEC with or without ivermectin against Wuchereria
bancrofti infection in human beings and mosquitoes. Lancet 351,
162-168
5 Meyrowitsch, D.W. et al. (1996) Mass diethylcarbamazine chemo
therapy for control of bancroftian filariasis: comparative efficacy of
Standard treatment and two semi-annual single dose treatments.
Trans. Roy. Soc. Trop. Med. Hyg. 90, 69-73
6 Balakrishnan, N. et al. (1992) Efficacy of bi-annual administration of
DEC in the control of bancroftian filariasis. J.. Com. Dis. 24, 87-91
7 Das, P.K. et al. (2001) Placebo-controlled community trial of four cycles
of single-dose diethylcarbamazine or ivermectin against Wuchereria
bancrofti infection and transmission in India. Trans. Roy. Soc. Trop.
Med. Hyg. 95, 336-341
1471-4922/03/S - see front matter 0 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/31471-4922(03)00068-0
Articles of interest in other journals
de Roode, J.C. and Read, A.F. (2003) Evolution and ecology, after the malaria genomes.
Trends Ecol. Evol. 18, 60-61
van Alphen, J.J.M. et al. (2003) Information acquisition and time allocation in insect parasitoids.
Trends Ecol. Evol. 18, 81-87
Foreman-Wykert, A.K. and Miller, J.F. (2003) Hypervirulence and pathogen fitness.
Trends Microbiol. 11, 105-108
Lang, T. and Greenwood, B. (2003) The development of Lapdap, an affordable new treatment for malaria.
Lancet Infect. Dis. 3, 162-167
TMIH5I5
Tropicnl Medicine mid liKcrnmion.il I Icnkli
VOLUME 5 NO I PP 000-000 JANUARY lOOO
Development of rapid assessment procedures for the
delimitation of lymphatic filariasis-endemic areas
A. Srividya, R. Lail, K. D. Ramaiah, K. Ramu, S. L Hoti, S. P. Pani and P. K. Das
Veclor Control Research Centre, Pondicherry, India
Summary
Lymphatic filariasis caused by Wuchereria bancrofli is a major public health problem in 73 tropical and sub
tropical countries including India. Delimitation of endemic areas is essential to plan control operations. The
current method of night blood survey (NBS) for delimitation is cumbersome, time-consuming and expensive.
1 herefore, there is a need to develop assessment procedures which can rapidly delimit endemic areas. Eor this
purpose we evaluated three procedures: direct interviewing of key informants using structured question
naires, an indirect method of a self-administered questionnaires to key informants and physical examination
by health workers for the presence of chronic filarial disease. Thirty rural communities in a filariasis-endemic
rcj’.ion in (aiddalore district in Tamil Nadu State in southern India constituted the study population. The
determination of filariasis cndemicity in the village communities assessed by the above procedures was com
pared in terms of rapidity, specificity, sensitivity and cost with the microfilaria rate and disease rate obtained
by night blood sample survey and clinical examination by physicians. Prevalence score, control preference
score and weighted mean number of cases with filarial disease per village were calculated using the key in
formant questionnaire techniques. While the prevalence and control preference score showed low sensitivity
and moderate specificity, weighted mean number of cases showed high sensitivity and moderate specificity in
identifying endemic villages. The prevalence of disease as determined by the physical examination of a
sample population by health workers was highly sensitive in identifying communities endemic for filariasis.
The degree of association between the disease rates estimated by physician and trained health workers was
significant (r — 0.56; P < 0.05). These observations suggest that the weighted mean number of cases per vil
lage obtained through key informant techniques may be considered at a primary level to crudely identify
endemic areas, followed by physical examination by health workers for filariasis, since it is relatively cheap
and rapid.
keywords lymphatic filariasis, RAP, epidemiology, distributio n, microfilaracmia, disease, cost effectiveness
Correspondence Dr I’. K. Das, Vector Control Research Centre, Indira Nagar Medical Complex,
Pondicherry 605 006, India. E-mail: mosquito@md2.vsnl.net.in
Iptroduction
The disease results in severe morbidity and globally is the
second most important cause of permanent disability (Wl IO
| ymphatic filariasis caused by Wuchercria bancrofli, Brugia
1995). While acute episodic adenolymphangitis causes severe
titalayi and B. tiniori, transmitted by a number of mosquito
physical suffering, chronic disease such as lymphoedema and
sjiectes, is a major cause of morbidity, affecting all ages and
hydrocele causes permanent disfigurement and psycho-social
lyith sexes. About 1.1 billion people arc at risk of infection
prol'flcms tPani cl al. 1^95; Gyaponget al. 1996; Ramaiah cl
worldwide, accounting for 20% of the world’s population
al. 1996b; Pani
(WHO 1997). India alone contributes about 47% of global
productivity, direct and indirect economic loss and functional I
inipairrneoclPani el al. 1995; Ramaiah el al. 1996c; Ramu el ' ' '
prevalence of chronic patients and 39% of the population at
dsk of infection (NPCP 1995; Wl 16 1997). Economic lo?s in
Q2
Srividya 1997). It results in loss of work,
impediment to socio-economic progress of the endemic
unpublished data; Ottesen cl al. 1997)7
countries. Eilariasis has been identified as a potentially cradi-
1.1 2000 Blackwell Science ltd
,
al. 1996f-1997a,b). Consequently, the disease is a significant
lljdia has been estimated at USS 1.5 billion *cvcryye^r (VCRC
I
Iiopic.il Mnlicinc .md liiirrn.iiionjl I Ir.dth
A. Sriviily;i ct ill.
Qi
volume 5
NO I IT (XX> rxto JANUAHY KXXJ
Rapid assessment procedures for the delimitation of lymphatic filariasis
cable disease (CDC 1993; WHO 1997) and the 5(kh World
Health Assembly 1997 passed a resolution th *t ‘elhnhmion
of filariasis as a public health problem’ should be considered
a priority by member states (WHO 1997). Delimitation of
endemic localities is an essential prerequisite for planning
control or elimination programmes. However, lymphatic
filariasis is one of the few diseases for which information on
the current global distribution and prevalencelTlioravaTlable.
For ar.
an example, the estimate that in India about 412 million
people are exposed to the risk of filarial infection (NFCP
1995), mostly to the bancroftian form (about 95%; Michael
el al. 1996); is based on survey data collected between 1955
and 1995, and therefore docs not reflect the current situation.
Currently used delimitation surveys such as the night blood
survey (NBS) for microfilaria and clinical survey arc cumber
some, costly and require skilled manpower (Das ct al. 1995).
Therefore, it is necessary to develop alternate Rapid
Assessment Procedures (RAP) for die delimitation of filarial
endemic areas which are not only fast but also reliable,
cheaper and acceptable to the community as well as the pro
gramme personnel.
We evaluated three procedures: dirca interview of key
informants using a struaured questionnaire, an indirea K
method of'a sei f-ad ministered questionnai re tokeynTFb rm
ants and physical examination by heaTtiTworkerslbr chronic
manifestations. The disease cndcmicity at the
village level obtained through these proposed methods was
compared with two gold standards, the microfilaria (mf) rate
obtained through night blood examination and the disease
prevalence, in stable endemic areas Iboth infection and disease
prevalence could be moderate_tQ_high.‘Therefore, it is not
expected that two indices would correlate with each other in
all endemic situations. In spite of these inherent difficulties
arising out of the complex natural history and epidemiology
of the disease, one could assume that areas where clinical
cases are detected (if migration is excluded), infection will be
prevalent, since clinical disease is a consequence of infection,
not vice versa. In other words, deteaion of disease could
suggest the presence of infection at community level. There
fore, for the development of RAP, the proposed procedures
use the communities as the unit, and also detection of disease
rather than infection. As a measure of efficacy, the ability of a
procedure to identify the endemic communities is compared
with that of the gold standard methods. 7 his approach is
further supported by the fact that detection of the clinical
disease in an area is relatively simple compared to parasite
detection in the blood. In the analysis of data, the relation
ship between infection and disease was also examined to sub
stantiate the assumption that disease can indeed rcflca
infection at the community level. However, any approach
which targets the detection of disease alone is likely to miss
communities where filariasis has been introduced recently,
recording low levels of infection prevalence but no disease. In
view of this, we propose to conduct RAP for dctcaion of dis
ease first and subsequently surveys for detection of infection
in those communities negative for disease. This paper investi
gates the suitability of certain methods for deteaion of dis
ease only in the initial stages.
rate determined by clinical examination by physicians. For
the cost-cffcctivcncss analysis, the proposed methods were
only compared with NBS, since this is the method used by the
Materials and methods
4
national programme authorities for delimitation purposes.
Selection of study villages
Theoretical basis for development of RAP
According to the protocol, only villages with population
between 500 and 2500 were to be included. Thirty villages in
So far there is no single index which can be uniformly used to
denote the filarial cndcmicity of an area. The basis or criteria
for declaring a given area or community as filariasis-endcmic
are still unclear, although establishing the presence of in-
two administrative blocks adjacent to Pondicherry within a
known endemic district of^
CyCuddalore in Tamil Nadu State of south India were ran
domly selected from the 62 villages satisfying this criterion.
The total population of the study villages was 42 100 (range:
cjidcniicLty level is mostly described in termsnf infection and
disease prevalence rates determined by NBS and disease sun
ycys by physicians.^iit the interpretation of these two indices
is complicated by the dynamics of infection and disease nt
507—2424). The mf and disease rates of the district were 0,5%
and 1.02%, respectively, according to the National Filaria
Control Programme (NFCPb_.No antifilarial measure had
been implemented in the study villages.
.individual and community level. At the individual level, it is
well known that most clinical cases arc amicrofilaraemic and
most microfilaria carriers are asymptomatic (Brabin 198^
Q3
Gold standard methods
Pani el al. 1990). Thus the two methods detect different
In each study village, 10% of the population from randomly
groups of individuals afflicted with filariasis. At the com
selected households (by systematic random sampling) were
munity level, while injircas where filariasis is recently intro
examined for microfilaria by NBS. All individuals in the
duced, infection prevalence may be high compared to disease
selected households were included for blood examination.
1
© 2000 Blarbvcll Science Ltd
ft
Ifopical Medicine and International I lealth
A. Srividyn ct al.
VOLUME J
NO J
I’P 000-000 JANUARY ZOOO
Rapid assessment procedures for the delimitation of lymphatic lllarlasls
ratio of cost to effectiveness. The most cost-effective method
Prevalence and control preference scores
ijj the one with the lowest cost-cffcctivcncss ratio.
Using the direct KI questionnaire method (QDIR), filariasis
(hydrocele and or lymphoedema) was recorded as a priority
Statistical analysis
health problem in only 6 of 30 villages and in these the score
Sensitivity and specificity were first analysed (using EPIINFO)
Lp see which one of the proposed procedures was appropriate
|y identifying endemic areas compared to night blood mf sur
vey and clinical examination by physicians, using the village
an unit. Regression analysis was used for the degree of
^sociation between the prevalence/preference scores and mf
^tc/discasc rate; disease rates estimated by health workers
;ipd physicians and mf rale; and disease rate estimated by
ranged between 0.14 and 2.00. The preference score for con
trol of filariasis was zero in all the villages. As far aTthe dis-
ease prevalence is concerned, only in 2 villages KIs were
unanimous in saying that there was no filariasis case in the
villages. In the rest, the disease prevalence rate ranged
between 0.1% and 6.1%.
Employing the indirect self-administered questionnaire
■method (QIND) method, filnriasis was recognized as a health
problem in 14 villages, with prevalence scores ranging
health workers and physicians.
between 0.20 and 1.71. Interestingly, by this method prefer
’i:
ence for the control of filariasis was recorded in 9 villages
(Results
(score range: 0.20-0.86). The disease prevalence rates ranged
between 0.05% and 1.3% in 27 villages and only 3 villages
(./old standards
were said to be free of filariasis. One of these was also
|)Iood samples were collected from 4929 persons in 30 villages
declared as noncndcmic by direct method. In both direct and
jjpd examined for mf. The number of samples collected per
indirect approaches, body ache and fever were scored high in
jjjllage ranged from 90 to 273. Seventeen villages had no mf
terms of prevalence and control preference in 29 villages,
^■jirriers and^he mf rate in the remaining 13 villages ranged
reflecting the community perception of health problems.
from 0.40%jo 5JOO% (Table 1).
4692 individuals were clinically examined for filariasis
(range: 100-245 persons per village). The.prevalence of the
Jiseasc (lymphoedema and hydrocele; either one or both) was
Physical examination by health workers
The number of individuals physically examined by the health
(pcorded in 25 of 30 villages. The disease rate ranged from
jf.50% to 4.70%.
workers was 2990 (range: 5^-178 per village). Of these, 1430
^Lapid Assessment Procedures
070% to 11.50% (Table: 1).
-------------
(47.8%) were males and 1560 (522%) were females. Disease
prevalence was recorded in 26 villages and it ranged from
)-.'r rd - s A
|87 KIs were interviewed directly using the structured ques-
|ionnaire (QDIR) and 167 of these also answered the sclf-
Statistical analysis
lulininistcred questionnaires (QIND). About 70% of the KIs
tyerc male; government employees (56%), farmers (27%) and
Sensitivity and specificity of the KI questionnaire methods in
identifying positive villages using prevalence and control pref
businessmen (7%) constituted the majority.
Table I Range of filaria prevalence rates (in percentage) as obtained
by various procedures
erence score for filariasis was poor by both direct and indirect
approaches (Table 2). When the disease rate (using weighted
mean number cases) was considered, a very high sensitivity of
100% was obtained for the direct method, against 85% for
Prevalence
the indirect method. The specificity of both questionnaire
By NBS
(rt = 30)
By Physicians
(n = 30)
By Health
Workers
(n = 30)
approaches was relatively low (Table 2).
Reliability of both questionnaire methods using prevalence
and control preference scores in identifying disease positive
and negative villages (as determined by physician) was poor
Microlilaraeniia
Disease
Hydrocele
Lymphoedema
0.40-5.(X) (13)
as shown by low sensitivity and specificity ('fable 2) compared
0.5^.7 (25)
1.4-13.4 (23)
0.4-2.3 (8)
0.7-11.5 (26)
12-14.8 (25)
0.6-52 (10)
figures in parentheses indicate number of villages positive out of the
surveyed; n, Total number of villages surveyed; NBS, Night Blood
Survey.
t
to CEPH. Interestingly, however, when the weighted mean
number cases was used for identifying disease positive and
negative villages, a high sensitivity was recorded both by the
direct (92%) and indirect (88%) methods, although using the
same index, the specificity was very poor (< 20%) in both
approaches.
© 2(XX> IHukwrll S<icn<.c l.ld
\
VOLUME 5 NO I pr 000-000 JANUARY 1OOO
Tropical Medicine and International I icalth
A. Srividya e/u/”Rapid assessment procedures for the delimitation of lymphatic filariasis
About 20 pl of blood was collected from each individual of
the sample population by finger prick method between 2000
and 2400 hours. The blood smears were processed and
examined the next day in the laboratory and the mf counts
recorded.
In each study village, 10% of the population (aged 15 years
or older) was also clinically examined by physiciansjor signs
and symptoms associated with lymphatic filariasis, particu
larly lymphoedema and hydrocele. The sampling design was
' similar to NBS but independent.
•
Do you know anyone suffering from filarial disease
(hydrocele and or lymphoedema) in your village? If so,
how many?.
The number of cases given by each KI was weighted by
the village population figures given by him or her and the
weighted mean of cases was calculated for each community.
This mean was used to calculate the disease rate of that vil
lage through these methods.
Physical examination by health workers for chronic disease
manifestations (PEHW)
J
Direct and indirect key informant questionnaire techniques
In each village, 6-7 key informants including government
employees (school teachers, postal staff, public health person
nel, etc.), business people and fanners were identified and
information on filariasis was collected using a structured
questionnaire in the local language. It consisted of questions
on filariasis and also on the general health status of the
community in order to eliminate any possible bias towards
filariasis. Two approaches (direct and indirect) were used
for collecting information. In the direct method, health
workers interviewed key informants using a structured ques
tionnaire (QDIR), and in the indirect method, the same
informants completed the questionnaire by themselves (self
administered; Q1ND). In the indirect method, questionnaires
were sent to key informants through the local PHC staff, to
be filled in and returned within a week. Both methods were
used in all 30 villages. To minimize any influence of one
method over the other, QDIR was conducted in first 15 vil
lages and QIND in the other 15 villages at the beginning of
rhe study. At the end of the study, i.e. after one year, QIND
was carried out in first 15 villages and QDIR in the other
half. The same key informants were used in a given village for
both methods.
Obtaining information on filariasis
I
To find out whether filariasis was prevalcnythat area, the fol
lowing two key questions were asked:
•
•
What arc the important diseases prevalent among adults
in order of decreasing importance?;
What arc the diseases preferred by you for control in
order of decreasing importance?.
The answers given by the KIs to these questions were ranked
in the order of decreasing importance. The mean of the rank
for a particular disease (by all the KIs of a given village) was
taken as ‘prevalence’ and ‘control preference’ scores for that
particular disease for the village. To calculate the filarial dis
ease rate of the communities under study, another question
was asked:
To estimate the disease prevalence, those households selected
for NBS were re-visited by trained health workers and all the
available adults (2: 15 years of age) in the households were
examined for chronic filarial manifestations such as hydrocele
(scrotal swelling) and lymphoedema (swelling of limbs) in
men, and lymphoedema in women. The estimates of filariasis
indices obtained by these three procedures were compared
with those determined by the gold standards, to assess their
rapidity, reliability (in terms of specificity and sensitivity) and
relative cost effectiveness.
Cost-cffcctivcncss
The cost of various inputs under different activities for each
approach was computed taking into account relevant par
ameters. The wages for personnel, cost of consumables such
as questionnaire forms, medicines, blood lancets, stationery
and other relevant field consumables under each approach
were recorded separately. The transport cost for each
approach was worked out separately as a product of the total
number of kilometers traveled and the running cost per kilo
meter. Existing goods such as vehicles, microscopes, com
puters, etc. which can be used for more than one year were
considered capital goods. Ibr these, the depreciation cost was
computed using an annualization factor table (Creese 6c
Parker 1994).
A cost-effectiveness measure incorporating cost, rapidity
and efficacy (using sensitivity and specificity data as given
below) was derived to compare the cost per unit effectiveness
of the methods per village. Rapidity of a method was based
on the mean number of man-days required for processing one
village by that method. The efficacy of the method was the
measure of its discriminatory power to detect infected com
munities as estimated by the ratio of sensitivity to specificity
of the method. Effectiveness was calculated by weighing effi
cacy inversely by rapidity. Thus, for a given efficacy, a more
rapid test (requiring less number of man-days) was con
sidered to be more effective. The combined impact of cost
and effectiveness for each method was determined by the
3
© 2000 BLukwell Sciaxc Ltd
Tropical Medicine and International Health
A. Srividya et al.
VOLUME 5
NOT
PP 000-000 JANUARY lOOO
Rapid assessment procedures for the delimitation of lymphatic filariasis
Table 2 Comparison of Gold standards with RAP in terms of sensitivity, specificity and predictive values
Gold standards
(parameter used)
NBS
(mf rate)
IT.CI.
(Disease rate)*
RAP
Para meter used
(%)
(%)
Positive
predictive
value (%)
VsQDIR
VsQIND
VsQDIR
VsQIND
Vs QDIR
VsQIND
PEHW
Disease rate*
100
85
15
NA
23
85
12
6
77
53
NA
65
12
46
41
33
43
NA
33
42
100
33
54
56
NA
52
50
VsQDIR
VsQIND
VsQDIR
VsQIND
VsQDIR
VsQIND
PEHW
Disease rate*
92
88
12
44
NA
32
92
0
0
40
61
NA
80
40
82
82
50
85
NA
89
89
0
0
8
18
NA
19
50
Prevalence score
Sensitivity
Specificity
46
Preference score
Disease rate*
Prevalence score
Preference score
Disease rate*
Negative
predictive
value (%)
•Disease rate includes both hydrocele and lymphoedema; NA, Not applicable.
(r = 0.40; P < 0.05) (Figure 1). The association between total
When the village positivity with respect to the disease rate
as estimated by health workers was compared with mf rate
disease rate estimated by physicians and health workers was
and disease rate by physicians, both had a relatively high sen
also significant (r = 0.56; /’ < 0.05) (Figure 2). Though the
total disease rates estimated by clinicians and health workers
sitivity but a low specificity ( Table 2).
were significantly correlated, the hydrocele rates alone did not
Prevalence and control preference scores for filariasis
show any such association.
obtained through KI questionnaires had no significant associ
ation with the mf rate or with the disease rate determined
by the physicians. Neither did the disease prevalence rate
Relative cost-effectiveness of various techniques
obtained using weighted mean number of eases have any sig
nificant association with mf rate or disease rate as deter
The average cost per village as calculated for night blood sur
mined by physicians. The relationship between total disease
vey, clinical examination by physicians, physical examination
rate (inclusive of both hydrocele and lymphoedema) esti
by health workers, direct questionnaire and self-administered
mated by physicians and the mf rate was significant
questionnaire methods was USS 57,39, 17,17 and 14, respcc-
14r
6r
1 12 "
g 5O)
V)
ro
g 10 4 -
©
tn
a.r-
.40
‘-O
2 8-
co
8
S 2j-
»♦-
■
I>
ro
S’
1
o^0
1
J________ I_________1_
1
2
3
4
_L
5
Prevalence of mf (%)
Figure I Relationship between mf and disease prevalence (as esti
mated by clinicians).
(0 2000 Blackwell Science Ltd
J
6
6 -
4 -
2
0^
0
I "________ |__________ I__________ 1---------------- J
12
3
4
5
Prevalence of disease (%) (Clinician)
Figure 2 Relationship between disease rates as estimated by clini
cians and health workers.
5
VOLUME 5 NO I
Tropical Medicine and International 1 lealth
A. Srividya et al.
PP 000-000 JANUARY 1OOO
Rapid assessment procedures for the delimitation of lymphatic filariasis
Table 3 Cost effectiveness ratios of RAPs
Cost per
Cost
RAP
Cost per
Village
(in US $)
Village
(in Rs.)
relative
to NBS
Rapidity
(man-days)
NBS
CEPH
PEHW
QDIR$
QINDS
57
39
17
17
14
2431.07
1671.58
749.09
710.94
593.03
1
0.69
0.31
029
024
9.7
5.3
3.3
3.5
1.5
Cost
effectiveness
Efficacy!
Effectiveness!
ratio*
0.23
0.29
0.33
0.6
7267.72
2583.06
2154.36
988.38
1.00
120
0.96
1.15
0.90
f Scnsitivit^(l-Spccifity); t Efficacy* (1/Rapidity); * Cost/Effectiveness; $ For these two methods, disea:,se rate based on the weighted mean number of eases has been considered.
lively (Table 3). For the KI questionnaire techniques, only the
assessment of infection prevalence in humans (Pani ct al.
sensitivity and specificity values obtained by using weighted
1997).
Among the three proposed procedures assessed in this
mean tnunlxT of eases were used ( Table 2).
It is obvious that the cost of the proposed procedures was
study for their utility in the delimitation of lilariasis-endemic
significantly lower than that of conventional night blood sur
areas, the questionnaire method, though very rapid and
vey or clinical examination by physicians. Cheapest was the
acceptable to the community, was neither sensitive nor
self-administered indirect questionnaire (QIND) method
specific enough using the prevalence and preference scores.
(24% of the cost of NBS), followed by the KI direct question
Overall, the study area recorded low prevalence of infection
naire (QDIR) method (29% of NBS) and physical examin
and disease; and quite expectedly, the prevalence and prefer
ation by health workers (PEHW: 31% of NBS). The cost
ence scores for filariasis as obtained by the key informants
of clinical examination by physicians was 69% of NBS
turned out to be low, since common ailments such as fever
(Table 3). However, with regard to efficacy in detecting posi
and body ache happened to be of more concern to the general
tive villages in relation to NBS, the most efficacious (dis
populace. Hence, the high preference for control of these ail
criminatory) method was CEPH followed by QDIR, PEHW
ments was recorded. Therefore, the suitability of use of the
and QIND. Table 3 indicates that the cost-effectiveness ratio
prevalence/prcfercnce scores and disease rate by KI question
was highest with QIND followed by QDIR (considering the
naire approach in areas with different endemicity levels needs
disease rate using the weighted mean number of cases),
further investigation. By the same KI questionnaire approach
PEHW and CEPH.
(both QDIR and QIND), the information on the number of
individuals filarial disease was relatively more useful com
pared to prevalence and preference scores, since the disease
Discussion
rate considering the weighted mean number of eases was
Rapid Assessment Procedures (RAP) have been successfully
reasonably sensitive in declaring communities positive/
used in the control of onchocerciasis (Ngoumou ct al. 1994)
negative for filarial disease. Although the specificity was poor,
and schistosomiasis (Lengclcr ct al. 199la,b, 1992). In high
considering the high sensitivity, the low cost, rapidity, sim
endemic areas of Ghana (Gyapong et al. 1996) and India
plicity and high community acceptance, the KI questionnaire
(Ramaiah et al. 1996a) reliable estimates of the burden of
method (using the weighted mean number of cases) could
l^nipliatic filariasis in the community were obtained by^
serve as a first-level rapid and crude delimitation tool in
gnthropo-sociological assessment criteria comprising direct
filariasis endemic communities in large areas.
key informant interviews, focus groupjjjscussions, routine
Since a significant correlation was found between the mf
reporting from health facilities and self-administered ques
rate and the estimate of disease prevalence by physicians and
tionnaires. The results were compared with data from stan
also between the estimate of disease prevalence by physicians
dard epidemiological surveys (Gyapong et al. 1996). A
and health workers, it can be deduced that trained health
random examination of adult males for hydrocele also pro
workers can estimate the prevalence of the disease by physical
vided a good correlation with the community microfilaria
examination of a sample population. Though there was a
prevalence in Ghana. An analysis of data collected on differ
significant association between the overall disease rate
ent variables showed a significant correlation between vector
(including both hydrocele and lymphoedema) between PEHW
infection rate and infection prevalence in humaps^suggesting
and CEPH, the hydrocele rates determined by these two
that the former can be used as an indicator in the rapid
methods did not show any significant association. This may
6
© 2000 Blackwell Sciaxc Ltd
VOLUME 5 NO I PP 000-000 JANUARY XOOO
Tropical Medicine and Internationa! Health
A. Srividya el al.
Rapid assessment procedures for the delimitation of lymphatic filariasis
|>c attributed to the tendency of over estimation of scrotal
dwellings as hydrocele by the health workers. Therefore, with
fetter training, the capability of the health workers to cor
rectly diagnose hydrocele cases (excluding nonhydrocelc
(ascs) could be enhanced.
It should be noted that all these proposed methods arc
xvholly based on the presence of the clinical forms of the dis
ease in the community. While using them for delimitation
purposes, we may miss those areas which do not have disease
A Training Manual for Programme Managers. World Health
Organization, Geneva.
Das PK, Manoharan A, Ramaiah KD, Balarajan K Sc Dhanda V
(1995) Cost-analysis of blood surveys for the detection of micro
filaria carriers in rural areas. National Medical Journal of India 8,
143-144.
Gyapong J W, Adjci S, Gyapong M &S AsamoahG (1996) Rapid com
munity diagnosis of lymphatic filariasis. Acta Tropica 61, 65-74.
Lengclcr C, de Savigny D, Mshinda HC et al. (1991a) Community
but only infection as discussed under the basis for the
based questionnaires and health statistics as tools for the cost-
development of RAP above. To overcome this difficulty,
efficient identification of communities at risk of urinary
delimitation can be achieved by a three-stage procedure. In
schistosomiasis. International Journal of Epidemiology 20, 1-12.
(he first stage, the KI questionnaire method could rapidly
Lengclcr C, Kilima P, Mshinda H, Morona D, Hatz C
Tanner M
(1991b) Rapid, low-cost, two step method to screen for urinary
schistosomiasis at district level: The Kilosa experience. Bulletin of
screen areas for filariasis. Since its specificity is low, the areas
classified as negative by KI method could include some posi
tive communities (false negatives) which in the second stage
(jhould be screened by PEHW. This would identify all com-
pumities with clinical eases of filariasis (which arc likely to
World Health Organization 69, 179-189.
Lengclcr C, Sala Diakanda DM & Tanner M (1992) Using question
naires through an existing administrative system: a new approach
have infection prevalence as well). In the final stage, the com-
to health interview surveys. Health Policy Planning 7, 10-21.
Michael E, Bundy DAP
Grenfell BT (1996) Reassessing the global
inunitics negative for disease by both KI questionnaire and
prevalence and distribution of lymphatic filariasis. Parasitology
f’EHW method could be examined for infection prevalence
using either a suitable and simple day human blood antigen
112, 409-428.
National Malaria Eradication Programme (1995) National Filaria
bit such as the ICT kit (Weil et al. 1997) or a PGR technique
Control Programme Operation Manual (1995) Directorate,
yvith pools of mosquitoes (collected by simple traps). Follow
National Malaria Eradication Programme, Delhi, pp. 1.
Ngoumou P, Walsh JF fie Mace JM (1994) A rapid mapping tech
ing this stepwise procedure could not only save time and
manpower, but tests for detection of infection or transmission
(which arc costlier) could be limited to the minimum number
pf communities. This could also enable us to stratify villages
(or deciding the best control option {cither one or ajxjmbin^
jition of vector, parasite or morbidity control).
/Xcknowledgements
The study received financial support from the UNDP/WHO
Special Programme for Research and Training in Tropical
diseases(TDR), Geneva. The authors are grateful to Dr
C. Appavoo, Director, Public Health and Preventive
>
Creese A & Parker D (1994) Cost analysis in primary health care In
nique for the prevalence and distribution of onchocerciasis. A
Cameroon ease study. Annals of Tropical Medicine and
Parasitology 88, 463-474.
Ottesen EA, Duke BOL, Karam M & Behbehani K (1997) Strategics
and tools for the control/ elimination of lymphatic filariasis. WHO
Bulletin OMS 75, 491-503.
Pani SP, Yuvaraj J, Vanamail P, Dhanda V, Grenfell BT
Bundy DAP
(1995) Episodic adenolymphangitis and lymphodema in patients
with bancroftian filariasis. Transactions of the Royal Society of
Tropical Medicine and Hygiene 89, 72-74.
Pani SP Be Srividya A (1997) Clinical manifestations of bancroftian
filariasis with special reference to lymphoedema grading. Indian
Journal of Medical Research 102, 114—118.
Pani SP, Srividya A, Krishnamoorthy K, Das PK & Dhanda V (1997)
Medicine, Government of Tamil Nadu State/or kind per
Rapid Assessment Procedures (RAP) for lymphatic filariasis.
mission and active support to carry out the study in the
National Medical Journal of India 10, 19-22.
Ramaiah KD, Das PK, Vanamail P 6c Dhanda V (1996a) Rapid
villages.
assessment of rural lymphatic filariasis through key informants.
References
Brabin I. (19K9) Sex differences in susceptibility to lymphatic filariasis
and inijdicaiions forinatcrnal child immunity. /iph/cMim/oxy
btfeclion 105,335-353.
Centre for Disease Control (1993) Recommendations of the
International Task Force for Disease Eradication. Morbidity and
Mortality Weekly Report 42, 1-38.
! Chantcau S, Moulia I’clat JI’, Glaziou P el al. (1994) Og4C3 circu
lating antigen: a marker of infection and adult worm burden in
I
Q9|
Wuchereria bancrofti filariasis. Journal of Infectious Diseases 170,
247-250.
© 2000 BLickwell Scinxe Ltd
Tropical Biomedicine 13, 13-36.
Ramaiah KD, Ramu K, Vijaya Kumar KN 6c Guyatt H (1996b).
Epidemiology of acute filaria! episodes caused by Wuchereria ban
crofti infection in two rural villages in Tamil Nadu, south India.
Transactions of the Royal Society of Tropical Medicine and
Hygiene 90, 639-643.
Ramaiah KD, Viyay Kumar KN 6c Ramu K (1996c) Knowledge and
beliefs about transmission, prevention and control of lymphatic
filariasis in rural areas of South India. 1 ropical Medicine and
International Health 1,433—438.
Ramaiah KD, Viyay Kumar KN, Ramu K, Pani SP 6c Das PK (1997a)
Functional impairment caused by lymphatic filariasis in rural areas
7
Tropical Medicine and International Health
A. Srividya el al.
VOLUME 5 NO 1 PP 000-000 JANUARY XOOO
Rapid assessment procedures for the delimitation of lymphatic filariasis
of South India. Tropical Medicine and International Health 2,
832-838.
Ramaiah KD, Ramu K, Guyatt H, Vijaya Kumar KN &: Pani SP
(1997b) Direct and indirect costs of the acute form of lymphatic
filariasis to households in niral areas of Tamil Nadu, South India.
Tropical Medicine and International Health 3, 108-115.
Ramu K, Ramaiah KD, Guyatt H
Evans DB (1996) Impact of lym
phatic filariasis on the productivity of male weavers in a south
Indian village. Transactions of the Royal Society of Tropical
Medicine and I lygiene 90,669-670.
Weil GJ, Lammicr 1’J & Weiss N (1997) The ICT filariasis Test: a
Rapid-format Antgcn Test for Diagnosis of Bancroftian filariasis.
Parasitology Today 13,401—404.
World Health Organization (1995). World Health Report. WHO,
Geneva.
World Health Organization (1997) Lymphatic fdariasis: Reasons (or
hope. WHO/CTD/FIL/97.4. 1-20, Geneva.
(
/
/
8
© 7000 BLirkwcll Srimcc l id
Page: I
| Q1 ] Au: is short title OK?
Page: I
|Q2]ottcscn 1997 has been changed to Ottesen ct al. 1997 so that this citation matches the list
Page: 2
[Q3]Pani et al. 1990 has not been included in the list
Page:4
[ Q41Typesetter: insert Table I near here
Page: 4
[ Q5]Typesetter: insert 'fable 2 near here
Page: 4
[Q6]Typesetter: insert Figure 1 near here
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[Q9]Chantcau ct al. 1994 has not been found in the text
Document TDR/TDF/ComDT/98.2
Research on
Rapid Geographical Assessment
of Bancroftian Filariasis
prepared during a protocol development workshop
held from 22-25 July 1997
in James Cook University, Townsville, Australia
hiI
£»
UNDP/World Bank/WHO Special Programme
for Research and Training in Tropical Diseases (TDR)
and
WHO/UNICEF Joint Programme for Health Mapping (HealthMap)
WHO Division of Control of Tropical Diseases (CTD)
/\ 5 /
Ht
2^06
VS
oL
[I
_0
-A
/J
0
Ses drog firms: PHM officials
■
Thursday. PHM officials said that with also call upon governments across the
700 volunteers from over 50 countries, it world to put health at the centre of their
Mumbai Jan. 14: Delegates to the Peo- is being held as a run up to the World policy making priorities, he added.
Ss Health Movement, a forum for. Social Forum.
'
Parttctpants
also expec:ted o calif
1
- ’■ .
.
“jjjg pan for legal campaign against the disbanding of the WTO and regional
organisations working on public health,
is the part of international agreements with similar characters as
called for law suits to be filed across Asia drug patents
well
against multi-national pharmaceutical effort to build moral pressure pn icom
P^as the withdrawal of key WTO
nies^d
fomeZem
to
place
the
lives
grants, who have been using patent laws
r’"~
~of agreements like the trade-related aspects
“
that make essential and life saving drugs people .before corporate profits .We will of Intellectual Property Rights, which
"■3 the commercialisation of
expensive and inaccessible to low- also oppose the World Trade Orgamsa- promotes
healthcare.
Dr Narayan explained that
income consumers.
tion, globalisation, militarisation and
the
most
important
point on the agenda
The two-day confluence of organisa- .. poor public health policies, Dr Kavi
will
be
the
reintroduction
of the 1978
tions working on public health, which Narayan, the coordinator of PHM secre
Alma
Ata
Declaration
of
“
health
for all.”
started on Wednesday, will go on till tariat said. Delegates at the PHM will
By Our Special Correspondent
I
t- •
------ -------------- '
------ -----------------
•
~~
.
CONTENT
Introduction
1
Geographical distribution patterns of filariasis
Size of filariasis foci
Ghana
Vellore district in India
Myanmar
Gulbarga district in India ...
Preliminary spatial analysis
Myanmar
Gulbarga district in India . . .
6
Proposed methods for Rapid Geographical Assessment of Bancroftian Filariasis
Exclusion of areas
Mapping of distribution of filariasis in remaining areas
Indirect questionnaire
RAP survey in a sample of communities
8
8
8
9
9
Field testing of the different methods
Study objectives
Study design
Spatial analysis of endemicity patterns
Analysis of costs and other resource requirements
11
11
11
12
References
15
Annex I: list of participants
16
Annex II: Interview of Key Informants
17
2
2
2
3
4
4
5
5
11
Ht
/\ 5 / 4A/
A6;t -
J.)>^
|C 0 I_ r- A
'DELH> )
/)
0
/
,
$ aJ
tn nis: PHM officials
Bv Our SrECiAi. Correspondent
\
MDR.bai, Jan 14: Dd.gales ,o ,te Peo- UMjj MJ M a ™ ap » .he World
pie s Health Movement a forum for. S^ F“
campaign against
health,
organrsanons workrng oj public
publrc health.
““ “ ''^XAnfenrafional
called for law suits to be filed across Asia
■maiti'maironal 7 pharmaeeotioal effort to build moral pressure on eompaagainst
Hiaiuo,
giants. who have been using patent laws nies and force them to place the lives o
that make essential and life saving drugs people before corporate profits. We will
expensive and inaccessible to low- also oppose the World Trade Organisawome consumers.
consumers
lion, globalisation, militarisation and
income
“The two-day confluence of organisa-. poor public health policies,” Dr Ravi
tions working on public health, which Narayan, the coordinator of PHM secrestarted on Wednesday, will go on till tariat said. Delegates at the PHM will
L_-
for
the disbanding of the WTO and regional
agreements «ith similar eh™™ as
well as the withdrawal of h™
key WH>
WTO
agreements like the trade-related aspects
of Intellectual Property Rights, which
c__ ‘
the commercialisation of
promotes
healthcare.
!’■'• • •• Dr Narayan explained that
the most important pointt on the agenda
will be
be the
there.mtroductio
reintroduction of the 1978
'-n
Alma Ata Declaration of “health for all.”
-1-
1
Introduction
Lymphatic filariasis is a major public health problem in tropical countries. Recent estimates suggest
that some 120 million persons are infected world-wide; 107 million with Wuchereria bancrofti and
13 million with Brugia malayi. The number of people with physical disabilities due either to
lymphoedema and hydrocele or the newly recognised sub-clinical abnormalities of lymphatic and
renal function are currently estimated at 43 million, with Bancroftian filariasis accounting for
almost 40 million of these cases (Michael 1996).
The International Task Force on disease eradication identified lymphatic filariasis as one of six
potentially eradicable disease since there are now good enough tools to combat the disease (CDC,
1993). The World Health Assembly at its meeting in May 1997, passed a resolution on the
elimination of the disease as a public health problem through mass treatment of affected
populations and appropriate management of clinical cases.
In order to initiate any disease control programme based on mass drug distribution, one needs to
understand the geographical distribution of the disease in the affected countries in order to know
where to target mass treatment. Unfortunately, data on the distribution of lymphatic filariasis are
not widely available primarily because the standard procedures for determining which communities
are affected are cumbersome, time-consuming, expensive and very intrusive. In areas where the
parasite exhibits a nocturnal periodicity, parasitological examinations need to be done at night. This
becomes logistically cumbersome to organize, and communities often refuse to co-operate.
Recent epidemiological studies in Ghana suggested that clinical filarial disease is a good proxy
measure ofthe levels of endemicity of filariasis. (Gyapo ng et al, 1996). This findings has since been
validated in a WHO coordinated multi-country study (WHO 1998a). On the basis ofthe results,
the study participants recommended the use of clinical examinations of a sample of adults as a
rapid method to assess the community burden of the disease.
Even with these new rapid assessment methods, it would be very time-consuming and expensive
to do filariasis surveys in all potentially endemic communities in order to determine the
geographical distribution of lymphatic filariasis. However, given the clustered distribution of
filariasis in most parts of the world, it may be possible to develop methods which allow the
estimation of the distribution of filariasis on the basis of surveys in a limited spatial sample of
communities. Such a method has already proven very valuable for onchocerciasis control in Africa
(Ngoumou et al 1994, WHO 1998b).
Building on this idea, the participants in the workshop reviewed spatial patterns of lymphatic
filariasis, designed different methods for rapid geographical assessment of Bancroftian filariasis,
and formulated a plan for field-testing of the proposed methods.
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„„ 50 countnes. *
700 volunteers from over 50 countries, it
■ ' ” as a run up to the World
Mumbai, Jan. 14: Delegates to the Peo- is being held
ociarrorum.
■
,
#
pie’s Health Movement, a forum for- Social Forum. .!■
“The call for legalorganisations working on public health,
legal, campaign against
called for law suits to be filed across Asia drug patents is the part of international
against multi-national pharmaceutical effort to build moral pressure on compagfants, who have been using patent laws . nies and force them to. placej.*6
Lt make essential and life saving drugs people.beforechorale profit ^WewH
expensive and inaccessible to low- also oppose the .World Trade Orgamsa
income consumers.
- ■
t™,
mihunsation and
The two-day confluence of orgamsa-;.. poor public health pohaes, ^r
tions working on public health, which Narayan ^coordinator of PHJUcrestarted on Wednesday, will go on till tanat said. Delegates at the PHM will
Br O« SrECAL CORREErONDENT
also call upon governments across the
world to put health at the centre of their
policy making priorities, he added.
Participants are also expected to call for
the disbanding of the WTO and regional
agreements with similar characters as
well as the withdrawal of key WTO
agreements like the trade-related aspects
of Intellectual Property Rights, which
promotes the commercialisation of
healthcare. Dr Narayan explained that’
the most important point on the agenda
will be the reintroduction of the 1978
Alma Ata Declaration of “health for all.”
-4-
2.1.3 Myanmar
Filarial antigen prevalence data from 70 randomly selected Townships spread over the 14 Districts
of the country were analysed/The prevalence of antigenaemia was determined using the ICT filarial
antigen detection kit on blood samples from 100 blood donors from each site. The majontyofthe
blood donors were residents of the main towns in the selected Townships. The map of the
prevalence data suggests that the central dry zone is highly endemic (20-30 %) and that the
northern, eastern and southern areas are less endemic or free from filariasis. (Map 3)
Map 3: Prevalence of filarial antigen in sample
townships in Myanmar
28.00
26.00'
0®
O
24.00
22.00
20.00
O
18.00
16.00
14.00
12.00
Prevalence of mf
o' 0% to 0%
0
0
0
O
e
10.00
0% to 2%
2% to 5%
5% to 10%
10% to 15%
15% to 25%
25% to 99%
94.00
96.00
98.00
100.00
2.1.4 Gulbarga district in India
After the workshop, an analysis was done of microfilarial prevalence data for the district of
Gulbarga in Karnataka State in India. These data were the result of a night blood filariasis survey
undertakgnjn^ujbai^a district between 1985 and 1988. The sampling-was doneToWwin^tlfe
guidelines of the National Filariasis Control Programme (NFCP). Of the villages sampled, 262
villages_whose geographical coordinates were available were plotted on a map using GIS. Theresults are given in Map 4. They show that filariasis in endemic throughout the study area except
in the West where there the prevalence of microfilaraemia was zero in most sample villages.
A
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Thursday. PHM officials said that with
700 volunteers from over 50 countries, it
Mumbai, Jan. 14: Delegates to the Peo- is being held as a run up to the World
for- Social Forum.
pie’s Health Movement, a forum for.
organisations working on public health,
“The call for legal campaign^agams
called for law suits m be filed across Asia drug patents is the part of international
■ ’ . effort to build moral pressure on compa
against multi-national pharmaceutical
Hants, who have been using patent laws . nies_ and force them to place the lives of
that make essential and life saving drugs people before corporate profits;. We will
expensive and inaccessible to low- aalso
— oppose
_rr — the World Trade OrganisaSme consumers.
tion, globalisaUon ^tansation and
Dr Jg
Ravi
The two-day confluence of orgamsa-. poor public health Pgcies’
health,^which
Narayan,
the^coordinator
of
PHM
tions working on public health, which
the coordinator
secre
started on Wednesday, will go on till ttanat
----- _said. Delegates at the PHM wi
By Our Special Correspondent
e
\
*11
1
1
-
-
________ 4.1- ~
I
I
also, call upon goverageng^rgfstgh®
world to put health at the centre of their
policy making priorities, he added.
Participants are also expected to call for
the disbanding of the WTO and regional
agreements with similar characters as
well as the withdrawal of key WTO
agreements like the trade-related aspects
of Intellectual Property Rights, which
promotes the commercialisation of
healthcare. Dr Narayan explained that
the most important point on the agenda
will be the reintroduction of the 1978
Alma Ata Declaration of “health for all.’
-5-
Map 4: prevalence of microfilaraemia in sample villages in Gulbarga district in India
t
17.6
>0
)
17.4
Si
O
■o
17.2
17.0
l000(?
09
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0
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0
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a
«0
Prevalence of mf
in sample villages
• 15% to 25%
• 25% to 99%
0
09
0% to 0%
0% to 2%
2% to 5%
5% to 10%
10% to 15%
0®
16.8
O
00
0®
0
0
16.6
76.0
76.2
76.4
76.6
76.8
77.0
77.2
77.4
77.6
Longitude
2.2
Preliminary spatial analysis
2.2.1 Myanmar
A preliminary spatial analysis of the Myanmar data indicates that there exists a spatial
autocorrelation between the prevalence data, with the semivariance being smallest for villages which
are located closest to each other (see Figure 1). An exponential model was fitted to the
semivariance data and this model was used in so-called kriging to estimate the prevalence of antigen
for each point of a grid overlaying the country. In kriging, the prevalence at a grid point is estimated
by a weighted average of the observed prevalences, with the weighting factor depending on distance
and spatial autocorrelation as defined by the semivariance model. The results of this estimation are
given m Map 5 which shows the contour lines for the estimated prevalence of antigen.
y(|h|)
Figure 1: An omnidirectional
semivariogram showing increasing
semivariance, •, of antigen prevalence
with distance till a distance of 2 when
• levels off (the units of distance, h,
are in degrees; 50 km is approximately
0.48 degrees). The fitted curve
represents an exponential model with
nugget 45, range 2.5 and sill 59.
100
80
60 -
40 20 -
oL
0
0.4
0.8
1.2
2
1.6
|h|
2.4
2.8
3.2
3.6
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Sue drug firms: PHM officials
also call upon governments across the
world to put health at the centre of their
policy making priorities, he added.
Participants are also expected to call for
the disbanding of the WTO and regional
...
characters
agreements Wlt^simiiar charact ; as
well as the withdrawal of key WTO
ag™.s"like ihe irade-reUed aapeeis
r intellectual
Rights,
of
Intellectual Property
Property
Rights, which
which
pLX^the
"ZXcilClon
of
r
the commercialisation of
explained that
tion, globalisation, militarisation and healthcare.
h??.1?’’'”'" Dr Narayan
.
> &
Hpalth nolicies ” Dr Ravi the most important point on the agenda
will he the —i„ el ide
Aima
Ata Declaration of “health for all.”
tanat said. Delegates at the PHM will
Thursday. PHM officials said that with
^Xoluntee'rs
-700 ,^i,,ntAArc from
frAm over
over 50
50 countries,
countries, it
it
Mumbai, Jan. 14: Delegates to the Peo- is being held as a run up to the World
,
pie’s Health Movement, aa forum for SocialForum. r
“The call for legal- campaign against
organisations working on [Ppublic health,
‘ 'l drug patents is the part of international
called for law suits to be filed across Asia
0—*- "£
Sf
against i----giants,
wuu imvc;
uwix using
lxoxxx& F
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f
,,,
giants,
who
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patent
that make essential and life saving drugs alTo^^pposrith^Wori^Trade^Organria-
Ln
Bv OUR SPECIAL CORRESPONDENT
expensive and inaccessible to ( lowincome
;
income consumers.
started on Wednesday, will go on till
i
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ii
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pi
.
.... ..................■■
-6-
Map 5: estimated prevalence of filarial antigen in Myanmar
Contour lines for the estimated
prevalence of filarial antigen
Prevalence of filarial antigen in
sampled townships in Myanmar
28.00
28.00
26.00
26.00
0®
24.00
24.00
SX,0
22.00
Prev.
of Ag
20.00
20.00
18%
18.00
18.00
16.00
16.00
22.00
o
16%
14%
12%
10%
14.00
12.00
10.00
Prevalence of Ag
O
0
0
0
(>
0% to 0%
0% to 2%
2% to 5%
5% to 10%
10% to 15%
• 15% to 25%
• 25% to 99%
„___94._00___96 .___
,___100__
00
98 00
00
8%
14.00
____ 6%
12.00
4%
---- 2%
10.00
___94.____
,___98r
■
00
96 00
00
100 00
0%
The contour map shows the existence of a major filariasis focus in the centre of the country, and
an area which is virtually filariasis free in the South-West. In the remaining part of the country, the
sample townships were widely dispersed with some isolated townships being located at more than
250 km from the nearest sample township. With such distances between the samples, interpolation
becomes questionable and there appears to be a need to extend the sample coverage of the country
before a complete map of the distribution of filariasis in Myanmar can be made.
2.2.2 Gulbarga district in India
The detailed data for Gulbarga district enabled a full spatial analysis of the endemicity pattern of
Bancroftian filariasis. The semivariogram analysis showed a strong spatial autocorrelation of the
prevalence of microfilaraemia (see Figure 2). The fitted linear variogram model was subsequently
used in kriging and contour analysis. The results are shown in Map 6 which combines a twodimensional plot of the observed prevalence of mf and a countour plot for the estimated prevalence
with a three-dimensional surface plot of the estimated prevalence of microfilaraemia.
Ht
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drug firms: PHM officials
By Our Special Correspondent
Thursday. PHM officials said that with
700 volunteers from over 50 countries, it
Mumbai, Jan. 14: Delegates to the Peo- is being held as a run up to the World
pie’s Health Movement, a forum for Social Forum.
i
organisations working on public health,
“.The call for legal campaign against
called for law suits to be filed across Asia drug patents is the part of international
against multi-national pharmaceutical effort to build moral pressure on compagiants, who have been using patent laws . nies and force- them to. place the lives of
that make essential and life saving drugs people .before corporate profits. We will
expensive and inaccessible to. low- also oppose the World Trade Organisaincome consumers.
. tion, globalisation, militarisation and
The two-day confluence of organisa-. poor public health policies,’. Dr Ravi
tions working on public health, which Narayan, the coordinator of PHM secre
started on Wednesday, will go on till tariat said. Delegates at the PHM will
___________
_------------------------------- —■
also call upon governments across the
world to put health at the centre oi their
policy making priorities, he added.
Participants
the disbanding of the WTO and regional
agreements with similar characters as
well as the withdrawal of key WTO
agreements like the trade-related aspects
of Intellectual Property Rights, which
promotes the commercialisation of
healthcare. Dr Narayan
explained that ’
-----------.
the^most^mportant point: on the agenda
will be the reintroduction of the 1978
Alma Ata Declaration of “health for all.”
y(|h|)
Figure 2: An omnidirectional semivariogram
for Gulbarga district showing an increasing
semivariance, •, between village MF prevalence
with distance, h. This pattern indicates a strong
spatial autocorrelation between the prevalence
data. The fitted linear model has a nugget of
14.56 and a slope of 21.336
40 35
30 25 -
20
15
10 -
50
0
04
0.2
06
0.8
IN
Map 6: Distribution of Bancroftian filariasis in Gulbarga district, India
.. .
"’•s
at*
1o%
§
4
5%
The pattern for this district is very clear, with high endemicity in the centre and the East, a peak
prevalence around 77.2° E and 17.3° N, and a gradually declining prevalence of microfilaraemia to
the West. Large scale treatment appears indicated for most of the district. These prevalence contour
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firms: PHM officials
Th,.rcriav PHM officials said that with also call upon governments across the
Thursd;ayJ ^Zonntnes it world to put health at the centre of their
700 volunteers from over 50 countries, it
m to'the World policy making priorities, he added.
Mumbai, Jan. 14: Delegates to the Peo- is .c^i
beingHomm
held as a run uj
'
Participants are also expected to call for
pie’s Health Movement, a forum for- Social
Forum.
;
J
’
!
” ‘‘The call for legal campaign against the disbanding of the WTO and regional
organisations working on public health, drug patents is the part of international agreements with similar characters as
called for law suits to be filed across Asia <
to build
moral pressures
picssuic on compaagainst multi-national pharmaceutical ettort
effort to
build moral
comp^- well as the withdrawal of key
ni
e
S
and
fd.ee
-hem
pladefc
d.es of yjmga*
giants, who have been using patent laws m----- - --- - -,
.
that make essential and life saving drugs people before co^or^e Pr°£
promotes the commercialisation of
expensive and inaccessible to low- also oppose the World Trade Orgamsa
P
tion globalisation, militarisation and healthcare. Dr Narayan explained that
income consumers.
non’ s ", L
nr,lip;ps>> n.
Dr Ravi the most important point on the agenda
The two-day confluence of orgamsa-,. poor public health pohctes JL.
will be the reintroduction of the 1978
tions working on public health, which Narayan, the coordinator of PHM^secresZed on Wednesday, will go on till tariat said. Delegates at the PHM will Alma Ata Declaration of “health for all.”
By Our Special Correspondent
-8-
maps should be very useful to control managers by clearly indicating priority areas for control and
by facilitating objective decision making on the boundaries of treatment areas.
3
Proposed methods for Rapid Geographical
Assessment of Bancroftian Filariasis
Although the available data from the above countries was limited, it was noted that in all cases the
fllariasis foci were fairly homogeneous and quite large with a diameter of at least 50 km. This
preliminary finding was used in the design of proposed methods for Rapid Geographical Assessment
of Bancroftian Filariasis (RAGFIL). These methods and the steps involved are described below.
3.1
Exclusion of areas
The first step is to evaluate regions of endemic countries, defined by ecological or other
features, in order to identify areas where there is no fllariasis or where there are only sporadic
infections which are unlikely to be significant for control. Such regions will be excluded from
further rapid assessments. Although it is important not to exclude endemic areas for which control
is appropriate, criteria should be specified for each country to exclude regions where the chance of
significant lymphatic filariasis is acceptably low. Criteria for exclusion may include negative results
in prior screening, and demographic and ecological features that are incompatible with the parasite,
vector, and disease (e.g. uninhabited areas, deserts, national parks, very high mountain ranges etc).
Historical survey data may be sufficient for inclusion of an area. Such data may include
either published literature or data from national programme activities. The latter may be obtained
from national health documents, reports from international sources (eg, sources from WHO; TDR
documents currently under review; South Pacific Commission Reports in New Caledonia, and
relevant published literature, such as Sasa’s Human Filariasis). Older sources (eg, before 1950)
should be sufficient for classifying regions as possibly endemic, and recent epidemiological data
from proper studies may be acceptable as community survey data.
3.2
Mapping of distribution of fllariasis in remaining areas
In known endemic or possibly endemic regions (ie, those not excluded), Rapid Geographical
Assessment of Bancroftian Filariasis (RAGFIL) will be done. Two different RAGFIL methods are
proposed:
(>) a method in which a large sample of villages will be surveyed indirectly using
questionnaires directed at key informants, and
('<) a method based on surveys using rapid assessment techniques (viz, health worker
examination for hydrocele and lymphoedema, or possibly antigen screening with the
ICT card) in a small sample of communities selected on the basis of a geographical
grid (grid spacing 50 km, subject to validation).
Mt
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15
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P
K 0L
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/ (4
f
4
2)
-~r_
Suellrug firms: PHM officials
fl
Thursday. PHM officials said that with also call upon governments across the
700 volunteers from over 50 countries, it world to put health at the centre of their
Mumbai, Jan. 14: Delegates to the Peo is being held as a run up to the World policy making priorities, he added.
Participants are also expected to call for
ple’s Health Movement, a forum for- Social Forum.
the
disbanding of the WTO and regional
organisauons
wuikih^ on puunv
The call for legal campaign against
organisations working
public uvaitii,
health,
agreements
with similar characters as
called for law suits to be filed across Asia drug patents is the part of international
well
as
the
withdrawal of key WTO
" ’ to ’build
” ’ moral\pressure‘ on compa
against multi-national pharmaceutical effort
agreements
like
the trade-related aspects
them to place the lives of
giants, who have been using patent laws nies and3 3force
.... ,u
of
Intellectual
Property
Rights, which
that make essential and life saving drugs people before corporate profits. We will
promotes
the
commercialisation
of
expensive and inaccessible to .low- also oppose the World Trade Organisa
healthcare.
Dr
Narayan
explained
that
tion, globalisation, militarisation and
income consumers.
The two-day confluence of organisa-. poor public health policies,” Dr Ravi the most important_ point on the agenda
lions working on public health, which Narayan, the coordinator of PHM secre- will be the reintroduction of the 1978
Alma Ata Declaration of “health for all.”
started on Wednesday, will go on till tariat said. Delegates at the PHM will i-----------------------
By Our Special Correspondent
I
JI IUII «|
I
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TROPICA
Acta Tropica 76 (2000) 197-19^
www.elsevier.com/locate/actatropica
t°rs. Il
Short communication
1
A prospect J
m*c area <£ I
II
citation of, |
s of splenic; I
Effect of lymphatic filariasis on school children
K.D. Ramaiah *. K.N. Vijay Kumar
^or Comrol Re^arch Cen.re. ^dical Comp^. Mira Nagar. Po„Mherrv-605 006 Mia
Reeved 20 December .999: reeved in rev.sed form 3 Apn. 2000: accepted .2 Apnl 2000
Trop. MeSf’
O H.,
> of Visceral'
led. Hyg 8T
Keywords: Lymphatic filariasis: Education: Children
evidence-: of
rbers resid* i
>m. Dis. 24^.'
Lymphatic filariasis affects about 120 million
people globally and 22 million of them are chil
dren below 15 years of age (Michael et al.. 1996).
. Kar, S.IS. Lymphatic filariasis has been listed as the second
iistigotes Erl
Acta Trap I leading known cause of disability (World Health
Organization. 1995) and the disease impairs mo
bility, day-to-day domestic and economic activi
ties (Evans et al., 1993; Gyapong et al.. 1996;
Ramaiah et al., 1997) and sexual and marital life
(Dreyer et al.. 1997). The disease is estimated to
oe responsible for the loss of about 0.63% of per
capitum GNP in India (Ramaiah et al., 2000).
Most socioeconomic studies on hlariasis involve
adults and the problem of filariasis in children has
received poor attention. In our studies on filariasis
rural areas, we have seen many children (5-15
yearS) a^ected wi(fi filariasis.
W Five hundred and six people were detected with
« c ronic manifestations of filariasis in two villages
I
Pondicherry in South India. They included
®
individuals (26 boys and two girls) below 20
i
I
H ^CorrespondinS author. Tel.:
+ 91-413-372422: fax: +91« ril3-372041.
^S'tnail address:
mosquito@md2.vsnl.net.in (K.D. Ramaiah).
years of age and clinical examination for chronic
disease (Pani et al., 1991) and inquiry on occur
rence ol acute disease (Ramaiah et al., 1996)
confirmed the presence of chronic and/or acute
disease manifestations in them. Seventeen (16
boys and one girl) ot the 28 were affected with
acute and/or chronic disease while they were in
school and 11 alter they had completed or discon
tinued school education. Of those 17, 14 were
affected with hydrocele and two (one girl and one
boy) with slight lymphoedema of the lower limbs
and one with frequent episodes of only acuteadcnolymphangitis (ADL). Five of the 14 -boys
affected
with
hydrocele
and
one
with
lymphoedema also reported occurrence of ADL
episodes. These 17 individuals were in the aue
group of 10-15 years (Table 1).
We have collected qualitative data through indepth interviews (Taylor and Bogdan, 1984- Ra
maiah et al., 1997) with all the 17 individuals to
assess the impact ot the disease on their educa
tion. Social stigma in terms of shame, embarrass
ment and ridicule involving enlarged genitals
forced a 15 year old boy studying tenth standard
in a local school to give up his education. While
-§l:^()l‘706x/00/s - see front matter O 2000 Elsevier Science
B.V. All rights reserved.
fH^SOOQ! -706X(00)00102-9
198
K.D. Kamaiah. k.N. Vijay Kumar Acia Tropica /6 (2000) 197-199
in school, he used to conceal his disease condition
by wearing loose garments. The convention of
going to secondary education classes (11th and
12th standard) wearing trousers, which he
thought would reveal his disease condition and
attract ridicule from his fellow students forced
him to give up his education. Lu et al. (1988) also
documented the stigma associated with hydrocele.
Another boy, while studying eighth standard,
used to suffer frequent ADL episodes coupled
with transient lymphoedema of lower limbs.
Severe fever and malaise associated with ADL
episodes (Ramaiah et al.. 1996) forced the boy to
abstain from school often. Angry reaction from a
teacher to absenteeism from school made him to
give up his education. In addition, six more pupils
also reported occurrence of ADL episodes and
hence absenteeism from school. All the seven boys
with ADL fell that the disease impaired their
performance in studies. The frequency of ADL
episodes reported to be.2- 12 per annum. The loss
of attendance ranged from 2-3 days per episode.
One boy told us that he used to get acute attacks
suddenly and had to leave the class room
abruptly.
The most common complaint among the pupils
with hydrocele was pain in the scrotum, which got
worse after walking or cycling, by which means
the pupils go to the local schools. The pain and
■ inconvenience also forced some of the victims to
curtail playing and other extra-curricular activiTable 1
Clinical manifestations and impact of the disease in school
children (10-15 year age group) in the study villages
Clinical manifestation/impact on
education
Boys
Girls
fpumber of children affected while in
school
Number with hydrocele
Number with lymphoedema
Number with only ADL
Number of dropped out of school
Number of frequently abstained from
school
16
1
14“
NAb
1
0
0
0
1“
1
6
a Five hydrocele patients and the lymphoedema patient were
affected with ADL also.
b NA, not applicable.
i- . ’ K’-'
ties. One boy reported precipitation of acute
te intervention
episodes following exertion caused by playing.g. Sge for the
The affected also felt anguish that they could not,f /tfgains also.
wear the dress of their choice. Physical comfort in ® While th<
scrotal area and concealment of the disease condi ’ Jstudy pro vic
tion weighed more in choosing the dress.
gmpact of tl
Epidemiological studies on lymphatic
filariasis
. .
——. detailed stuc
have not focussed on school children. However, Spact on schc
prevalence of microfilaraemia
1976). acute 4form
--------------- (Sasa.
--------------------------e
(Ramaiah et al.. 1996)
1
and chronic (Pani et al.,
1991) disease has been recorded in school age X
children. In our study, more boys were found with ^Acknowledge.
clinical manifestations than girls and most of the
boys (14/16) were affected with hydrocele. This is
The stud\
in conformity with earlier observations that
WHO/TDR 'l
prevalence (Pani et al.. 1991; Mcyrowtisch et al.,
1995) and risk of being affected with hydrocele
(Chan et al.. 1998) is significantly higher than that References
■ of lymphoedemca of limbs in the male
Wpopulation.
Bundy. D.A.P.. (
About 35% of the pupils drop out from pri -■ on healih. cd
mary and secondary level schools due to various p Today 12 (Pl
reasons including ill-health in the study region. Chan. M.S.. Srivi
> K.D.. Vanani
Bundy and Guyatt (1996) have discussed specifi
EPIFIL. a d
cally the impact of parasitic infections such as
lymphatic fiiai
intestinal helminths, malaria and dracunculiasis Dreyer. G.. Noro
on children and their physical and mental devel j sexual disabiii
< Trop ^3. 57opment. Our data for the first time, throws some a-ans.
...
light on the effect of lymphatic filariasis on educa
economic fa.-..
tional performance of school children. Unlike pa '? review. Acta 7
tients in higher age groups, no school age ■tyapong. J„ Gyaj
individual underwent surgical intervention for hy .g S., 1996. The
J Ghana. Ann. “
drocele in the study villages (Vector Control Re
search Centre, unpublished). This combined with
lack of adequate and effective treatment methods •f
for individual patients (Ottesen et al., 1999) may
contribute to the progression of the disease h1
affected individuals. Thus, the overall impact of
the disease appears to be very complex — P0°r
educational achievement affects the quality of fu*
ture life (Bundy and Guyatt. 1996) and the pr0*
gression of disease causes sociopsycholom^
problems (Dreyer et al., 1997). Therefore,
segment of the endemic population needs spe^
attention and support. School-based interventi.0115
are cost effective and show greater impact 0°
health status than many other types of ^nterVgj
tions (Bundy and Guyatt, 1996). School
-fly
i
f
i
s
'-1
Sr-
J
tK
Ramaiah' A'.W. Vijay Kumar / Acta Tropica 76 (2000) 197-199
199
| interventions may ensure better treatment covcrcover| -age for the control of filariasis and educational
’ j also.
s . gains
j
While the qualitative data gathered
< '
J in this
study provides evidence for the first
time
— -....... e on the
impact of the disease on school children, more
detailed studies are rnecessary to quantify the impact on school absenteeism and educational performance of children.
Acknowiedgements
The study received financial support from
WHO/TDR, UNDP'World Bank.
References
Bundy, D.A.P.. Guyatt. H.L.. 1996. Schools for health: focus
on health, education and the school-auc child. Parasitol
Today 12 (PT102). 1-16.
Chan. M.S.. Srividya. A.. Norman. R.A.. Pani. S.P.. Ramaiah
K.D.. Vanamaii. P.. Michael. E.. Bundv. D.A.P 1998
• EPIFIL: a dynamic model of infection and disease in
lymphatic lilariasis. Am. J. Trop. Med. Hve. 59. 606-614
Dreyer. G.. No rocs. J.. Addis. D.. 1997. The'silent burden of
sexual disability associated with, lymphatic lilariasis Acta
Trop. 63. 57 60.
Evans. D.B.. Gclband. II.. Vlassoff. C.. r*'*’ "
1993. Social and
economic factors and the control of lymphatic fihriasis*
: a
review. Acta Trop. 53. I 26.
Gyapong, J.. Gyapong. M„ Evans. D.B.. Aikins. M.K.. Adjei
1996. The economic burden of lilariasis in northern
Cxhana. Ann. Trop. Med. Parasitol. 90. 39- 48.
**■
r
L B- de las Llagas- Aballa- L- Pos'rado.
L.. 1988. A study of knowledge, attitude and practices of
the people ot Sorsogon. UNDP/World Bank/WHO Special
Programme tor Research and Training in Tropical Dis
eases (TDR). Social and Economic Research Reports. No.
Meyrowtisch. D.W.. Simonsen. P.E., Makunde. W.H.. 1995.
Bancrottian filariasis: analysis of infectio.
----- ..on and disease in
five endemic communities of north-eastern Tanzania. Ann
Irop. Med. Parasitol. 89. 653-663.
Michael E Bundy. D.A.P.. Grenfell. B.T.. 1996. Reassessing
the global prevalence and distribution of lymphatic filariaSIS. Parasitology 112. 409-428.
Ottesen. E.A.. [small. M.M.. Horton. J.. 1999. The role of
albendazole in programmes to eliminate lymphatic filaria
sis. Parasitol. Today 15. 382-386.
Pam. S.P.. Balaknshnan. N.. Srividya. A.. Bundv DAP
Grenfell. B.T.. 1991. Clinical ep.demiology of bancroftian
etfect Ot age and gender- Trans. R. Soc. Trop
Med. Hyg. 85. 260-264.
Ramaiah. K.D.. Ramu. K.. Vijay Kumar. K.N.. Guyatt. H..
1996. Epidemiology of acute filarial episodes caused by
Wiichereria bancrojti infection
------- 1 *n two rural villages of
S°Ulh
India’
Trans‘
R‘
Soc’Trop’
Med’
Hyg-
Ramaiah. K.D.. Vijay Kumar. K.N.. Ramu. K.. Pani. S.P..
Das. P.K.. 1997. Functional impairment caused bv
lymphatic lilariasis in rural ureas of South India Trop
Med. hit. Health 2. 832 -838.
Ramaiah. K.D.. Das. P.K.. ?*'
' ’ "E.. Guyatt. H.. 2()()(). The
Michael.
economic burden of lymphatic
lilariasis
•
- ........
—■> in India. Parasitol.
Today 16. 251-253.
Sasa. M.. 1976. Human Filanasis: A Global Survey of Epidcmioiogy and Control. University of Tokyo Press. Tokyo.
ay or. S.J.. Bogdan. R.. 1984. Introduction to Qualitative
Research Methods: The Search for Meanings. Wiley New
York.
World Health Organization. 1995. World Health Report.
1995. Geneva.
yis-
Community Development and Partnership Strategy
for LF drug delivery in urban areas in India
Draft Research Protocol
Content
BACKGROUND
1
COMMUNITY DEVELOPMENT AND PARTNERSHIP STRATEGY (CDPS) FOR LF DRUG
DISTRIBUTION IN URBAN AREAS
......................................................................................
2
PROCESS:
2
Drug delivery.
PURPOSE AND OBJECTIVES OF THE STUDY
Research questions ..
Purpose of the study
Study objectives
5
5
5
5
STUDY DESIGN
6
Annex 1: Conceptual Framework for the intervention strategies
7
ANNEX 2: COMMUNITY DEVELOPMENT
8
8
9
Definition of Community Development
Principles of the Community Development method
1
Background
Lymphatic filariasis is a major health problem in many countries of the tropical
world. An estimated 1.2 billion live in areas endemic for the disease all over the wold
while 120 million have one form of the disease or the other. India accounts for over 40%
of global burden of the disease with an estimated 450 million people “at risk” of infection
and 50 million already infected. The disease does not kill but can cause significant
morbidity and impede productivity and economic development of affected communities.
However, recent advances in mapping, diagnostics and development of
chemotherapy and monitoring tools have made it possible to plan tor the elimination of
the diseases. The World Health Assembly in 1997 passed a resolution for the global
elimination of lymphatic filariasis by the year 2020. The global plan for elimination is
based on the twin strategy of interruption of transmission for the prevention of new cases
and alleviation and prevention of morbidity in individuals who already have the disease.
Interruption of transmission is achieved through mass administration of single annual
doses of either DEC alone or a combination of DEC and albendazole. The success of this
strategy is dependent on achieving high levels of coverage in endemic communities
(>85%) and sustaining such coverages for 5 to 7 years.
This strategy of single annual administration is currently being implemented in 13
districts on India on an experimental basis. A recently completed TDR sponsored multi
centric study showed coverages to be far below the expected levels at all study sites. This
study was conducted primarily in rural areas and highlighted the need for advocacy and
development of better delivery strategies for achieving high levels of coverages.
The National Control Programme envisages rapid expansion of the revised
strategy of single annual dose based mass chemotherapy to over 100 districts shortly.
This expansion will cover both rural and urban areas in the endemic districts. While a
drug delivery strategy for rural areas has been developed and is being continuously
modified no such strategy exists for drug delivery in urban areas.
Bancroftian filariasis is recognized as a disease of urbanization and there is a
growing need to develop strategies for drug delivery to achieve high levels of'coverages
Fn urban areas. Urban populations also differ from rural populations in several ways. The
presence of both organised and unorganized settlements requires a mix of approaches. In
addition the problem-of migration is more pronounced than in the rural areas. The higher
levels of literacy and economy make these populations more demanding in terms of
information and quality of services. Similarly the affluence of some urban communities
makes them rely, heavily on the private sector for the health needs. More importantly the
health care system in urban communities lacks the infrastructure and the outreach that is
found in rural areas. Thus urban drug delivery strategies which take into consideration
these factors need to be developed well in time before the mass drug administration
strategy is expanded to cover more districts and urban areas including large metropolitan
cities.
i
2
Community Development and Partnership Strategy
(CDPS) for LF drug distribution in urban areas
During two protocol development workshops, the challenges for LF mass drug
administration (MDA) in urban areas in India were reviewed. Furthermore, experiences
with selected community development programmes in some of the study sites were
discussed. Based on the review, the workshop participants designed a framework for a
Community Development and Partnership Strategy (CDPS) for LF drug distribution in
urban areas. It was hypothesized that this CDPS strategy might overcome some of the
current major obstacles to effective MDA in urban areas, and at the same time contribute
to community and health sector development.
The participants noted that the available information was limited and that the proposed
design was still provisional. A proper scientific situation analysis would need to be
undertaken in the study areas to provide a sound evidence base for a final design of the
intervention. Hence, the CDPS strategy defined below should at this stage only be seen as
a provisional framework that will guide the situation analysis. The final design of the
intervention, and the decision how much emphasis to give to community development,
will be made on the basis of the evidence to be collected during the situation analysis.
According to the provisional CDPS framework, the strategy will have the following
elements.
Process:
1. Stakeholders involvement in planning and decision making
a. Preparatory discussions with the municipality
b. Creation of Steering Committee (MHO, journalist, social worker, women group
rep, NGO, elected rep)
c. Sensitization of stakeholders
d. Exploratory local stakeholders meetings (councillors and community members),
to discuss needs for LF drug delivery
e. Stakeholders meetings at Municipality level
2. Advocacy
a. General advocacy campaign addressing both the endemic population as well as
providers, implemented through municipality
3. Initiating Community Involvement
a.' Planners and implementors have to get acquainted with the community first
before commencing their work and make a study of the general characteristics of
the local community
2
b. Community profile needs to be prepared with the community as a preliminary
document
c. Identification of places, days and time for organising community meetings, local
community leaders who would organise the meetings and enlighten the
community on various aspects of the plans are the preliminary exercises
d. Before commencing any planning any MDA activities, general discussion with
the community is necessary to find out its receptivity
4. Partnerships for mobilization, resource contribution and drug delivery. The
following partnerships are essential:
i) Private practitioners and traditional healers
Private practitioners and traditional healers have to be approached by the program
planners and the implementation of plans have to be explained to them so that
they are enlightened and their endorsement is assured
Private practitioners and traditional healers have to be requested to educate and
enlighten the community on its participation in planning and implementation
(compliance)
Provide necessary informative literature in private hospitals and clinics for
dissemination to the people
ii)
CBOs
Prepare a list of CBOs/NGOs/VOs already existing in the community and find out
their activity plan
Prepare a list of office bearers of all the CBOs
CBOS have to be sensitised to the LF elimination programme
Provide necessary informative literature to all these organisations for
dissemination
iii)
Inter-sectoral partnerships
Identify and list relevant institutions, organisations and field offices of all
government depts (central, state and local), private sector
Identify the heads of these institutions and their manpower as. well as other
resources
They have to be sensitized to the LF elimination programme
At all stages of formulation & implementation of plans these institutions/
organisations have to be involved
Drug delivery
This CDPS process should result in local decision making and planning for drug
distribution to be executed by one or more of the groups below:
2
4
Health workers
Community volunteers / schools (students)
Private practitioners
Drug distribution will involve the use of family drug delivery cards
4
5
Purpose and objectives of the study
Research questions
What are the main determinants for the low treatment coverage in urban areas, and
which factors make MDA more difficult in urban than in rural areas
Can these problems be overcome by the application ot the CDPS strategy or
alternative strategy designed to address the specific problems in urban areas.
Can such a strategy significantly enhance the perceived need of, and support for LF
treatment among all stakeholders, e.g. the community, the health workers, the
municipality officials.
What level of treatment compliance can be achieved through the application of such
an alternative strategy.
Is effective application of the alternative strategy possible using the existing human
resources at the municipality and community level, and if not, what else is required.
Is the strategy cost-effective for achieving the required coverage in urban areas
(taking also into account the contributions by different partners, incl. the community)
Purpose of the study
To develop and test alternative innovative strategies for mass drug administration, which
would achieve the desired high treatment coverage in urban populations necessary for
elimination of LF.
Study objectives
To identify the mean determinants of the low treatment coverage in urban areas, and
which of these factors are particularly important in urban areas.
2) To determine for the principal socio-economic strata ot the urban community their
priority health & development needs, their knowledge of and importance given to LF,
and to determine the potential for involvement of other stakeholders in MDA and
identify opportunities for linkage to other health & development activities
3) To develop and implement an intervention strategy that addresses the challenges for
MDA in urban areas, building on the CDPS framework or an alternative framework
developed on the basis of the research findings on the above two objectives.
4) To evaluate the impact of this intervention strategy on perceived need of, and in
enhancing support for, MDA amongst all stakeholders including the community,
health workers, municipal officials
as developed by the stakeholders, and to assess
5) To describe the drug delivery process
its strengths and weaknesses
1)
5
6
6) To evaluate the treatment coverage (consumption rate) achieved with the new
strategy, and to assess whether after three years of intervention it reaches the desired
level of treatment coverage with DEC/Alb that is required for elimination of LF.
7) To determine the feasibility of implementation of the new stategy using existing
human resources (health and other sectors) at the municipal and community level.
8) To document the contributions made by various stakeholders and to determine the
cost-effectiveness of the new strategy.
Study design
The study will be implemented at 3 sites -Varanasi (implemented through NICD, New
Delhi) and Tamil Nadu and Orissa implemented through ICMR. The National Filariasis
Control Program has plans to extend the revised strategy of mass annual drug delivery
program to include about 100 districts endemic for LF. The study area will be selected
from these districts.
Improve
CDPS
Improve
CDPS
Design
CDPS
CDPS
’
L
CDPS
CDPS
L
A
Situation
analysis
MDA
evaluate
MDA
evaluate
A situation analysis will be undertaken in all study areas to provide the evidence base
needed for the design of the final intervention strategy (CDPS or modified strategy). The
situation analysis will at the same time provide some of the baseline data needed for later
evaluations. The intervention will be implemented annually. An evaluation after the 1st
round of MDA will assess improvements in perceptions and felt needs for LF elimination
as well as assess treatment coverage. The interventions will be reinforced and an
evaluation will be done after the 2nd round of MDA. Trends in felt need, demand
generation for LF elimination, as also treatment coverage will be. A final evaluation will
be done at the end of the 3 rd round of MDA to determine the changes in treatment
coverage, which can be attributed to the interventions.
6
i
7
Annex 1: Conceptual Framework for the Intervention strategies
Drug delivery
strategy
Community
■
Other
stakeholders
Provider
Policy maker
CDPS package
1. Community
development/involvment
2. Partnership with
stakeholders
Advocacy package
---
No felt need,
low priority
•
fbiilh
MDA
High treatment
coverage,
community
ownership,
sustainability
Felt need, i
—> demand
generated
Reinforcing
loop
As part of the strategy, through a continuous interaction and negotiation process, the
community will be conscientized and a felt need for elimination tor LF will be generated.
This will be achieved using the community development approach as described in the
Stakeholder Partnership Strategy. The municipal bodies will be simultaneously and also
subsequently approached to generate a political will and commitment towards LF
elimination using advocacy strategies. This may result in a collaborative planning and
implementation of the MDA strategies jointly by the community and providers. This
process will increase community participation and result in high treatment coverage
essential for LF elimination. The process is repeated before each MDA round resulting in
a reinforcing loop, which increases community ownership and sustains the high treatment
coverage.
7
\
8
Annex 2: Community development
All over the world, three-fourths of the global population live in small communities in
rural and remote areas. The rest of the population live in urban and metropolitan areas. In
the implementation of development programmes in various sectors such as agriculture,
education and health etc. governments and local authorities are playing the lead role the
formulation and implementation of the programmes. However, success in implementation
has not been to the desired extent. This is largely due to the fact that people and
communities are not involved at the stage of identification projects, formulation of the
plans and implementation of the schemes. Unless people are involved from the beginning
of identification and formulation of welfare and development schemes, community
participation can not be guaranteed. Hence, community development methods are
advocated to achieve greater success in the implementation of the development schemes
and higher realization of the objectives of the programmes. How this could be done is
essentially a basic requirement in formulating and implementing schemes.
Communities are aware of some needs, which are called as felt needs. There are
needs which have to be fulfilled to improve the quality of life of community about which
communities are not aware of. In respect of these needs development planners and field
workers have to create an awareness of such non-felt needs in the communities and
generate initiatives and participation of the comminutes in implementing schemes for
fulfillment of such needs. Creating community awareness and new needs which are basic
for better living, creating conditions and an environment for community decision making,
developing capacities for community management in the formulation and implementation
of schemes enabling communities to contribute resources - physical, material and
financial - and developing community leadership for guiding and implementing the
schemes, enabling community to find out what are the forms of assistance, technical and
financial, require from outside and creating people’s organizations which would assume
responsibilities for meeting the needs of the community or the basic components of the
community development process. This method is equally applicable in any sector of
development for the formulation and implementation of schemes. It has to be realized
that if the community is not actively involved at the state of the formulation of schemes
its participation will not be effective during the course of implementation of schemes.
Programme planners as well as field workers have to be conscious of this fact while
performing their functions. The community development process is equally applicable
both to rural and urban areas.
Definition of Community Development
Community development is a movement defined to promote better living for the whole
community with the active participation, and if possible, on the initiative of the
community, but if this initiative is not forthcoming, by the use of the techniques for
arousing and stimulating it in order to secure its active and enthusiastic response to the
movement.
8
9
Principles of the Community Development method
Involve the community right from the beginning of the planning process and get their
inputs
Planning should first take care of the felt needs and priority needs of the community
Planners should also create awareness among the community on the needs meant for
bettering their lives if the community is not already expressing these needs
Planners should address all the needs of the community in a holistic manner
Planners and others from' outside the community should only play the role of indirect
leaders (facilitators) and work through community leaders who are acceptable to the
community
Planners have to work through the existing community groups such as women’s
groups, youth clubs, religious groups, VEC etc.
In implementing the plans, the planners have to facilitate the community contribute
physical, financial and material resources possible by it and then supplement it with
outside technical and financial assistance
All decision making has to be made by the community and not by any outside agency
on behalf of the community
9
Development & testing of new strategies for mass drug distribution for lymphatic filariasis
elimination in urban areas.
Principal investigator: KrP.Ramaiah,
Project no. A10310
Development and evaluation of community development & partnership strategies for drug
delivery for control of LF in urban areas of Orissa.
Principal investigator: B.V. Babu.
Project no. A10320
Objectives and Instruments for the Baseline Survey
Overall Objective
To explore and identify opportunities within urban communities, which would help design
innovative urban-specific intervention strategies for mass (drug administration for elimination
of lymphatic filariasis.
Specific Objectives
1. 'To describe the demographic, socio-economic, political and cultural structure and
relationships within the community
the age/sex/educational/occupational/religion/caste/kinship and social
a. Study
i
networks of community residents
b. Understand the formal and informal structures for decision making for health and
development issues.
c. Study formal and informal channels of communication
d. To identify subgroups requiring special intervention relevant to the development
process towards MDA.
2. To assess the felt needs of the community (including health needs)
needs include the priorities as expressed by the community members for
a. Felt
1
health and development
3. To identify stakeholders, understand their roles and assess their perceptions towards
Lymphatic Filariasis, Mass Drug Administration, drug related issues, and their potential
involvement in the development process towards Mass Drug Administration.
4. To identify and understand functioning of various ongoing health and development
processes / activities (resource mobilization) carried out by GOs/NGOs/CBOs/private
sector in the urban community.
5. To assess the knowledge and perceptions of the community to LF and their perceptions
and experiences (if any) with MDA.
1
.
, ■
■
a *
I
■ . I
For the purpose of the study, the urban community is categorized into four settlement patterns
based on socio-economic status, infrastructure and health seeking behavior variations viz.
1. high income area
2. middle income area
3. low income area (slums)
4. hutments'
Information Framework
Specific Objectives
(1) To describe the
demographic, socio
economic, political and
cultural structure and
relationships of the various
communities within the
urban areas
Age/sex/educational
/occupational/religio
n/caste/kinship and
social networks.
Formal and informal
structures for
decision making
(includes elected
reps, religious /caste
associations, family
level) for health and
development issues.
Formal and informal
channels of
communication
To identify
subgroups requiring
special intervention
relevant to the
development
process towards
________ MPA.____________
(2) To assess the felt needs
of the community (including
health needs)
Felt needs include
the priorities as
expressed by the
community
members for health
and development
Variables_____________________
Age- <2 years, 2-4,5-14, >15, Sex,
Education, Occupation, Religion,
Caste, Economic Status
(SC/ST/BC/MBC/OC)
Description of political,
administrative structure
# of Cinema Halls, Schools,
Hospitals, Industry, Trade centers.
Festivals
Morbidity Pattern/rates_______
Listing socio-cultural, religious
institutions, individuals,
relationships, decision-making
processes, roles, interests in
community programs.
Radio/ Television/ Computer/
Telephone Ownership, Internet Cafe
usage. News Paper readership.
Cultural Troops
Cable TV viewership, informal
communications, meetings of
associations, groups etc.___________
List vulnerable groups, assessing
needs, differentials in access to
developmental / health benefits, any
refusals to participate in community
programs, how they can be involved
in community programs.
List and prioritize felt needs, identify
and describe individual and
community level efforts to address
those felt needs, describe attempts to
link up with local body authorities,
describe efforts at resource
mobilization
| Source______________
Census 2001
HMIS
BPL records
Morbidity Data
Research study reports.
Data source of
Government / NGO /
local bodies
Education dept records
Anganwadi records
Method
Review of
secondary
data
Elected reps (municipal
councilors, MLAs),
Govt officials (health
/non-health), local
bodies.
Formal/informal groups
- Religious /Caste
associations. Elected
Reps etc._____________
Households
KI interviews
HH survey
KI interviews
Stakeholders (as above)
Secondary data sources
on TV viewership etc.
Any special group
identified during
interviews with
stakeholders
Stakeholders in the 4
SE strata of the
community
SHG, women’s groups
Review of
secondary
data______
FGD
Free Listing
(amongst KI)
FGD
(3) To identify stakeholders,
understand their roles and
assess their perceptions
towards LF, MDA and the
drug, and their potential
involvement in the
development process
towards MDA
(4) To identify and
understand functioning of
various ongoing health and
development processes /
activities (resource
mobilization) carried out by
GOs/NGOs/CBOs/private
sector in the urban
community.
(5) To assess the knowledge
and perceptions of the
community to LF and their
perceptions and experiences
(if any) with MDA.
List stakeholders. Map providers
(formal and informal).
Describe their roles in various
program activities undertaken by
them. Understand their perceptions
about LF (burden in community,
causative factors, transmission,
preventability, treatment seeking
behavior, stigma etc), perceptions
towards MDA strategy (concept of
mass treatment, healthy people
taking drugs, side effects, perceived
benefits, sustainability of MDA
etc.). Assess their potential
involvement in MDA in future, roles
and responsibilities, how to link up
with MDA program. Assess
involvement in terms of.human
resources, finance, logistics etc.
NFCP experience.
Identify past or ongoing health
(NFCP, leprosy elimination, malaria
control, AIDS prevention program,
pulse polio or development activity),
describe community involvement in
planning, decision making,
implementing, resource
mobilization, evaluate degree ot
community ownership___________
Knowledge, perceptions of LF,
transmission, causation, prevention,
perceived risk of filariasis,
perceptions about effectiveness,
perceptions of MDA in terms of
delivery of drug and health benefit.
Health seeking behavior.
Willingness to participate in future
MDA. Prevalence of elephantiasis
and hydrocele__________________
Elected reps (municipal
councilors, MLAs),
Govt officials (health ,
non-health), local
bodies.
Review of
secondary
data (for
entire
city/towm)
LIG-slum leaders
MlG/HIG-secretaries
of society, resident
welfare associations,
prominent citizens.
FGD
(for
community
from 4 SE
strata)
Service organizations,
NGOs, CB’Os.
Public/pvt health care
providers.
KJ interviews
(for NGOs,
public/pvt
health care
providers)
NFCP official
Case study
KI interviews
Key functionaries from
the formal health and
non-health sectors who
participated in the
activity, local body
officials
Households
review of
records
Household
survey
Sampling design:
1. Information from the sample should be representative of the each urban area of the
study for Bhubaneswar site and a municipal zone for Chennai.
2. Based on the discussion and consensus in the group, it is proposed to divide the urban
area in following four strata:a) High income group
b) Middle income group
c) Slums
i) Low income groups (LIG)
ii) Hutments
While it is understood that LIG and Hutment are well demarcated and list can be
procured from Municipal Authorities/ Slum department, such clear demarcation
between HIG and MIG areas do not exist
4. For practicality, it is proposed that a purposive categorization of HIG and MIG may
be done as under:a) HIG- wards which have more than 60% of houses are HIG.
b) MIG- wards which have more than 60 % MIG houses.
5. Steps for selection of households from HIG and MIG strata
a) All the wards of the town should be categorized into HIG or MIG for sampling.
b) Select randomly 2 wards from each strata viz. HIG and MIG.
c) List all the streets/ mohallas/ colony.
d) Select 5 of the streets/Mohalla/colony randomly from each ward.
e) From each street/mohalla/colony select a random start point and then select
10 consecutive households.
6. Selection of sample slums and households
a) List out all the wards which have slums
b) Select 10 slums randomly.
c) Get the list of registered households from Public Distribution System (PDS)/
electoral list.
d) Randomly chose 10 households in each slum from the list to get a total household
of 100.
Summary
Household surveys: 100 households to be surveyed per strata
Focus Group Discussions (FGD): 3 FGD from each strata
Interviews of Key Informants (KI): 6 from each strata
Sample design and size___________
Hutments
LIG
MIG
HIG
Activities
NA__________
2__________ NA
2__________
NA__________
5__________ NA_______
5__________
Street__________
10___________
10 .
NA________ NA_______
Slums__________
10 per hutment
10 per street 10 per slum
10 per street
Households_____
100__________
100
1QQ________
100_______
Total households
3-4__________
3-4________ 3-4_______
3-4
FGD___________
6
6
6
6
KI
■
Summary of work load
Households = 400
FGD at ward level = 12
Interviews of Key Informants = 24
The following qualitative techniques will be administered by each site in each of the 4 SE strata:
Focus Group Discussions'. Each site will conduct at least 3 FGDs in each of the 4 SE strata for a
total of at least 12 FGDs per site. Each site may conduct more FGDs till the stage of information
saturation. The FGDs may be conducted amongst community leaders, members of different
Community based organizations, women’s groups, minority groups, as appropriate.
Indepth Interviews'. Each site will identify and interview in-depth at least 3 key informants in
each of the 4 SE strata, identified from within the community for a total of at least 12 key
informant interviews per site. Each site may conduct more in-depth interviews till the stage of
information saturation. Key Informants could be elected representatives, private practitioners,'
formal / informal community leaders, representatives / office bearers of community based
organizations, representatives of formal charity organizations like Lions, other NGOs, etc.
Additionally, each site will identify and interview in-depth, local body officials (at the
municipality level) as well as program managers (at the district / State level) who have been
directly involved with the mass drug administration programs in the past.
Free Listing'. A free listing exercise will be conducted with each of the Key Informants before the
administration of the in-depth interview. A similar free listing exercise will be conducted with
each individual of the FGD independently and not collectively before the beginning of the focus
group discussion.
All information will be noted by the researcher on paper as well as recorded on tape wherever
feasible after the written informed consent of the participants.
Instrument 1: Focus Group Discussions
Preparatory visit to community
•
•
•
•
•
Make a visit 2-3 days before the actual day of FGD.
With the help of the local leaders, enlist the FGD participants
Indicate the venue, date and time of FGD and request their participation
Explain the purpose of the FGD
Moderator should participate in this activity
Guidelines for FGD
•
•
•
The researcher goes to the community
Identify and list all formal and informal groups (includes women’s groups, self help
groups, NGOs, CBO’s, media, youth groups, associations etc)
Choose at least 3 FGDs per strata
•
•
•
•'
•
•
7-10 participants
Homogenous groups in terms of sex, socio-economic background etc.
One moderator and one note taker
Orientation to moderator and note taker
Record the discussion as back up to FGD
Duration 1-1.5 hours
Issues to be covered during FGD:
1.
2.1.
2.2.
2.3.
2.4.
2.5.
3.1.
3.2.
4.1.
4.2.
4.3.
5.1.
5.2.
5.3.
5.4.
6.1.
6.2.
Introduction by*the moderator (Brief details on control of LF and drug distribution
programme. Encourage free discussion)
Common diseases in the area
Perceived reasons for such diseases
Available health facilities
Treatment seeking behaviour (availability of health services for treatment and prevention,
various sources of treatment, frequency of availing health services, satisfaction with
health services etc.)
Preventive measures taken
Assessment of health needs in the community (deficiencies in health services with
reference to treatment and disease prevention)
Assessment of other needs in the community
Perceptions on and attitude towards LF
Knowledge about transmission
Priority accorded to LF (in general and in relation to other diseases)
Knowledge about MDA
Past experience in MDA programme
Community’s willingness to participate in planning and implementation
Community’s expectation from GOs/NGOs/CBOs
Experiences of participating in any health/community development programme
Reasons for participation/non-participation
Instrument 2: Key Informant Interviews
Suggested Categories tor the key informant interviews
1. Elected representatives/political leaders
2. Professionals-private/public practitioners and paraprofessionals
3. NGOs/CBOs/social workers/associations
4. Women’s groups/ self help groups/youth groups
5. Local body officials (health and non health)
6. Local media
Identification of the key informant
Name, age, sex, education, position in the community; reasons for selection of the key informant.
Based on preliminary exploration with the study community, identify knowledgeable/prominent
persons across the categories for in-depth interview. The investigator may choose appropriately
for each category.
Issues to be covered as appropriate in Key Informant Interviews
Build rapport with general information about the nature and duration of work of the KI in the
community, and his personal impressions about community activities.
• Free Listing of all the major problems faced by the community (no probing or prompting).
• Free Listing of all the important illnesses in the community (no probing or prompting).
• Ongoing developmental activities; the extent of community participation in health and
development activities-extent and nature of participation; planning and decision making
process; experience with these activities; suggestions for effective implementation - Explore
with specific experiences.
• Past / ongoing efforts of government/local body for problems like malaria, filaria and dengue
etc, sanitation, sewage disposal, and mosquito control, water supply etc. Any community
initiated efforts for any of the above interventions. Explore for any partnerships initiated
between government and other agencies in the community.
• The extent and nature of interaction among social groups- which are the dominant groups,
any groups that are marginalized / not cooperative; describe any conflicts while
implementing development programs in the community.
• Explore reasons for non involvement / participation of marginalized groups in health and
development programs; suggestions to involve such groups for future activities.
• Wherever applicable, describe efforts / problems at community involvement in planning and
implementation of MDA program for LF?
• Who distributed the drug in your area? Were they acceptable to the community? Describe the
community attitudes towards drug distributors.
• Note instances of rumored or reported side effects following MDA. Explore for efforts by
community / drug distributor to respond to side effects (who responded, what was done, was
the response quick etc.)
•
r
(For fresh areas for MDA - explain to the key informant about the concept, nature and scope of
MDA)
•
Based on your past experiences in other developmental programs, probe for suggested
strategies for involving the community in MDA (who could be the potential partners; in what
•
ways can the community be involved; who will be acceptable to the community as drug
distributor etc.)
Explain the necessity for even healthy people to take the drug. Probe for strategies / ways in
which this can be done.
4
Specific issues to be addressed based on different types of Key Informants
Elected representatives
• To what extent was the KI involved/wish to be involved in the MDA program.
• Probe for ways how the KI will mobilize political support from various higher and lower
levels.
• Probe for ways how the KI will mobilize additional human / material resources for the
program.
Professionals and Para-professionals
• Attitudes towards MDA strategy and the effectiveness of single annual dose of DEC in
eliminating LF.
• Explore for willingness to participate in the program and the nature of their participation.
Women’s Groups/ Self Help Groups
• Probe for community acceptance of women from SHGs / women’s groups as drug
distributors
• Understand training needs and nature of support required for a drug distributor before, during
and after .MDA.
Media
• Impressions / attitudes towards the MDA concept.
• Probe for potential problems in MDA and how to address them.
• Explore for role that media can play to support the program.
• If there were problems in MDA in the past, suggestions for improvement.
• Explore for ways that the media can help motivate people to take the drug.
Interview of key functionaries involved in the MDA program in the past
• Build rapport with general information on the person’s role and responsibilities and
association with the MDA program in the previous rounds.
• Probe for details on his role in the planning and implementing MDA for his area.
• Probe for efforts to involving other non-health organizations and also the community — which
groups were involved, in what capacity, how he enlisted their support etc.
• Probe for details of training imparted to the drug distributors - its quality, adequacy,
problems in training etc.
• Probe for problems that he faced with implementing MDA and explore how they were
addressed.
• Did all sections of the community accept the drug from the distributors? What were the
reservations expressed? (probe the experience)
• Probe details of reasons for poor coverage/ compliance in the area and suggestions for
improving compliance and greater involvement of the community
What are your rights?
Your Participation is voluntary.' If you decide not to participate you can indicate
it at the time that you are contacted for your consent. You can choose to discontinue your
participation any time without assigning any reason
Do you agree to participate in this study?
By signing this form you agree that the information provided by you may be
presented in whatever medium or format to appropriate persons / authorities. However,
we assure you strict anonymity by delinking your identity from the information that you
may provide. The information collected by you will be kept confidential at all times. A
numerical code will be assigned to all study forms, not your name. Your identity will not
be revealed in case of publication.
I have read this form or have had this form read out to me and have understood its
contents.
Volunteer’s name
Signature
interviewer’s name
Signature
*
i
t
Informed consent
Why we would like you to participate in this study?
We would like you to participate in a study on filariasis conducted by
'
with support from the World Health Organization. We are interested in knowing your
opinions, views about filariasis and the program initiated by the Govt of. This
information will be kept strictly confidential but will help us improve on the present
program of the govt to control filariasis. The disease filariasis, also known by other
names such as elephantiasis and hydrocele when it involves the external genitalia, can be
eliminated from our area if all people including healthy people (excepting pregnant
women and infants below 1 year age, take a single dose of medicine once a year for the
next few years.
We are inviting you along with approximately 500 other volunteers to share your
experience about filaraisis and its control program or experience with participation in
other community development programs. This information will help us design
appropriate programs to control filariasis in our area
What will your participation consists of:
You will be asked to answer a series of questions / invited to join a group to
discuss vour experiences with lymphatic filariasis along with your health seeking
behavior. These questions/discussions could include your views regarding filariasis,
where you seek care, what test and medicines normally you and your community use for
common diseases and how much time and money is spent by you and your community on
these activities.
The questionnaire/discussion will take approximately 45 minutes to one hour. It
can be administered at a time and place that is convenient to you.
How will you benefit for participation in this study:
The information that you provide will be extremely helpful in designing an
effective control programme for lymphatic filariasis in urban areas.
Only by
understanding this process from your perspective can we evaluate the real benefit of
various strategies that may be implemented in your area, in addition, your answering the
questionnaire will allow you an opportunity to voice how you think the system could be
improved.
2^
No. 1-1/2002/NAMP (NFCP)/ TASKFORCE/LFE
Govt, of India
Dte. of National Anti Malaria Programme,
22-Sham Nath Marg,
Delhi - 110054.
Date: 25/01/2002
■7
Subject: Meeting of the National Task Force for Lymphatic Filariasis Elimination (LFE)
held on 21st December 2001, New Delhi - Minutes Regarding
Dear Sir/Madam,
Please find enclosed a copy of the approved minutes of the above stated meeting held
under the Chairpersonship of Dr.(Mrs.) Ira Ray, Addl. DGHS, Government of India on
21/12/2001 at Resource Centre, DGHS, Nirman Bhawan, New Delhi for favour of
information.
Yours faithfully.
.1
(V.K. Raina)
Dy. Director
N.A.M.P.
To
s'
I
4? Dr. P.K. Das, Director, VCRC, Indira Nagar, Pondicherry-605006
2. Dr. (Mrs.) Usha Baveja, Director, N1CD, 22-Shamnath Marg, Delhi-110054
3. Dr. S.K. Kar, Director, RMRC (1CMR) Chandrashekharpura, Bhubnehswar751023
4. Dr. P Krishnamurti Director Public Health and Preventive Medicine, DMS
Complex, 259-Anna Salai, Chennai-600006 Tamil Nadu
Contd. 2
4'
I
I
5.
Dr. Gayatri Sharma, Director General Health Services, Dte. of Health Services ,
DhecX Heakh^erviccs, Department of Health and Family Welfare, West
6.
Head ofDeparlment BuMng.
7.
■
D^Srini^' Starama, Director of Health Services, Sultan Bazar, H yderabad-
8.
D°r0 v.K. Rajan, Director of Health Services, Thiruvanthapuram, 37 Kerala
9.
Geeta Prasad,Director in chief. Department of Health Services, New
10. Dr.
11. DnMadhud Sht^^^
(P)’45’ A’Wing’ DGHS’ Nirman
12 D^NX Gangdy^Director General, ICMR, Ansari Nagar, New Delhi-110029
13. Dr. P.N. Sehgal, Ex. Director NICD, A-103, Swasth Vihar, Vikas Marg, Delhi/•
14. Dnip2 Gupta, Ex. Director NIH FW, B-89, Swasth Vihar, Vikas Margm New
15. Dr. Chusak Prasittisuk, Addl. Advisor .W1IO/SEARO, I.P. Estate, New Delhi-
16. Dr. S.Pattanayak, B-19, Swasth Vihar, Delhi-110092
17. Sh. C.P. Viyas, Asst. Controller of Programme, Directo r General Doordarsan ,PB,
18^^^^Sag^Asstt-r-Professor ;-Centre-of Social Medicine and Community.
Health, Jawahar Lal Nehru-University,.New Delhi
iu- nnnil
19 Dr. (Mrs.) Ira Ray, Addl DGHS, GO1, Nirman Bhawan, New Delh>-10 011
90 Dr Shiv Lal, Addl. DGHS, GOL, Nirman Bhawan, New Delhi-110 011
21. Dri Mna Sokhey, Addl. Project Director, NACO, MOI I & FW, Nirman Bhawan,
Room No. 403, D-Wing, New Delhi-110011
22. PPS to DGHS, Nirman Bhawan, New Delhi-110011
•3Draft
Minutes of the meeting of National Task Force for Lymphatic Filariasis
Elimination (LFE) held on 21st December 2001 at the Resource Centre
(Room No. 445), Nirman Bhawan, New Delhi
A meeting of National Task Force for Lymphatic Filariasis Elimination (LFE) was held
on 21st December 2001 at the Resource Centre (Room No. 445) , Nirman Bhawan, New
Delhi. Dr. S. P. Aggarwal, DGHS, Govt, of India and Chairman of the National Task
Force for LFE could not attend the meeting due to certain unavoidable circumstances
and thus, Dr. (Mrs.) Ira Ray, Addl. DGHS, Govt, of India Chaired this meeting which
was attended by twenty experts/members ( Annexure-I).
While welcoming the participants. Dr. Ashok Kumar, Director, NAMP and Member
the
Secretary highlighted the purpose of the meeting and following key agenda items, the
details notes on which had already been sent to all members well in advance.
I.
2.
3.
4.
5.
6.
Renaming of t echnical Advisory Group on Lymphatic Filariasis (LF) as
l^tionalJla^Bircefor Lymphatic Eilariasis.Elimination (LFE) under the
Chairmanship of Director General of Health Services, Govt, of India.
Review of Pilot Project using annual single dose mass DEC administration
(MDA) for Lymphatic Filariasis Elimination in 13 districts with effect from
1997.
Review of multicentric pilot study by ICMR (VCRC, Pondicherry) using
annual single dose mass DEC + Albendazole administration for Lymphatic
Filariasis Elimination in 9 districts vv.e.f. Feb. - Mar. 2000.
Umiting DEC dosage schedule (s) for different age groups for MDA.
National Workshop on Social mobilization and community education
strategy to achieve the objectives of MDA, May 2001— Recommendations.
Policy
on
Lymphatic
Filariasis
Elimination
through
MDA
(DEC+AIbendazole) in India.
Aller introduction of the agenda items, Dr. (Mrs.) Ira Ray requested the members to give
their opinion / suggestion for the Agenda Point No.l - Renaming of Technical
Advisory Group on Lymphatic Filariasis as National Task Force for Lymphatic
Filariasis Elimination.
It was also proposed that some additional members having expertise in different fields of
social sciences, mass communication, Economics, IMA etc. may be included in the
National Task Force for LEE. Dr. Shiv Lal, Additional DGHS, GOI wanted to know if
there would be changes in Terms of References (TORs) as well. Dr. Ashok Kumar
replied that the TORs generally would remain same as most of the activities to be looked
into are covered under the existing TORs ofTAG. Dr. Jotna Sokhey, Additional Project
Director, NACO, while agreeing to the renaming of Technical Advisory Group for
Lymphatic Filariasis to National Task Force for LFE, mentioned that probably certain
reconstitution of TORs is required as LFE involves social mobilization & community
1
(1
I
Education and various logistic issues etc. Dr. K. K. Datta, Director NICD said that
Health Economists, Scientists from related streams may also be included in the National
Task Force. Dr. S. Pattanayak, Ex. Director, NMEP, mentioned that the Technical
Advisory Group was meant for giving guidance on various issues related with National
Filaria Control Programme (NFCP) while the National task Force will specifically
‘ concentrate on Lymphatic Filariasis Elimination issues, so the renaming is justified.
Dr. Chusak Prasittisuk, Regional Advisor, (VBC), WHO/SEARO, was of the same view
and stated that the National Task Force would develop National Strategic plan for LFE
and would focus on elimination rather than treatment only and serve two purposes.
Dr. (Mrs.) Ira Ray concluded that since the National Task Force is to advise,
formulate, implement and monitor Lymphatic Filariasis Elimination, the renaming
appeared to be justified although certain modifications in TORs are needed which
might be incorporated.
Agenda Point No. 2
,
^ev/eip of Pilot Project using annual single dose mass DEC administration (MDA)for
Lymphatic Filariasis Elimination in 13 districts with effect from 1997.
_A-presentation-was-made-oirthe pilot studies being-carried out by Dte. NAMP since
1997, involving annual single dose mass DEC administration (MDA) for LFE in 13
districts in 7 states. The results of population coverage and actual compliance during
MDA rounds in 13 pilot districts and mid term assessment recommendations (January
2000) were also highlighted. It was proposed to the members to decide on issues viz.
whether to continue or stop this project after 5 years duration as was envisaged in the
; beginning and get it evaluated or switch over all the 13 districts to mass co
administration of DEC+Albendazole.
Dr K K. Datta wanted to know if any evaluation of the study in all the states has been
taken up or not. Dr. Jotna Sokhey stated that there is a large difference between the
distribution and actual compliance, states should look into it so as to put more efforts in
the implementation of their action plans . Dr. Lalit Kant, Sr. DDG, ICMR mentioned
that a minimum percentage of coverage is to be there to have an impact on compliance.
Dr. P. N. Sehgal, VHAI, was of the view that probably after proper evaluation, one
could make out the reason of low coverages.
Dr.
Dr. P.
P. K.
K. Das,
Das, Director
Director VCRC
VCRC made
made aa small
small presentation
presentation on feasibility and operational
aspects of the coverage & compliance with regard to annual single dose DEC mass
administration which he said, is very difficult to achieve more than 70 % inspite of best
efforts. He also presented data on impact of six rounds of chemoprophylaxis on mf
prevalence. He mentioned that there is a threshold level beyond which the mfdoes not
get lower, whatever additional inputs are there, especially where transmission is going
on So there is a need for chemotherapy as well as vector control measures to be
undertaken together. Dr. S. Pattanayak, Ex-Director, NMEP, said that mass DEC given
over years in French Polynesia produced no remarkable reduction in ml rates. Hence,
DEC alone can not sustain the programme, unless anti larval measures are also taken up
simultaneously as demonstrated by CRME, Madurai in one of their studies. Therefore,
the rationale for mass administration of DEC alone for coverage rate of 80% should be
2
debated further and the National Task Force should come to a conclusion soon. Dr.
Alpana Sagar, Assistant Professor, CSMCH, JNU, said that due to complexity of several
factors involved simultaneously, maximum of 70 to 75% coverage could only be
achieved in the afore presented pilot studies using MDA. Dr. Shiv Lal added that there
is a need to evaluate the issue of achievement of 80% coverage necessary for elimination
of the disease.
Dr. Ashok Kumar mentioned that there should be an independent evaluation by ICMR
through VCRC, Pondicherry. Dr. N. K. Ganguly, Director General^ICMR mentioned^
that this independent evaluation may be done by VCRC by involving any one of other |'—J>
^centers like IRMS, NICD, Institute of Epidemiology and funds for the same may be \
provided by the Programme Directorate. |
- ------------- --------------- --------------------------------------------------------------- ------------------------------- --' /
(
The Chairperson stated that VCRC, Pondicherry shall evaluate the MDA project
J on single dose mass DEC administration involving other institution as may be
/ required & funds for this evaluation will be looked into by Dte. NAME.
■(
Agenda Point No. 3
Revieyv of multicentric pilot study by ICMR (VCRC, Pondicherry) using annual single
dose mass DEC + Albendazole administrationfor Lymphatic Filariasis Elimination in
9 districts w.e.f 2000.
I
Dr. P. K. Das presented the details of the Multicentric Pilot Study by ICMR and
_ej_4bp rated—the—operational—feasibility and—impact—of co-administration of
albendazoIe+DEC in controlling LF. He presented that assessed coverage and
consumption show a large range, as no incentives are given to the staff / persons
involved in the exercise as well as due to poor infrastructure. Besides, improving
coverage and compliance, sociological analysis is required. The need fora detailed study
on the operational aspects and consumer compliance for both the types of intervention,
i.e., DEC and DEC+ Albendazole in Tamil Nadu and Kerala was also emphasized by
him. Dr. K. K. Datta desired to know the reason of low coverage, to which Dr. P. K.
Das replied that during the second round of the project they are expecting better results,
although it still may not achieve the desired level. Dr. (Mrs.) Ira Ray stated that for the
other states, fresh strategies would be needed to evaluate such programmes. She also
emphasized that the second round is therefore essential for proper evaluation. Dr.
Chusak Prasittisuk, Regional Advisor (VBC), WHO/SEARO, stated that IEC, social
mobilization, behaviour change are required so as to fill up big gap between coverage
and compliance. Dr. N. K. Ganguly emphasised that these aspects should be taken up by
the investigators and in the second round the results would be coming up clearly.
Dr. D. J. Augustin, Jt. DI IS, Tamil Nadu stated that even if albendazole is not successful
in eliminating worms, at least some benclit could be expected in the form of better child
growth. Dr. Ashok Kumar pointed out that while agreeing to the mass administration of
DEC+albendazole it has been given to understand that albendazole would also act as an
add-on advantage for improving the compliance.
With regard to MOHFW / GO1 decision for co-administration of DEC+albendazole to
be taken up in all the four districts in Orissa, Dr. N. K. Ganguly stated that if in Orissa
all 4 districts are to be covered with DEC+albendazole, then it would, go out of the
3
1CMR stud, as .. least one district with DEC
Tl,e state Go.t. is not willing to node. «k' MO.* w«h DEC
iiZ
X
'decided that Dr. S. P.ltnayah wodd go to Orissa to
“scuss this issue with the Orissa Slate Govt, anthortl.es.
The Chairperson endorsed the
f ICMR task force
technical issues
"’jXcd”ZwdHXnned to the State authorities before all four districts are
Xn up for Co-administration of DEC + Albendazole.
Agenda Point No- 4
Limiting DEC dosage schedule (s) for different age groups for MDA.
A Presenlation was made on the DEC
NFCP used under MDA (DEC) and propos
dividing int0 three dosage schedule (s),
future MDAs. Dr. Ashok Kumar men
drugs falling in 2.14 yrs
few would be getting more drug and fevx wou b 8
*
iven according to
age groups. Dr. S. Pattnayak also expres d tlut a s DECtob
.
ver hcareWly811^" K^rDaTsta^that VCRC is carrying out such study and results
wilfbe available in next 6-months or so..
available for taking further actiono^ttnsjssi^—
Agenda Point No.JL
desired drug compliance (abow
for successful MDA as and when expanded to o 1
guidance in th
Jj Tainj| Nadu and the amount ol money
community education (SMC •,) -str^y
Dr-p'N-
i
4
Ary » f r / ( \
suggested association of community level workers as well as local health officials in the
pre-tesling of the model.
Dr. Jotna Sokhey raised the issue of sustainability aspects of this programme, which
according to her is also an equally important issue, which needs to be looked into. Dr.
D. J. Augustin at this point mentioned that while the GO! is funding only 2 districts for
DEC alone, WHO is providing funds for ah 12 districts, so in view of funding
constraints and benefiting the people, the state govt, has gone ahead with the agreement
with WHO. Similarly, Dr. S. K. Kar, RMRC, Bhubaneswar, explained reasons for
getting the WHO support for SMCE during mass co-administration of
DEC i Albendazole. Dr. S. Pattnayak stated that the ICMR should be actively involved
in social mobilization study or should at least monitor the same. Dr. Lalit Kant, Sr.
DDG, ICMR, at this juncture suggested strongly that the Dtc. of N AMP should make it
clear to the states that the selected districts in the pilot.study_can not change their MDA
-oirtheir“0wfrahcTthey should comply with the original ICMR study plan. Mr. C. P.
Vyas, Assistant Controller of Programme, Dte. General Doordharshan mentioned that
the Doordarshan and AIR platforms could be used for effective social mobilization and
community education.
It was decided by the Chairperson that ICMR should conduct a subsidiary \
meeting to discuss whether this SMCE strategy stands good or bad under the j
different geographical areas with different socio-economic status.
1
Agenda Point No. 6
Policy on Lymphatic Filariasis Elimination through MDA (DEC + Albendazole) in
India.
It was unanimously decided that unless the ICMR study on annual single dose co
administration of DEC + Albendazole is over, no policy decision can be taken for
further extension of MDA (DEC+Albendazole) in India.
Dr. (Mrs.) Ira Ray closed the meeting with vote of thanks.
I
5
1
Annexure -1
21“st December
2I
List of Members, Co-opted
- "”11
Name
Sr.
No.
Address
Designation
1.
DGHS_________ L
Addit^O5GHsn^
Dr. (Mrs.) Ira Ray__A.t
I 110011.
Govt, of India
2.
Dr. Shiv Lal
3.
Dr. Ashok Kumar
""TkTtotna Sokhcy
6.
110054._____________________
Tteal
Cominumcablc
Institute
Diseases, 22, Shamnath Marg, Delhi
Director
Additional
Director
- 1 10054.
NACO, Ministry of Health & l l''n'
Project Welfare, Nirman Bhawan, New Delhi
- 110054.____________ __________
h^iarTCouncn^oFMedical Research,
ICMR
J____________ ___ _ ____ r
"'DAN? kTGanguly Director General
7.
Dr. Lalit Kant
8.
Dr. Rashmi Arora
9.
"DmGDas
10.
Dr. S. K. Kar
11.
STATE
PROGRAMME
oficers
Dr. D. J. Augustin
1
Delhi
Additional DGHSTp^hma^Bhm^^
Govt, of India
n^hMTAiuTM^HrT^^^
Director
(NAMP), 22, Shamnath Marg, Delhi
4. ” Dr. K. K- Dalia
5.
New
(ICMR) Ansari Nagar, New Delhi
Sr. Deputy Director
General
Director
Deputy
General
Director
Director
110029.__ _____
-do-
-do^F^TControl Research Centre, Indra
Nagar, Pondicherry - 605006.----Regional Medical Research Centre,
(ICMR) Chandrasekharpur,
Rhiibaneswar- 751023---------
DMKComplex, 259, Anna Salai,
joim Director of
Chennai-600006, TamiNadu
Public Health &
PreventiveMedicine
6
I
*»
<4
13.
Dr.Ramesh
Chandra
State Entomologist
DGHS, Swasthya Bhawan,
Pradesh, Lucknow - 226002
14.
Dr. J. N. Pandit
15.
Dr. H. K. Das
Assistant Director
of Health Services
(Filaria)
Director of Health
Services
Dte. of Health Services, 36, Nirmal
Chandra Street, 3rd Floor, Calcutta 700013.
Heads
of
Department
Bui
Bhubaneswar - 751023, Oris;
16.
Dr. P. K.
]
Siva Additional Director
Raman
of Health Services
WHO
Dr.
Chusak Regional Advisor
Prasittisuk
Others
j__________
Dr. S. Pattanayak
Ex.
Director,
NMEP
Dr. P. N. Sehgal,
Ex
Director,
NICD
17.
18.
19.
20
Sh. C. P. Vyas
21
Dr. Alpana Sagar,
Uttar
0/0 DBS, Thiruvanthapuram, Kerala
WHO/SEARO, I. P. Estate,
New Delhi - 110002
B - 19, Swasthya Vihar, Delhi - 110092
National Institute Communicable Diseasi
Voluntary Health Association of India
Saheed Jeet Singh Marg, Institutional
_________ New Delhi - 110067._____
Assistant Controller Dte. General Doordharshan,
-of-Programme------- PB^BCI,~~Mandi House, New Delhi.
Asstt. Professor , Jawahar Lal Nehru University, New
Centre of Social Delhi
Medicine
and
Community Health,
*Dr. S. N. Sharma, Assistant Director, NAMP and Dr. (Ms.) Shampa Nag, Social
Scientist, NAMP assisted in the meeting.
i
7
54
FIFTIETH WORLD HEALTH ASSEMBLY WHA50.29
Agenda item 20 13 May 1997
Elimination of lymphatic filariasis
as a public health problem
I
The Fiftieth World Health Assembly,
Deeply concerned at the widening spread and increased distribution of lymphatic
filariasis throughout the world in both urban and rural areas and concerned that it affects
all ages and both sexes;
Appreciating with grave concern the human suffering, social stigma and costs tosociety
associated with lymphatic filariasis morbidity;
Recognizing that there is a general lack of awareness concerning this disease and its
impact on health status, and that there are insufficient data on its prevalence and
distribution;
Welcoming the recent studies which have defined new, simplified, highly effective
strategies;
Acknowledging that an international task force on disease eradication has recently
identified lymphatic filariasis as one of only six “potentially eradicable” infectious
diseases,
1. URGES Member States:
(1) to take advantage of recent advances in the understanding of lymphatic filariasis and
the new opportunities for its elimination by developing national plans leading to its
elimination, as well as for the monitoring and evaluation of programme activities;
(2) to strengthen local programmes and their integration with the control of other
diseases, particularly at the community level, in order to implement simple, affordable,
acceptable and sustainable activities based on community-wide treatment strategies, but
supplemented where feasible by vector control and improved sanitation;
(3) to strengthen training, research, diagnostic laboratory, disease and data
management capabilities in order to improve clinical, epidemiological and
; operational activities directed toward eliminating lymphatic filariasis as a public health
problem..
**
(4) to mobilize support of all relevant sectors, affected communities and
nongovernmental organizations for the elimination of the disease.
2. INVITES other specialized agencies of the United Nations system, bilateral
development agencies, nongovernmental organizations and other groups concerned to
increase cooperation in the elimination of lymphatic filariasis through support of national
and international programmes relevant to the prevention and elimination of lymphatic
filariasis;
3. REQUESTS the Director-General:
(1) to bring to the attention of the other specialized agencies and organizations of the
United Nations system, bilateral development agencies, nongovernmental
organizations $nd other groups concerned the need for closer collaboration in the
elimination of lymphatic filariasis as a public health problem;
(2) to mobilize support for global and national elimination activities;
(3) to keep the Executive Board and Health Assembly informed as necessary of progress
in the implementation of this resolution.
Ninth plenary meeting, 13 May 1997
‘
HELMINTHIASIS AND INTESTINAL PERMEABILITY
669
Lunn, P. G., Northrop, C. A. & Northrop, A. J. (1989). Aut(>
mated enzymatic assays for the determination of intestinal
permeability probes in urine. 2. Mannitol. Clinica Chimica
Acta, 183, 163-170.
MacDonald, T. T., Spencer, J., Murch, S. H., Choy, M. Y„
Venugopal, S., Bundy, D. A. P. & Cooper, E. S. (1994). Im
munoepidemiology of intestinal helminthic infections 3. Mu
cosal macrophages and cytokine production in the colon of
children with Trichuris trichiura dysentery. Transactions (if the
Royal Society of Tropical Medicine and Hygiene, 88, 265-268. '
Mahaianabis, D., Simpson, T. W., Chakrabortv, M. L., Ganguii,
C., Bhatarjee, A. K. & Mukherjee, K. L. (1979). Malabsorp
tion of water-miscible vitamin A in children with giardiasis
and ascariasis. American Journal of Clinical Nutrition, 32,
313—318.
Northrop, C. A., Lunn, P. G., Wainwright, M. & Evans, J.
(1987). Plasma albumin concentrations and intestinal perme
ability in Bangladeshi children infected with Ascans lunibn
coides. Transactions of the Royal Society of Tropical Medicine and
Hygiene, 81, 811-815.
Northrop, C. A., Lunn, P. G. & Behrens, R. H. (1990). Auto-
enzymatic assays for the determination of intestinal
permeability probes in urine. 1. Lactulose and lactose. Clinica
Chimica Acta, 187, 79-88.
Stephenson, L. S., Latham, M. C., Kurz, K. M., Kinoti, S. N. &
Brigham, H. (1989). Treatment with a single dose of albenda
zole improves growth of Kenyan schoolchildren.with hook
worm, Trichuris trichiura and Ascans lumbricoides infections.
American Journal of Tropical Medicine and Hygiene , 41, 78-87.
Thein-Hlaing, Thane-Toe, Than-Saw, Myat-Lay-Kin & MyintLwin (1991). A controlled intervention trial on the relation
ship between Ascans lunibncoides infection and malnutrition
in children. Transactions of the Roval Society of Tropical Medi
cine and Hygiene, 85, 523-528.
Van Elburg, R. M„ Uil, J. J., de Monchy, J. G. R. & Heymans,
H. S. A. (1992). Intestinal permeability in paediatric gas
troenterology. Scandinavian Journal of Gastroenterology, 27,
supplement 194, 19-24.
Received 12 April 1996; revised 19 June 1996; accepted for
publication 26 June 1996
TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE (1996) 90, 669-670
Short Report
Impact of lymphatic filariasis on the
productivity of male weavers in a
south Indian village
K. Ramu1, K. D. Ramaiah1, Helen Guyatt2 and David
Evans3 'Vector Control Research Centre, Medical Com
plex, Indira Nagar, Pondicherry, India; ^Centre for the
Epidemiology of Infectious Disease, Department of Zoology,
University of Oxford, South Parks Road, Oxford, OXI 3PS,
UK; ^UNDP/World Bank/WHO Special Programme for
Research and Training in Tropica! Diseases (TDR), World
Health Organization, Geneva, Switzerland
Keywords: filariasis, Wuchereria bancrofti, labour productivity.
Assessment of the economic impact of infectious dis
eases is hampered by the lack of qualitative and quanti
tative information of the impact on productivity of af
fected individuals and communities. The few studies
that have been undertaken were often poorly designed
and, in many instances, provided contradictory results
(Evans, 1992). The infectious diseases which have re
ceived most attention in this area are malaria
(Audibert, 1986; Shepard, 1991), schistosomiasis
(Collins et al., 1976; Barbosa & Pereira-da-Costa,
1982; Audibert, 1986), guinea worm disease (Belcher
et al., 1975; Brieger & Guyer, 1990), and leprosy (Max
& SHEPHERD, 1989). Despite the obvious debilitating ef
fect of chronic lymphatic filariasis, there has been no
quantitative study of its impact on economic output, un
til a recent multi-centre study funded by the World
Health Organization (TDR).
The present study investigated the impact of chronic
lymphatic filariasis, caused by Wuchereria bancrofti, on
the productivity of male weavers in a rural community
in Villupuram Ramasamy Padaiatchiar district of Tamil
Nadu state in south India. A cohort of 39 male weavers
• .with chronic filariasis (27 with hydrocele, 10 with lym
phoedema and 2 with both), and a cohort of 39 without
filariasis were recruited to this case-control study. The
cases and controls were loosely matched by age (mean
ages were 36-4 and 34-9 years respectively). The 78 weav-
ers were visited daily for 184 consecutive days (6
months). The number of hours worked on the handloom '
and the length of cloth produced were recorded daily for
each individual weaver. The weavers receive payment in
accordance with the length of the cloth produced, not
the number of hours or days worked. The prevailing
wage rate was 12 rupees (US$ 0-33) per metre of cloth
produced.
These data are unique. There was unlikely to have
been preselection of healthy workers as observed in
some of the studies of plantation workers and schis
tosomiasis (Prescott, 1979), as individuals could de
cide whether or not to become weavers and were paid
simply according to their output. Moreover, there were
not the problems involved in trying to estimate the im
pact of other types of inputs, such as fertilizer and pesti
cides, on output as in the case of agriculture (AUDIBERT,
1986). Apart from the loom, labour input directly deter
mined output and these data allowed the impact of the
quantity of labour and the productivity per hour to be
related directly to disease status for the first time.
The analysis demonstrated a linear relationship be
tween the numbers of hours worked and the length of
cloth produced over 6 months for both the case
(2?2 = 0-97) and control (/?2 = 0-94) cohorts, with controls
consistently producing more cloth than cases (see Fig
ure). Matched analysis demonstrated that the median
difference in number of hours worked was not signifi
cantly different from zero (sign test, P=0-75), but that
f
I w.
o
I
700
200
400
*00
wo
tooo
’200
M00
Number of hours worked
Figure. The relationship between metres of cloth produced and
number of hours worked by weavers in the case (A) and control
(■) cohorts. The lines represent the best fit linear regression
calculated by least squares for cases (y=0-318x, 7?2 = 0-97) and
controls (y=0-438x, Z?2 = 0-94).
670
K. RAMUETAL.
the median difference in productivity (metres of cloth
produced per hour) was significantly different from zero
(sign test, P—0-0001). Therefore, although the cases and
controls worked a similar number of hours, the produc
tivity of the cases was significantly less than that of the
controls; the productivity of cases was reduced by an av
erage 27-4%, in comparison with the matched controls.
The results of the study clearly imply that lymphatic
Iilariasis has an adverse impact on the productivity and
wage-earning capacity of this particular occupational
group. Many previous studies have assumed that illness
simply reduces time, and in previous filariasis studies,
tor example, it was assumed that one dav of acute attack
was equivalent to one day of non-work. However, this
study has shown that the impact of chronic disease is
more complex, affecting output per hour rather than
hours worked, and therefore more careful design of stud
ies investigating economic impact is required. More de
tailed analysis is under way to investigate the influence
of type and duration of chronic disease, occurrence of
acute episodes, and socio-economic variables on the pro
ductivity functions.
Acknowledgements
n ^Av/Vix ceceiv?lfinancial suPPon from the UNDP,/World
Bank/WHO Special Programme for Research and Training in
Tropical Diseases (TDR). We thank Dr Vijai Dhanda (Direc
tor. ector Control Research Centre) for his suggestions, and
1 rofessor Marcel Tanner (Swiss Tropical Institute) for his sup
port and encouragement during the studv. Helen Guvatt ac
knowledges the support of the Wellcome Trust
References
Audibert, M. (1986). Agricultural non-wage production and
health status. Journal of Development Economics, 24, 275—291.
Barbosa, F S. & Pereira-da-Costa, D. P. (1982). Incapacitating
eitects of schistosomiasis mansoni on the productivity of
sugar-cane cutters in northeastern Brazil. American Journal of
Epidemiology, 114. 102-111.
W-’ Wurapa’ F‘ K--’ Ward’ W- B- & Lo™e, I- M.
,
(iy/5). Guinea worm in southern Ghana: its epidemiology
and impact on agricultural productivity. Amencan Journal of
Tropical Medicine and Hygiene. ^4, 243-249.
Brieger, W. R. & Guyer, J. (1990). Farmers’loss due to Guinea
. worm disease: a pilot study. Journal of Tropical Medicine and
Hygiene, 93, 106-111.
Collins, K. J Brotherhood, R. J., Davies, C. T., Dore, C., Hackett, A. J., Imms, F J., Musgrove, J., Weiner, J. S., Anica, M.
v’
y-arim’
Ismail, H. M., Omer, A. H. and Sakkar, M.
Y (1976). Physiological performance and work capacity of
Sudanese cane cutters with Schistosoma mansoni infection.
Amencan Journal of Tropical Medicine and Hygiene, 25
410-421.
'
’
Evans, D. B. (1992). Economics and tropical disease: a research
agenda using schistosomiasis as an example. Southeast Asian
Journal of Tropical Medicine and Public Health, 23, 641-646.
Max, E. & Shepherd, D. S. (1989). Productivity loss due to de
formity from leprosy in India. International Journal of Leprosy
and other Mycobactenal Diseases, 57, 476-482.
Prfr,C0,tyriN’
<1979)- Schistosomiasis and development.
World Development, 7, 1-14.
Shepard, D. S. (editor) (1991). Economic impact of malaria in
Mrica^’/roprca/ Medicine-and Parasitology, 42, supplement 1,
^C
^Ved 24 ^Une I,996; accePted f°r publication 11 July
Announcement)
International Conference on Emerging Zoonotic Infectious Diseases
Taipei, Taiwan (Republic of China)
1-4 March 1997
—4
■pis -^8-^3
*f
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
i
z
RECORD OF THE
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
FOLLOW-UP OF THE SECOND GLOBAL ALLIANCE MEETING
Liverpool School of Tropical Medicine, United Kingdom
11-13 December 2002
CONTENTS
1.
Purpose
2.
Review of Global Programme
3.
Regional Plans, Priorities and Funding Needs
4.
Alliance Key Issues
5.
Partner Contributions
6.
Advocacy and Fundraising
7.
Alliance Organizational Framework
8.
Meeting Resolutions
9.
Calendar Events
Attachments
A
B
C
Workshop Attendees
List of Presentations
Global Alliance Framework
.1
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
Il-13 DECEMBER2002
1.
PURPOSE
The meeting was an ad-hoc gathering of representatives of different Alliance partners to
follow up the decisions taken at GAELF2. Specifically how the Global Alliance can
assist the Global Programme to Eliminate Lymphatic Filariasis (PELF) to scale up rapidly
to treat 350 million people by 2005. The major Terms of Reference for the meeting were
tK cover:
Planning and costing for 2003-5 by regions and countries
Resource mobilization to upscale the programme
Alliance partner contributions
Internal and external communications of the Alliance
Arrangements for the next GAELF meeting
Additionally the meeting discussed the major strategic issues facing the programme,
proposals from the Advocacy and Fundraising Task Force, and agreed working
arrangements for the Alliance for the period up to the next GAELF meeting.
This record provides a summary of key information, agreements and actions. Copies of
the presentations are available on request from the Liverpool Lymphatic Filariasis
Support Centre (LFSC) - see Attachment B for list of presentations.
2.
REVIEW OF THE GLOBAL PROGRAMME
WHO
Dr N Zagaria presented a review of the global programme covering of progress achieved
to date, lessons learned and detailed objectives for the short, medium and long term.
Progress:
• Number of people treated rising from 3m in 2000, 26m in 2001 to 82m in 2002
• Disability prevention strategy and training packages developed
Lessons learned:
• Importance of political commitment
• Key role of national level partnerships
• Social mobilization to achieve high coverage
• Task of defining and measuring progress indicators
Short Term Objectives (2003-5):
• Complete mapping in all countries with ongoing MDAs
• Scale up to 350 million people treated
• Scale up disability prevention interventions
• Develop technical support capacities in regions
Medium Term Objectives (2006-10):
• Initiate MDAs in all endemic Implementation Units (IU)
• Assess interruption of transmission in lU’s with five rounds of MDA
• Large scale disability prevention interventions in all countries
9
•I
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
1
Long Term Objectives (2011-20):
1 • Reduce infection levels in all I Us to interrupt transmission
• Surveillance in children
• All lymphedema patients access self care knowledge
• AH hydrocele patients access to surgery
Strategic issues raised:
• Communications and coordination between the centre, regional PRG’s and
countries required to support country programmes.
• Strengthening the scientific and evidence base, and monitoring and evaluation.
• Enhancing political commitment and awareness, and acquiring funding required
for a rapid scale up in Africa.
• Integration of LF elimination into health systems and other local health
programmes.
• Research into a macro-filaricide.
Redefinition and clarification of the goal? - interruption of transmission vs
I
elimination as a public health problem.
3.
REGIONAL PLANS, PRIORITIES AND FUNDING NEEDS
Regions
Plans for up-scaling in 2003-5 were presented by each region as follows:
Africa
Americas
Eastern Mediterranean
Mekong Plus
India Sub-continent
Pacific Islands
Drs P Kilima/J Gyapong/J.B. Roungou
Drs J Ehrenberg/G Gonzalvez
Drs M El-Setouhy/R. Ben Ismail
Drs CP Ramachandran/EA Padmasiri/K. Ichimori
Drs M Ismail and EA Padmasiri
Drs K Ichimori and J Koroivueta
The meeting divided into two groups to allow the regions to develop the costs and
funding requirements in a standard format. The figures presented are summarised
below:
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
Country and Regional Costs and Funding Summary
Funding
Regional
Cost
Available
$ million1' $ million
Funding
Gap
$ million
Country Cost
per person
US Cents
2.76
8.36
94.0
0.83
5.1
20.49
5.3
4.77
0.46
0.45
4.78
2.5
9.3
0.85
0.73
1.21
0.37
9.1
EMRO
18.1
5.22
0.83
1.58
4.47
28.8
Africa
169.2
65.63
6.93
16.41
56.15
38.8
TOTAL
869.6
111.376
10.754
27.51
94.62
12.8
Region
Number
T reated
2003-5
Country
Cost
$ million
Americas
10.8
10.15
0.97
India SC
469.5
24.76
Mekong +
192.7
PacELF
The conclusion from this analysis was that the Global Programme has a funding gap of
$95m for 2003-5. If this is extrapolated over the planned 20 year life of the programme
this results in a total budget requirement of $893m. With estimated funds available of
$253m this leaves a funding gap of $640m over the life of the programme.
The regional representatives were requested to review these figures and advise
any changes.
4.
ALLIANCE KEY ISSUES
The second group discussed key issues, which were summarised by Dr F Richards as
follows:
Health and functioning of the Regional Programme Review Groups:
• Structures and financing
• Organizational models and model programmes
• Facilitating arrangements
Messages and advocacy:
• Operational definitions of success
• Milestones of scientific progress need to be established
• Visuals needed for communications and resource mobilization
A
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
Others:
• Treatment targets and scaling up
• Integration with primary healthcare
• Synergy with other disease programmes
• K Roles of NGDOs
• Unstable populations, conflict zones, and cross border issues
• Customs clearance and taxation
Possible Alliance issues:
• National capacity building
• Responsibilities of RPRGs and National functions
Other points raised but not classified as Alliance issues:
• Operations research
• Incentives for distributors/precedents of other programmes
• Social mobilization
• Certification process
• Treatment in urban areas
• Adverse experiences
• Disability alleviation programme
5.
PARTNER CONTRIBUTIONS
The various Alliance partners attending the meeting presented the scope of their
contributions to the Global programme.
Dr E Ottesen presented a summary of the different roles played by partners as follows:
Donors
GSK
Merck
Gates
DFID
JICA
Arab Fund
Enhancers
WHO
Liverpool
Emory
MDP
Implementers
Ministries of Health
NGDO’s
Carter Center
This helps in clarifying that many Alliance partners act in more than one role, and the
“Enhancers” in particular have dual roles of passing on donor funds or drugs to
countries, as well as participating in support activities.
Each partner presented their contributions to the global programme. The table below
summarises the presentations together with verbal answers to questions.
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
Summary of Partner Contributions for 2003-5
Partner
Cash
GSK
$5.1m
Merck/MDP
Emory
$1.3m
(Gates)
Liverpool
$4.1 m*
(DFID,
Gates)
n/a
(Gates,
Other)
$5.3m
(Gates,
other)
NGDOs
WHO
Internal
Costs
$5.0m
Staff etc
Drugs
Support
716m
Advocacy and fund raising,
communications, academic
support centres
Jointly fund MDP, research
support,
Country support (MDP)
Model programs, AME
Economics & costs, US
fundraising____________
Country support, capacity
building, mapping, training
materials, communications
Country support in many
African programmes
Disability alleviation_____
Country support, health
policy and technical
guidelines, training
material, operational
support, advocacy,
programme monitoring,
secretariat to Alliance.
albendazole
value $136m
467m *
Mectizan®
value $700m
$3.0m *
MDP costs &
shipping
$2.2m
(Gates,
GSK)
$1.5m*
(DFID,
Gates, GSK)
na
(Gates,
Other)
$5.2m
Regular &
extra budget)
DEC
procurement
* Numbers submitted/revised post meeting.
6.
ADVOCACY AND FUNDRAISING AND COMUNICATIONS
6.1
Advocacy and Fundraising
Dr B Bagnall and Ms P Wuichet presented the progress achieved since GAELF2. This
was summarised in a paper tabled at the meeting (copies available from LFSC). The
Task Force has focused on developing a framework for fund raising for use by Alliance
partners as follows:
Bilaterals
US Private Sector
UK/Europe Private Sector
Other Regions
lead by
lead by
lead by
lead by
WHO
Emory
Liverpool
Regional groups
Proposals included:
• Creation of a global data base of donors and prospective donors
• Assisting regions in accessing training and materials and arranging donor meetings
• Providing a global framework for communications
A
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
•
•
•
Encouraging country programmes to use the framework and advocacy materials to
aid fund raising efforts within the countries.
Promoting an Alliance identity (logo, slogan etc)
Assisting the establishment of regional support centres for advocacy and fundraising
Dr Bagnall estimated that the Task Force would need two full time staff and a budget of
$0.25m per year to undertake a professional fundraising effort.
There was an extensive discussion on issues including:
How does LF compete with other health priorities such as HIV/AIDS?
What are the key advocacy messages?
Time-scale for raising funds and how do we handle them.
Need for country training on financial management and fund raising.
Need to involve the countries in the fund raising activities.
Countries can raise funds existing basket funding by making LF a priority.
Need advice on how to structure mechanisms for financial management
Need an entity to make decisions on allocation of funds.
How do we initiate programme synergies.
The meeting agreed that there was an urgency to continue the work and for the
Task Force to prepare a plan.
6.2
Communications
Dr F Rio presented the progress on Alliance communications, the website and work to
develop an Alliance logo and identity. A process has been followed to develop a list of
criteria for a logo which has been given to three design agencies, each of which will
produce 2 or 3 example logos for review. Dr Rio will send the logos and review criteria to
Alliance partners in the next few weeks.
Action: WHO
It was agreed that the Alliance partners supported the work in developing an Alliance
identity, and would participate in the review and adoption of a logo for use in Alliance
materials.
Agreement
7.
ALLIANCE ORGANIZATIONAL FRAMEWORK
Dr N Zagaria outlined the proposal contained in a paper circulated by WHO prior to the
meeting (see Attachment C). This covered the history of the Alliance and the
Programme, the role of WHO and the roles of the Secretariat and the Task Force for
Advocacy and Fundraising. The paper describes the need for the Alliance to address the
issues of: resource mobilization to support the scale up, arrangements for distribution of
funds received, planning and organization of GAELF3, communications and
development and expansion of the partnership.
7
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
The letter from Dr S Stansfield of the Gates Foundation was circulated and key points
emphasised and discussed. In it the Gates Foundation recommends to be attractive to
potential donors the Alliance should adopt a framework for the partnership which is low
on overhead cost and bureaucracy and high on accountability and leadership.
The McKinsey report commissioned by the Gates Foundation on Public Health Alliances, II
was presented by Prof D Molyneux, and the implications for the LF Alliance were
7/
discussed.
There was a wide ranging discussion on options for how to organize the work of the
Alliance and a resolution was agreed which is documented below.
8.
RESOLUTIONS (as documented and agreed in the meeting)
8.1
Alliance Secretariat
The Secretariat of the Global Alliance be organized to include 5 members as follows:
•
•
•
•
The Chair of the Alliance
The Chair of the Task Force for Advocacy and Fundraising
The Chair of the Task Force on Communications and GAELF3
Two representatives from WHO (GRELF)
The Secretariat will be action oriented, strategic, and empowered to advance Alliance
activities until the next meeting of the Global Alliance in 2004. The Secretariat wilHnitiallY
be based in WHO Geneva.
It was agreed that the Alliance will always be chaired by areBresentatiye from an
endemic countryJt was agreed unanimously that Dr J. Galvez Tan from the Philippines
will be the Chair of the Alliance up to the GAELF meeting in March 2004.
The Secretariat will draft its Terms of Reference for review and adoption as follows:
Draft Terms of Reference circulated to Alliance partners
Review and finalize the Terms of Reference
15 Jan 03
1 Mar 03
The Terms of Reference will include:
•
•
8.2
Support the GRELF in updating the Program Strategic Plan
Develop and recommend alternative GA governance structures (including
supporting financial mechanisms) for ratification during GAELF3
Task Force on Advocacy and Fundraising
Q
i
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
The Task Force for Advocacy and Fundraising will be chaired by Dr B Bagnall and
based in the US.
The Terms of Reference will be drafted by 15 Jan 03
Suggested ToR will include:
• Expand the donor base for the GRELF
8.3
Task Force for Communications and GAELF3 Meeting
The Task Force for Communications and GAELF3 will be chaired by Prof D Molyneux
and be based in Liverpool.
A sub-group will be established for the GAELF3 meeting.
The Terms of Reference will be developed by 1 March 03.
8.4
GAELF3
Dr El Nasr from the Government of Egypt announced that the Global Alliance were
invited to hold the next GAELF meeting in Egypt. This invitation was warmly received
and it was agreed the next GAELF meeting will be held in March 2004 in Egypt. The
meeting thanked the Government of Egypt for offering to host the meeting in Egypt.
A planning sub group will be organized. Suggestions for members to be sent
electronically by 15 Jan 03.
The two Task Forces will draw inputs from the Regional PRG chairs.
o
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
9.
CALENDAR EVENTS UP TO GAELF3
15 Jan 03
Draft Te^rns of Reference for Task Forces
29-30 Jan 03 Gates GGRC5 meeting, Washington
Feb 03
PacCARE meeting, Fiji
28 Feb 03
Government of Egypt confirm dates for GAELF meeting in Egypt
1 Mar 03
Final Terms of Reference for Task Forces
March 4-6/03 MEC/AC meeting in US
March 03
India SC RPRG meeting, Dhaka, Bangladesh
March 03
Mekong + meeting, Kuala Lumpur, Malaysia
March 25-28
TAG meeting, near Geneva
April 03
AFRO RPRG meeting, Ghana
Aug 03
PacELF Prog Mgrs and PacCARE meeting, Fiji
1 Sept 03
AMRO RPRG meeting, Maceio, Brazil
Oct 03
AFRO RPRG plus Program Managers meeting, Togo
Nov 03
EMRO RPRG Sudan
Dec 03
JAF meeting, tba
Dec 03
Centennial meeting of the American Society of Tropical Medicine, in
Philadelphia. This is a good opportunity to advance the LF program to a
large audience. A working group comprising Dr E. Ottesen, Dr M. ElSetouhy, Dr J. Gyapong, and Dr B. Bagnall was established to prepare
for the meeting.
Mar 04
GAELF3 Meeting in Egypt
Mar 04
Meeting of RPRG Chairs after GAELF3 meeting in Egypt
in
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
ATTACHMENT A
WORKSHOP ATTENDEES
Lymphatic Filariasis Global Alliance Ad-Hoc Strategic Planning Workshop
Follow-up of the 2nd Global Alliance meeting, 11-13th December 2002
Liverpool School of Tropical Medicine, United Kingdom
X
Chair
Dr. J.Z. Galvez Tan, (1) Professor, University of the Philippines,
College of Medicine, Department of Family and Community
Medicine, Pedro Gil Street, Malate, Manila, Philippines; (2)
Health Futures Foundation Inc. 1086 Del Monte Avenue, Quezon
City 1105, Philippines. Tel +632 374 3745; Fax +632 413 8669;
Email izgalveztan@hotmail.com ; galveztan@pacific.net.ph
AFRO
Chair of PRG
Dr. P Kilima, Regional Coordinator (Anglophone Africa),
International Trachoma Initiative, 7th Floor NSSF Building,
Morogoro/Bi Titi Rd, P.O. Box 3545, Dar es Salaam, Tanzania.
Tel. +255. 748 620620/ 255 22 212 7101; Fax. +255 22 212 2350;
Email kilima@trachoma.or.tz
Country representatives
Dr. J. Gyapong, Director, Health Research Unit, Ministry of
Health, P.O. Box 184, Accra, Ghana. Tel.+233 21 230220; Fax
+233 21 226739; Email John.Gyapong@hru-ghs.org
Dr. D. Kyelem, LF Elimination Program Manager, Ministry of
Health. 01 BP 2935, Ouagadougou 01, Burkina Faso. Tel. +226
308790; Fax +226 32 4662; Email dominiquekvelem@yahoo.fr
Regional Adviser
Dr. J.-B. Roungou, WHO/AFRO Temporary Office in Harare, P.O.
Box BE 773, Belvedere, Harare, Zimbabwe. Tel. +263 746000 (M)
+263 91263734; Email roungouj@whoafr.org
AMERICAS
Chair of PRG and Country representative
Dr. G. Gonzalvez, Director General, Centro Nacional de Control
de Enfermedades Tropicales (CENCET), Secretaria de Estado de
Salud Publica y Asistencia Social, Av. Duarte No. 269, Villa Apdo.
Postal 1303, Santo Domingo,Dominican Republic. Tel. + 809 536
9604 X228; Fax. +809 536 2281; Email malaria@centennialrd.net
Regional Adviser
Dr. J. Ehrenberg, Regional Adviser, HCT, PAHO, 525 23rd Street,
Washington DC 20037, USA. Tel. +1 202 974 3894; Fax +1 202
974 3688; Email ehrenbej@paho.org
EMRO
Chair of PRG
Dr. M. El-Setouhy, Ain Shams University, College of Medicine,
Department of Community Environmental and Occupational
11
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
Medicine, Abbasia, Cairo 11516, Egypt. Tel. + 202 403
9761/+202 261 3624; Fax +202 683 9622/+202 483 7888; Email.
setouhy@menanet. net
Country representative
v Dr. Mahmoud Abou El Nasr, First Under-Secretary, Ministry of
V Health and Population, Cairo, Egypt. Tel. Fax. Email
mabuelnasr@hQtmail.com
Regional Adviser
Dr. R. Ben Ismail, CTD, WHO EMRO, Abdul Razzak al-Sanhouri
Street, P.O. Box 7608, Nasr City, Cairo 11371, Egypt. Tel. +202
276 5280; Fax +202 276 5414; Email ismailr@emro.who.int
INDIAN
SUB
CONTINENT
Chair of PRG
Professor M.M. Ismail, Professor Emeritus, Department of
Parasitology, Faculty of Medicine, University of Colombo,
Kynsey Road, Colombo 8, Sri Lanka. Tel. +94 1 695880; Fax. +94
1 699284; email mismail@slt.lk
Country representative
Dr. M. Hossain, DPM (Filariasis Elimination Program) and Program
Manager (Filariasis), Directorate of Health Services,
CDC Division, Mohakhali, Dhaka-1212, Bangladesh. Tel +880 2
812 2074/881 3839; Fax +880 2 811 5646; email
hossainm@bdcom.com
Regional Adviser (SEARO)
Dr. E.A. Padmasiri, SEARO, World Health House, IP Estate, Ma
Marg, New Delhi, India; Tel +91 11 233 70804; Fax +91 11 233
70197; Email Padmasiri@whosea.org
MEKONG
PLUS
Chair of PRG
Professor Dato Dr. C.P. Ramachandran , Faculty of Medicine and
Health Sciences, Universiti Putra Malaysia, Selangor Darul Ehsan
43400 UPM Serdang, Malaysia. Tel. +603 269 87275; Fax. +603
269 86152; Email ramacp@hotmail.com
Country representative
Dr. L. Hernandez, National Filariasis Elimination Program
Coordinator, Infectious Diseases Office, National Center for
Disease, Prevention and Control, Department of Health, 3F, Bldg
No. 13, San Lazaro Compound, Sta. Cruz, Manila, Philippines.
Tel/Fax +63 2 711 6808; Email dr_leda@edsamail.com.ph
Regional Adviser (SEARO)
Dr. E.A. Padmasiri, SEARO, World Health House, IP Estate, Ma
Marg, New Delhi, India; Tel +91 11 233 70804; Fax +91 11 233
70197; Email Padmasiri@whosea.org
PacELF
Chair of PRG and Country representative
Dr. J. Koroivueta, Ministry of Health and Social Welfare,
Wellcome Virus Laboratory, Tamavua Hospital, Private Mailbag,
IO
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
Suva, Fiji. Tel. +679 332 0066; Fax +679 332 0344/+679 332
3276; Email joekv@CQnnect.com.fj
Regional Adviser
Dr. K. Ichimori, WHO, South Pacific, P.O. Box 113, Suva, Fiji.
Tel. +679 330 4600; Fax +679 330 0462; Erqail
ichimorikgfi j. wpro. who. int
PARTNERS
Atlanta group
Dr. E. Ottesen, Director, Lymphatic Filariasis Support Centre,
Department of International Health, The Rollins School of Public
Health, Emory University, 1518 Clifton Road, Atlanta GA 30322,
USA. Tel. +1 404 712 9263; Fax +1 404 727 5530; Email
eottese@sph. emory.edu
CDC
Dr. P. Lammie, Centers for Disease Control, Mailstop F-13, 4770
Buford, Highway, Atlanta, GA30341-3724, USA. Tel.+I 770 488
4054; Fax +1 770 488 4108; Email plammie@cdc.gov
GSK
Dr. B. Bagnall, Director, Lymphatic Filariasis Program,
GlaxoSmithKline, One Franklin Plaza, 200 North 16th Street,
Philadelphia PA19102-1225, USA. Tel. +1 215 751 6168; Fax +1
215 751 4046; Email brian.g.bagnall@gsk.com
Mr A. Wright, Director of Planning, Lymphatic Filariasis
Programme, GlaxoSmithKline, GSK House, Floor C5 12, 980 Great
West Road, Brentford, Middlesex TW8 9GS. Tel +44 (0)20 8047
5515; Fax +44 (0)20 8047 0684; email andy.l.wright@gsk.com
Liverpool
Professor D.H. Molyneux, Director, Lymphatic Filariasis Support
Centre, Liverpool School of Tropical Medicine, Pembroke Place,
Liverpool L3 5QA, UK. Tel. +44 (0)151 705 3291; +44 (0)151 709
0354; Email fahy@liv.ac.uk
Merck/MDP
Ms. B. Colatrella, Director,Worldwide Product Donation Policy &
Programs,, Merck & Co.lnc. One Merck Drive, P.O. Box 100
W51A-35, Whitehouse Station, New Jersey 08889-0100, USA.
Tel. +1 908 423 2047; Fax +1 908 423 1987; Email
Brenda Colatrella@merck.com
Dr. B. Thylefors, Mectizan Donation Program,Task Force for Child
Survival and Development, 750 Commerce Drive, Suite 400,
Decatur, Atlanta 30030, USA. Tel +1 404 371 1460; Fax +1 404
371 1138; email bthylefors@taskforce.org
NGDO
(Carter Center)
Dr. F. Richards The Carter Center, One Copenhill, Atlanta,
GA30307, USA. Tel. +1 770 488 4511; Fax +1 770 488 4521; Email
fxr1@cdc.gov
1Q
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
X
World Bank
Dr. B. Liese, Senior Adviser, Human Development, Africa Region,
The World Bank, 1818 H. Street NW, Washington DC 20433, USA.
Tel. +1 202 458 4481; Fax +1 202 522 3157; Email
bliese@worldbank.org
WHO/HQ
Dr. N. Zagaria, Coordinator, Strategy Development and
Monitoring for Eradication and Elimination (CPE/CEE), World
Health Organization, 20 Avenue Appia, 1211 Geneva 27,
Switzerland. Tel +41 22 791 2534; Fax +41 22 791 4TT1\ Email
zagarian@who.int
Dr. G. Biswas. Lymphatic Filariasis Elimination (CEE/FIL),
Strategy Development and Monitoring for Eradication and
Elimination (CPE/CEE), World Health Organization, 20 Avenue
Appia, 1211 Geneva 27, Switzerland. Tel +41 22 791 3850 (M) +41
79 477 1736; Fax +41 22 791 4777; Email biswasg@who.int
Chair/TAG
Dr. Y. Dadzie, P.O. Box OS-1905, Accra, Ghana. Tel/Fax +1 233
21 401353; Emailyankumdadzie@iname.com
Observers and
Advisers
Advocacy and
Fundraising
Dr. A. Haddix, Rollins School of Public Health, Emory
University, 1518 Clifton road NE, Atlanta GA 30322, USA. Tel.
+1 404 727 3558; Fax 1 404 727 5530; Email
achaddi@sph.emory.edu
Mr C. Maddock, Strategy Development and Monitoring for
Eradication and Elimination (CPE/CEE), World Health
Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland.
Tel +41 (22) 791 2473; Fax +41 22 791 4777; Email
maddockc@who.int
Dr. F. Rio, Strategy Development and Monitoring for Eradication
and Elimination (CPE/CEE), World Health Organization, 20
Avenue Appia, 1211
Geneva 27, Switzerland. Tel +41 (22) 791 3833; Fax +41 22 791
4777; Email riof@who.int
Ms. P. Wuichet Project Resource Group, P.O. Box 5743,
Atlanta, GA31107, USA. Tel. +1 404 853 7888; Fax +1 404 876
9440; Email pwuichet@proiectresourcegroup.com
i/i
Jt.
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
ATTACHMENT B
LIST OF PRESENTATIONS
Lymphatic Filariasis Global Alliance Ad-Hoc Strategic Planning Workshop
Follow-up of the 2nd Global Alliance meeting, 11-13th December 2002
Liverpool School of Tropical Medicine, United Kingdom
Day 1
AFRO
Introductory remarks. The general trend of disease burden. (Dr P Kilima)
Multinational Research. Dealing with Cultural Pluralism (Dr J Gyapong)
Americas
LF regional plan (Dr G Gonzalvez/Dr J Ehrenberg)
EMRO
Lymphatic Filariasis Elimination Program in EMRO (Dr M El-Setouhy)
Indian Subcontinent RPRG
Elimination of ELF in Indian Subcontinent (Prof M Ismail)
Update on country activities and strategic planning (2003-2007) - Bangladesh, India,
Maldives, Nepal and Sri Lanka
Funding
Mekong-Plus (MK+ELF)
Countries of the Greater Mekong Sub-Region and Neighboring Countries (Prof Ismail /Dr
Padmasiri)
Pacific Elimination of Lymphatic Filariasis
PacELF Approach (Dr J Koroivueta/Dr K Ichimori)
Day 2
Advocacy and Fundraising Group
Closing the Fundraising Gap (Dr B Bagnall/Ms P Wuichet)
www.filariasis.org, Consolidating information and communication (Dr F Rio)
Atlanta Group (Emory LF Support Center)
Identification of contributions to be made by partners and arrangements for coordination
(Dr E Ottesen)
GlaxoSmithKline
Contribution to the Global programme to eliminate Lymphatic Filariasis (Dr B Bagnall)
Country/Regional costs and funding Global programme to eliminate Lymphatic Filariasis
(Mr A Wright)
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
TO
Liverpool LF Support Center
Why a support centre in the UK? (Prof D Molyneux/Mrs J Fahy)
Breakdown of the McKinsey Report (Prof D Molyneux)
X
NGDO (The Carter Centre)
Identification of contributions to be made by partners to the Global Programme ELF and
arrangements for coordination. NGDOs (Dr F Richards)
World Health Organization
The framework of the Global Alliance to eliminate Lymphatic Filariasis (GAELF) (Dr N
Zagaria)
1A
LYMPHATIC FILARIASIS GLOBAL ALLIANCE
AD-HOC STRATEGIC PLANNING WORKSHOP
11-13 DECEMBER 2002
7*
ATTACHMENT C - GLOBAL ALLIANCE FRAMEWORK
The framework of the Global Alliance
to Eliminate Lymphatic Fil&riasis
(GAELF)
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National Programmes to Eliminate Lymphatic Filariasis
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Communication and GAELF3
Regional Programme
Review Groups
Co-ordination/Communications/Technical Advice
CCC: GSK/WHO Collaboration Coordinating Committee
EMEC: Expanded Mectizan® Expert Committee
Global Programme to Eliminate Lymphatic Filariasi$
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Health and Global Public-Private Initiatives (Partnerships)
DRAFT 01
Elements for the case studies
°bieC^nhance CSOs' input and influence in the decision processes about GPPIs
-
in countries where this initiatives are implemented
Strengthen CSO's negotiation capacity to influence health policies and
strategies aiming to the fulfilment of the right to health
Create evidence on the performance of GPPIs at local level
Generate evidence about the effects of GPPIs on local health systems
Concepts
-
GPPI
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-
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“A collaborative relationship which transcends national boundaries and brings together at least
three parties, among them a corporation (and/or industry association) and an intergovernmental
organization, so as to achieve a shared health-creating goal on the basis of a mutually agreed
division of labour. (Buse and Walt 2000. 550)1
-
The right to health
The Committee nn FmnomicaL Social and Cultural Rights in its Comment No. 14 of April-May 2000
declare that it “interprets the right to health, as defined in article 12.1 of the International CESCR, as
an inclusive right extending not only_to_ timely and appropriate health care but also to the underlying
determinants of health, such as access to safe and potable water and adequate sanitation, an
adequate supply of safe food, nutrition and housing, healthy occupational and environmental
conditions, and access to health-related education and information, including on sexual and
reproductive health”. 2
- Key elements of the right to health
In the same document, the following elements are mentioned as essential
(a) Availability. Functioning public health and health-care facilities, goods and services, as well as
programmes, have to be available in sufficient quantity within the State party. The precise nature of
the facilities, goods and services will vary depending on numerous factors, including the State party’s
developmental level. They will include, however, the underlying determinants of health, such as safe
and potable drinking water and adequate sanitation facilities, hospitals, clinics and other health-related
buildings, trained medical and professional personnel receiving domestically competitive salaries, and
essential drugs, as defined by the WHO Action Programme on Essential Drugs.
(b) Accessibility. Health facilities, goods and services have to be accessible to everyone without
discrimination, within the jurisdiction of the State party. Accessibility has four overlapping dimensions:
Non-discrimination: health facilities, goods and services must be accessible to all, especially
the most vulnerable or marginalized sections of the population, in law and in fact, without
discrimination on any of the prohibited grounds.
Physical accessibility: health facilities, goods and services must be within safe physical reach
for all sections of the population, especially vulnerable or marginalized groups, such as ethnic
minorities and indigenous populations, women, children, adolescents, older persons, persons
with disabilities and persons with HIV/AIDS. Accessibility also implies that medical services
and underlying determinants of health, such as safe and potable water and adequate
sanitation facilities, are within safe physical reach, including in rural areas. Accessibility further
includes adequate access to buildings for persons with disabilities.
Economic accessibility (affordability): health facilities, goods and services must be affordable
for all. Payment for health-care services, as well as services related to the underlying
determinants of health, has to be based on the principle of equity, ensur'ng that these
services, whether privately or publicly provided, are affordable for all, including socially
poorer households should not be
disadvantaged groups. Equity demands that ooorer
disproportionately burdened with health expenses as compared to richer households.
Information accessibility, accessibility includes the right to seek, receive and impart
information and ideas concerning health issues. However, accessibility of information should
not impair the right to have personal health data treated with confidentiality.
(c) Acceptability All health facilities, goods and services must be respectful of medical ethics and
culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and communities,
sensitive to gender and life-cycle requirements, as well as being designed to respect confidentiality
and improve the health status of those concerned.
(d) Quality. As well as being culturally acceptable, health facilities, goods and services must also be
scientifically and medically appropriate and of good quality. This requires, inter alia, skilled medical
personnel, scientifically approved and unexpired drugs and hospital equipment, safe and potable
water, and adequate sanitation.3
Other elements to be applied to assess the implementation of GPPIs
- Participation
A further important aspect is the participation of the population in all health-related decision-making at
the community, national and international levels.
- Sustainability
It is the capacity of the health system to function effectively over with minimum external input.5
- Transparency and Accountability
It refers to transparency in decision-making processes and mechanisms on financing, planning,
implementation and monitoring of the activities of a GPPI in a certain country.
Accountability means that GPPI structures and mechanisms of implementation being required to
account for decisions, policies and actions, usually to an individual or group but ultimately to the
public.
- Effectiveness
Effectiveness means that the GPPI programmes achieve the goals and targets they have proposed in
a certain country I geographical region or related to a certain target group
The cases of GPPIs
(D
Contact
Address
GAELF Global Alliance for the Elimination of Lymphatic Filariasis
Zagaria
Nevio
Person(s)Dr.
Global Alliance for the Elimination of Lymphatic Filariasis (GAELF)
Organization
Health
World
CPE
Elimination
Filariasis
Lymphatic
L361
Appia,
Avenue
20
Switzerland
1211,
27,
Geneva
2534
791
22
+41
Tel:
4850
791
22
+41
Fax:
filariasis@who.ch
zagarian@who.int;
Email:
http://www.filariasis.orq
Mission / Objective
The primary objective of the Alliance is to eliminate lymphatic filariasis (LF) as a
public health problem by the year 2020. The strategy has two components: 1) to
stop the transmission in all countries; and 2) to alleviate and prevent the suffering
of over 20 million affected individuals. Additional aims of the Alliance are to
support ongoing de-worming programs, provide an overall strengthening of the
health services in endemic countries, enhance efficiency of drug distribution
systems, and promote economic benefits to individuals and the community.
-----
L
The efforts of GAELF have been aided, in part, by two generous drug donations. In
1998, SmithKline Beecham, jiow GlaxoSmithKline (GSK), agreed to donate its
drug albendazole free-of-charge until the disease is eliminated. This is likely to be
a donation of between 4-6 billion tablets over a 20-year period. Merck & Co., Inc.
also pledged to expand its Mectizan Donation Program for Onchocerciasis jn all
areas of Africa where the two diseases co-exist. In February 20Ul~~tlTe Bill &
Melinda Gates Foundation gave $20 million to accelerate the elimination of
Lymphatic Filariasis (LF) during the first five years of the 20-year global program.
Disease / Condition
Lymphatic Filariasis (LF)
Product / Service
Albendazole; Diethylcarbamazine (DEC); Mectizan
Legal status
No separate legal status - a WHO-initiated alliance.
Established
Formed in 1997; new agreement signed 2 December 1999
Major Participants
Public sector
World Health Organization (WHO), World Bank, UNICEF, Spain, Government of,
Belgium, Government of, Italy, Government of, Japan, Government of, Kuwait,
Government of, UK Department for International Development (DFID), US Centers
for Disease Control & Prevention (CDC), Netherlands Ministry for Development
Cooperation. Ministries of Health.
Non-profit sector
Liverpool School of Tropical Medicine, other international NGOs and academic
institutions.
Commercial sector
GlaxoSmithKline , Merck & Co., Inc.. Binax, Inc., U.S.
Major funders
GlaxoSmithKline , Merck & Co., Inc.
Governance
WHO controlled
6
GPEI Global Polio Eradication Initiative
Contact
Address
Person(s)Mr.
Global
World
20
Geneva
Tel:
Fax:
Email:
Mission / Objective
Olivier
Polio
Rosenbauer,
Eradication
Health
Avenue
27,
+41
+41
Communication
Initiative
1211,
22
22
Officer
(GPEI)
Organization
Appia
Switzerland
791
3832
791
4193
rosenbauero@who.int
-To interrupt transmission of the wild poliovirus globally and certify all WHO
regions
polio-free
by
the
end
of
2005.
- To conduct effective and high quality supplementary immunization activities,
including national immunisation days and mop-up campaigns to interrupt wild
poliovirus
transmission.
- To develop and sustain certification standard surveillance and laboratory
systems
that
can
rapidly
identify
polio-infected
areas.
To
ensure
laboratory
containment
of
wild
poliovirus
stocks.
-To develop a consensus strategy to stop polio immunisation after certification of
eradication.
- To use polio eradication to strengthen and expand routine immunisation
services.
Disease / Condition
Product / Service
Polio
Technical and financial support for all polio eradication activities, including
activities (ie.
National Immunization Days), and
supplementary immunization^-..^-v
acute flaccid paralysis surveillance including a global laboratory network. Support
for routine Immunization services, along with Vitamini supplementation during
polio National Immunization Days.
Legal status
No separate legal status. WHO programme.
Established
1988
Major Participants
Public sector
World Health Organization (WHO), World Bank, UNICEF, Danish Agency for
Development Assistance (DANIDA), Belgium, Government of, Italy, Government
of, Japan, Government of, US Agency for International Development (USAID), UK
Department for International Development (DFID), US Centers for Disease Control
& Prevention (CDC), Canadian International Development Agency (CIDA),
Netherlands Ministry for Development Cooperation. Ministries of Health of all
recently or currently polio endemic countries, including India, Pakistan,
Afghanistan, Nigeria, Niger and Egypt.
Non-profit sector
Bill & Melinda Gates Foundation, Australian International Health Institute. Rotary
International, De Beers, governments of Finland and Germany, Rotary Foundation
and the United Nations Foundation.
Commercial sector
Aventis SA. Wyeth and De Beers.
Major funders
US Agency for International Development (USAID), Japan, Government of. Bill 8i
Melinda Gates Foundation, Canadian International Development Agency (CIDA),
US, Government of, Netherlands, Government of, UK Department for International
Development (DFID). Rotary International, the United Nations Foundation.
Governance
A programme spearheaded by WHO, Rotary International, the US Centers for
Disease Control and Prevention and UNICEF. WHO provides the overall technical
direction and strategic planning for the management and coordination of the
initiative.
7
AAI Accelerating Access Initiative to HIV Care
Contact
Address
Person(s)Dr. Joseph
Accelerating
The
Joint
20
Geneva
Tel:
Fax:
Email:
Perriens, Manager, Strategy Development for Responses
(AAI)
HIV
Care
to
Initiative
Access
(UNAIDS)
HIV/AIDS
on
Programme
Nations
United
Appia
Avenue
Switzerland
CH-1211,
27,
4456
791
22
+41
4898
791
22
+41
perriensj@unaids.org
Mission / Objective
To promote and support the implementation of the comprehensive care agenda,
including treatments for opportunistic infections and antiretroviral therapy, in the
hardest hit regions of the world. To support countries in developing national
actions plans for improving access to HIV care, including outlining possible
suppliers of HIV-related treatments and other commodities; facilitating
negotiation with suppliers as requested, and promoting "tiered" pricing of
medicines by all suppliers from the R&D and generics pharmaceutical industries.
Disease / Condition
HIV/AIDS
Product / Service
Coordinating action and facilitating negotiations with a range of suppliers.
No separate legal status. Part of the existing remit of UNAIDS to promote the
Legal status
expanded response to HIV/AIDS.
Established
2000 May
Major Participants
Public sector
UNAIDS, World Health Organization (WHO), World Bank, UNICEF, UN Population
Fund (UNFPA).
Non-profit sector
n.a.
Commercial sector
GlaxoSmithKline , Merck & Co., Inc., Boehringer Ingelheim, Bristol-Myers Squibb
Company, Roche Holding AG. In addition 34 additional suppliers of HIV related
medications have expressed interest in supplying the countries. These are being
evaluated.
Major funders
At country-level, the individual countries and patient payment.
Governance
The UNAIDS Secretariat is coordinating the endeavour.
8
Roll Back Malaria
Contact
Address
Department
Control
Malaria
Director
of
Alnwick,
David
Person (s) Mr.
(RBM)
Partnership
Global
Malaria
Back
Roll
Organization
Health
World
Appia
Avenue
20
Switzerland
1211,
27,
Geneva
2394
791
22
+41
Tel;
alnwickd@who.int
Email:
Executive
Nafo-Traore,
Fatoumata
Dr.
Partnership
Global
Malaria
Back
Roll
Health
World
Avenue
20
1211,
27,
Geneva
791
22
+41
Tel:
Email: nafotraoref@who.int
Secretary
(RBM)
Organization
Appia
Switzerland
2635
Mission / Objective
Roll Back Malaria (which now consists of two entities) remains a global movement
to halve the burden of malaria by 2010 with a“ focus on Africa. Its priorities are:
globaT pohtTcaT commitment to tackle malaria more effectively
-To increase
coordinated
action;
through
- To assist the health sector to focus resources on high disease burdens such as
malaria
and
cost-effective
intervention
packages;
- To increase the commitment, among the research community and private
and
sector;
‘—
- To discover new products and cost effective control tools.
Disease / Condition
Malaria
Product / Service
Global leadership, strategy, global partnership secretariat as coordinating
mechanisms, new tools for malaria control.
Legal status
No separate legal status. Partnership Secretariat is housed within WHO as a
cabinet level project.
Established
1998 October
Major Participants
Public sector
World Health Organization (WHO), World Bank, UNICEF, US Agency for
International Development (USAID), United Nations Development Program
,UNDp>
,
(Founding
partners).
Governments and ministries of endemic countries and bilateral aid organizations
(Core partners).
Non-profit sector
Commercial sector
Nongovernmental organizations, research and academic institutions.
Members of the international oil and gas producers such as ExxonMobil and Eni,
multinational pharmaceutical corporations such as Novartis SA., and
GlaxoSmithKline; companies that manufacture and /or distribute insecticides for
vector control such as Bayer and Syngenta; other industries operating in malaria
endemic countries.
Eu^an’^mmLiX^^^
Major funders
Foundation, UK Department for International Development (DFID). The
governments of Italy, Germany, Netherlands, Luxemburg, Norway and Japan.
Executive Secretary of RBM Partnership Secretariat is accountable to the RBM
Partnership Board, and reports to the Executive Director of Communicable
Diseases within WHO, as does the Director of the Malaria Control Department
Biannual global forum meetings are held for global partners to review progress of
Governance
RBM.
9
GAVI. Global Alliance for Vaccines and Immunization and
VF Vaccine Fund
Contact
Address
Jacobs,
Lisa
Person(s)Ms.
Vaccines
for
Alliance
Global
UNICEF
des
Palais
10,
Geneva
22
+41
Tel:
Email:
http://vww.VaccineAHiance.orq
Mission / Objective
o a js
c
eec-
Communications
and
Immunization
1211,
909
Officer
(GAVI)
Nations
Switzerland
5042
ljacobs@unicef.org
To fulfill its mission of protecting children of al^l nations and of
socioeconomic
levels <against vaccine-preventable diseases, GAVI has established six strategic
objectives:
access
_to
immunization
services,
sustainable
to
access
1.
Improve
of
airexistTng,
safe
and
cost-effect
ive
vaccines
where
they
use
<
2. Expand the
problem,
----------------''public
health
public
address
3. Support the national and international accelerated disease control
diseases,
for
vaccine-preventable
targets
i
vaccines
and
new
development
and
introduction
of
4. Accelerate the
technologies.
5. Accelerate R&D efforts for vaccines needed primarily in developing
countries.
.
6. Make immunization coverage a centerpiece in international development
efforts.
Disease / Condition
Vaccine-preventable diseases of the poor
Product / Service
Vaccines
Legal status
No separate legal status. Secretariat housed at UNICEF Regional Officejor Europe.
1999
Established
Major Participants
Public sector
World Health Organization (WHO), World Bank, UNICEF, US Centers for Disease
Control & Prevention (CDC). Developing country governments and international
development agencies.
Non-profit sector
Bill & Melinda Gates Foundation. Children's Vaccine Program at PATH, UN
Foundation and Pasteur Institute.
Commercial sector
Representation from the industrialized and developing country vaccine industry.
Major funders
US Agency for International Development (USAID), Bill & Melinda Gates
Foundation, Canadian International Development Agency (CIDA), Netherlands,
Government of, UK Department for International Development (DFID). The above
are funders to GAVTs financial arm, the Vaccine Fund.
Governance
The GAVI Board includes five renewable members - WHO, UNICEF, The World
Bank, and the Bill & Melinda Gates Foundation and eleven additional, rotating
members responsible for representing the collective expertise and perspective of
their constituencies: governments - developing countries (three) and
industrialized countries (three), nongovernmental organizations, the vaccine
industry - industrialized country and developing country, research institutes, and
technical health institutes. The Working Group and Task Forces are comprised of
members from the GAVI partner institutions.
10
Contact
Address
Person(s)Mr.
Vaccine
36
Lyon,
Tel:
Fax:
Email:
Fund
4
4
+33
+ 33
Ms.
Nancy
Vaccine
601
Washington,
Tel:
Ives,
13th
DC,
+1
President
(VF)
Fulchiron
France
73
10
56
34
24
42
jfma rti n ©vacci nefu nd. org
Martin,
Jacques-Frangois
Quai
69005,
72
78
Vice
President
Fund
St.
20005,
202
Communications
(VF)
820N
NW
States
United
4910
628
of
Email: nives@vaccinefund.org
Mission / Objective
The Vaccine Fund's mission is to mobilize resources for, champion, monitor the
results of, and help sustain the Global Alliance of Vaccines and Immunization's
program to protect the children of the world's poorest countries from vaccine
diseases.
preventable
diseases.
The Vaccine Fund's strategic objectives: mobilize resources to achieve
immunization sufficiency and sustainability; achieve recognition of and support for
The Vaccine Fund's mission so as to maximize the value of its brand; manage The
Vaccine Fund for efficiency and accountability for results; and ensure with GAVI
partners a secure supply of all relevant vaccines are accessible to all target
countries.
Disease / Condition
Vaccine-preventable diseases of the poor
Product / Service
Financial assistance, grant making, fund disbursement, fund management.
Legal status
A 501(c)(3) charitable foundation under US law (contributions are tax-exempt for
U.S. citizens and corporations).
Established
1999 October 26.
Major Participants
Public sector
Bilateral donor governments, recipient country governments and UN agencies.
Non-profit sector
Rockefeller Foundation, Bill & Melinda Gates Foundation.
Commercial sector
Pharmaceutical industry representatives.
Major funders
US Agency for International Development (USAID), Ireland, Government of,
Danish Agency for Development Assistance (DANIDA), Bill & Melinda Gates
Foundation, Canadian International Development Agency (CIDA), Netherlands,
Government of, UK Department for International Development (DFID). As well as
the governments of Norway and Sweeden and seeking additional governments
and private donors.
Governance
The Vaccine Fund is governed by an independent Board of Directors with
responsibility for the disbursement of all funds. The Vaccine Fund Board makes
decisions to allocate resources to recipient countries based on the
recommendations of the GAVI Board.
11
IPAAA International Partnership Against Aids in Africa
Contact
Address
Person(s)Dr.
Int’l.
World
20
Geneva
Tel:
Email:
Partnership
+41
Meskerem
Grunitzky-Bekele
Against
Aids
in
Africa
(IPAAA)
Health
Organization
Avenue
Appia
27,
1211,
Switzerland
22
791
4412
grunitzkybekelem@unaids.org
Dr.
Michel
de
Against
Aids
in
World
Health
20
Avenue
Geneva
27,
1211,
Tel:
+41
22
Email: degroulard@unaids.org
Int’l.
Partnership
Africa
791
Groulard
(IPAAA)
Organization
Appia
Switzerland
4269
Mission / Objective
- A coalition under the leadership of African countries to reduce the number of
new HIV infections in Africa, promote care for those who are infected with the
virus
and
mobilise
society
to
stop
the
advance
of
AIDS.
- To address social, economic and cultural inequalities as well as injustices which
are the root causes of the epidemic; and not just health issues.
- To contribute to global efforts to curtail the spread of HIV in Africa and reduce
its
impact
on
human,
social
and
economic
development.
-To increase the resources available to national governments and communities to
mount
an
adequate
response
to
the
AIDS
epidemic.
- To ensure that countries are linked to sub-regional, regional and international
resources and initiatives in order to benefit from other international and regional
investments
in
addressing
the
epidemic.
-To step up prevention programmes.
Disease / Condition
HIV/AIDS
Product / Service
To expand AIDS activities so as to make an impact on the epidemic, through
governments committing their political prestige and financial resources, involving
civil society fully, emphasizing prevention and care, and supporting activities in a
range of sectors, so as to limit the spread of the epidemic and mitigate the
impact, and attract international support.
Legal status
No separate legal status. Secretariat within UNAIDS.
Established
1999
Major Participants
Public sector
governments of African countries and bilateral organisations for technical
cooperation and development.
Non-profit sector
NGOs, CBOs, Networks of people living with HIV/AIDS.
Commercial sector
Other private companies.
Major funders
Governance
World Bank, US Agency for International Development (USAID), Japan,
Government of, Ireland, Government of, European Commission, Bill & Mei’nda
Gates Foundation, Canadian International Development Agency (CIDA),
Netherlands, Government of, UK Department for International Development
(DFID), France, Government of, Belgium, Government of. Italy, government pf,
Sweden, government of, Norway, government of, Finland, government of,
Germany, government of and United Nations Foundation.
Annual International Partnership Against AIDS in Africa Stakeholder meeting at an
international level with representatives from all partnership constituents.
Secretariat functions performed by UNAIDS.
12
Information needed
- The health situation in the area where the case study will take place
• Main health problems
o IDescribed in terms of magnitude, distribution by social economic
groups (specially disadvantaged groups), women/men, ethnic
groups
o Correlation with national situation
o Major determinants of the health problems in the area
- The health system in the area
• What is the health system doing in the area?
o Related to the main health problems?
o Major programmes and activities carried out in the area
o Analysis of relevance of those programmes/activities
• Strengths of the health system in the area
• Weaknesses of the health system in the area
The right to health at national / local level
• According to the national constitution
• Ratification and signature of international agreements and conventions
(convenants)
• Clarity about who (institution) is responsible for what, related to key
elements of the right to health
• Existence and functioning of mechanisms and specific places (offices) to
get information, notify and make denounces about the right to health
• Is people informed about contents, mechanism and procedures about the
right to health
- The selected GPPI
A. About the health condition concerned to the GPPI
The health problem concerned to the GPPI
. .
o Magnitude
distribution by social economic groups (specially disadvantaged
o
groups), women/men, ethnic groups
o Correlation with national situation
o Major determinants of the health problems in the area
•
The health system in the area in relation with the health problem
concerned to the selected GPPI
o What is the health system doing in the area?
o Major programmes and activities carried out in the area
o Analysis of relevance of those programmes/activities
• Strengths of the health system in thet area
• Weaknesses of the health system in the area
•
B. About the process of implementation in the country
•
Formulation of national plan
contents for the
o The process of negotiation of the programme
country
o Process and responsible institutions
o Procedures
of the target group, local authorities, local
o Participation
organizations, etc.
** Assessment in relation to elements of the right to health and
elements for the assessment of the right to health (see above)
•
The implementation
o Human resources
o Physical resources
o Management aspects (planning, monitoring, reporting, etc)
o Technical aspects
o Administrative aspects
** .Assessment
______ in relation to elements of the right to health and
elements for the assessment of the right to health (see above)
•
The effects of the GPPI on the local health system
o Positive effects (see elements of implementation)
o Non-anticipated harmful effects
1 Buse, K. and G. Walt (2000). “Global public-private partnerships for health, part I - a new development in
health?” Bulletin of the World Health Organization/The International Journal of Public Health 78, pp. 549-61.
2 OUNHCHR, 2000. E/C. 12/2000/4, CESCR. General Comment 14
3 OUNHCHR, 2000. idem
4 OUNHCHR, 2000. idem
5 La Fond, A. (1995). Sustaining Primary Health Care. Earthscan. London, pp 17
6 http://www.ippph.org/ consulted 13.03.2003
7 http://www.ippph.orq/ consulted 13.03.2003
8 http://www.ippph.org/ consulted 13.03.2003
9 http://www.ippph.org/ consulted 13.03.2003
10 http://www.ippph.org/ consulted 13.03.2003
11 http://www.ippph.org/ consulted 13.03.2003
12 http://www.ippph.org/ consulted 14.03.2003
Website: Eliminating Lymphatic Filariasis
The Lymphatic Filariasis website, “Eliminating Lymphatic Filariasis”,
(http://www.filariasis.org) presents material generally at a higher scientific level than
what is usually found on the Web. It is comprised of two parts: public and private.
The public site has five components:
•
Elimination Programme: presenting a thorough background and overview of the
Collaborative Global Programme to Eliminate Lymphatic Filariasis; this section
will be particularly useful for individuals seeking an overall understanding of the
Programme.
Disease:
detailing basic information about lymphatic filarial infection and
disease; appropriate for lectures to medical students or to update scientific
knowledge of health personnel.
•
News and Documents: containing: i) a page on which websites of related interest
are grouped and accessible; ii) a page from which relevant documents in PDF
format (a format that can be viewed and printed by most computer programmes)
can be downloaded; iii) a calendar of upcoming events.
•
Partnership: will contain information on the various partners involved in, or
supporting, the programme
•
Research and Development: will contain relevant information and be directly
linked to the website of the WHO Communicable Disease Research and
Development Programme (CRD).
To access the various pages of the website under each component click the hyperlink
(the underlined word) on the left part of any page.
The private site, the Intranet, can be accessed by clicking the hyperlink “Intranet” on
the left part of each page. It is a working tool for the various actors involved in efforts
to eliminate lymphatic filariasis. To enter the Intranet the user is required to log in and
type a password. Permission to use it is given by the “Eliminating Lymphatic
Filariasis (ELF)” website administrator. This is to ensure confidentiality in the case
of documents that are still in draft format or have restricted distribution. The Intranet
is divided into the following sections:
•
•
•
•
•
•
•
Stakeholders
Programme Review Group (PRG)
Collaboration Coordinating Commit.
Mectizan® Expert Committee
Programme Managers
Projects
Documents
WebsitesynopsisRev.doc
•
•
•
•
•
•
•
Communications
Economics
WHO Regional Offices
Collaborating Centres
Who’s Who
Website Administration
View Comments
F .
The sections Documents and Who s Who are open to everybody who has access to the
Intranet. The sections Stakeholders, PRG, CCC, Mectizan® Expert Committee,
Programme Managers, Projects, Communications, Economics, WHO Regional
Offices and Collaborating Centres are accessible to individuals who are members of
working groups or committees. The sections Website Administration and View
Comments are only available to the Eliminating Lymphatic Filariasis website
administrator in WHO.
The sections PRG, CCC, and Communications contain subsections called ‘Minutes \
Documents ‘Leave Comments on Documents \ ‘Leave a message on the Bulletin
Board’, and ‘e-mail everyone’. The sections Stakeholders, Mectizan® Expert
Committee, Programme Managers, Projects, Economics, WHO Regional Offices and
Collaborating Centres contain all these subsections except ‘Minutes'. These
subsections enable the members of working groups and committees to read the
Minutes of their meetings, access, read and print relevant documents, as well as to
leave comments on those documents. The subscribers of the above-mentioned
sections can also leave messages on a bulletin board and send e-mail to everyone in
that particular section.
WebsitesynopsisRev.doc
for all leprosy patients in the world. The Novartis
Foundation for Sustainable Development con
tinues to support country-level efforts to change
the image of leprosy, encouraging people to seek
timely treatment as well as bringing leprosy serv
ices closer to patients. The foundation, founded
25 years ago, also supports and fosters programs
in health and social development in developing
countries.
ognize and manage disabilities; patients, too, are
trained to care for themselves. Introduced first in
Gujarat state in 1989, CLCP now also operates in
Goa. In Sri Lanka, CLCP supports government
efforts to integrate leprosy care into the general
health care services. Seven thousand doctors and
1,500 pharmacists have been trained, and MDT,
patient files and leprosy information are now
available at all 1,000 health services. In Brazil the
foundation is supporting local efforts to train
health care workers and traditional healers and to
establish a free phone information service for
patients.
http ://www.who.int/lep/
For example, the foundation’s Comprehensive
Leprosy Care Project (CLCP) in India pioneered
the provision of field-based disability care servic
es. CLCP trains health care workers to better rec-
LYMPHATIC FILARIASIS (ELEPHANTIASIS)
Parasitic disease of the lymphatic system, often called elephantiasis. The disease is found in Africa,
Asia and South America where 120 million people are infected and 1 billion are at risk.
1
■y/
WrK
r r
fill
II
___
lilf
disfigurement, as a public health problem by the
year 2020. Initiated by the World Health Organi
zation and GlaxoSmithKline, the work has
evolved r|ipto a global alliance between interna
tional organizations in the public and private sec
tors, academia and non-governmental organiza
tions working in partnership with ministries of
health in tropical countries where lymphatic
filariasis is endemic. Over the next 20 years GSK
expects to donate up to 6 billion preventative
albendazole treatments to any of the 80 endemic
countries that are accepted into the program by
the WHO. One of the other medicines needed to
prevent lymphatic filariasis is Merck’s drug, Mectizan. In 1998, Merck & Co., Inc. widened the
scope of its Mectizan Donation Program to
include LF in African countries where river
blindness and LF co-exist. GSK has also already
provided grants to support partners through
coalition building, workshops and communica
tions. A study published in January 2003 reports
that nearly 80 million people have been treated
in over 34 countries in the African, American,
Eastern Mediterranean, Mekong, Indian Sub-con
tinent and Pacific regions.
http://www.filariasis.org/index.pl
Ww
I * *
Courtesy of Merck & Co.. Inc.
Global Alliance to Eliminate Lymphatic
Filariasis (GAELF)
The Global Alliance to Eliminate Lymphatic
Filariasis was created with the aim to eliminate
one of the worlds leading causes of disability and
17
Evolving Programme (as on 23rd Dec 2003)
6
13.30- 14.30:
Lunch
15th January 2004
14.30-16.30
Key Issues in Women’s Health
Moderator: ? Jaya Velankar (India)
Chair:
1) Testimonies
a) Mary Sandasi (Zimbabwe)
b) Elvire Beleoken (Cameroon)
2) Panelists
a) Women’s Access to Health Care - Nadia (Netherlands)
b) Reproductive Technologies: Mayhem on women’s bodiesSarojini(India)
c) Right to Abortion* - (??)
d) Sex Selective Abortion* - ?Kalpana (India) ?Sabu George (India)
e) Trafficking, migration & labour rights - Rina Sengupta(Bangladesh)
3) Interactions from the floor
Parallel
Workshop 8
Coordinators:
Mira Shiva/
WGNRR
15th January 2004
14.30-16.30
Parallel
Workshop 9
Coordinators:
Vandana/
15th January 2004
14.30-16.30
Parallel
Workshop 10
Coordinators:
Thelma Narayan
15th January 2004
14.30- 16.30
Parallel
Workshop 11
Coordinators:
Abhay Shukla,
Voices of the Unheard.. Children, adolescents and people with disability
Moderator:
Chair : Pam Zinkin (UK)
1) Testimonies
a) Children’s dreams through paintings - Arturo (Ecuador)
b) Children’s testimonies by Radio - Child to child (Ecuador)
c) Mama Huaca Video - Dibujos Animados ( Latin America)
d) A street child’s perspective* (India)
2) Panelists:
a) Disability and Health - Enrico Pupulin (Italy)
b) Child health - The key issues - Vandana Prasad (India)
c) Adolescent Health - Usha Nayar* (India)
3) Interactions from the floor
HIV/AIDS and the Resurgence of Communicable Diseases
Chair:
Moderator:
1) Testimonies:
a) Jennifer Atieno (Kenya)
b) Parinchay Health worker*, FRCH (India)
c) Perspectives of PLWA,CHIN (India)
2) Panelists:
a) HIV/AIDS: Confronting the Crisis - WHO Team
b) Lawyers Collective, HIV / AIDS Unit
c) CHIN network (India)
3) Interactions from the floor particularly focused on WHO proposed
initiatives
Globalisation, Poverty, Hunger and Health
Chair: Thomas Kocherry, World Forum of Fisherpeople, (India)
Moderator: Abhay Shukla (PHM India)
1) Testimonies:
a) Poverty in Germany: Gopal Dabade, BUKO
b) Tackling malnutrition, Shanti / Kalpana, Arogya lyakkam, Tamil Nadu
(India)
2) Panelists:
a) Veena Shatrugna (India)
b) Sheila Zurbrigg* (Canada)
c) P. Sainath (India)
d) Eugenio Villar (Peru)
e) PRSP and Health - Atiur Rehman / Jobair Hassan (Bangladesh)
3) Interactions from the floor
Annex 1
DISCUSSION DOCUMENT
GLOBAL ALLIANCE TO ELIMINATE LYMPHATIC FILARIASIS (GAELF)
“Evolving the partnership to meet the challenges ahead”
Background
■
The Global Alliance to Eliminate LF (GAELF) was founded at its first meeting in
Santiago de Compostela (SpajnXiTLMayiZOOa. as a free and non-restrictive forum for
discussion and co-ordination of the global effort to eliminate lymphatic filariasis (LF).
The WHO served as the secretariat of this partnership.
The aim of the GAELF is to support the Global Programme for the Elimination of
Lymphatic FjlMasis_(GEELE)Jn achieving the internationally mandated goal of
elimination of lymphatic filariasis as a public health problem. The Alliance acts
especially through creation of political and societal commitmen£and the promotion of
financial support forTh^programme through effective advocacy.
The second meeting of the GAELF was held in New Delhi, India, in May 2002, where
the medium term challenge to achieve 350 million people covered with MassDrug
Administration in 45 endemiC-GQiintdes by the end of 2005 was agreed. To help
achieve this gdal, a Task Force for Advocacy & Fundraising was set up.
An “ad-hoc representatives meeting" was held in December 2002 at Liverpool (UK) to
take forwardTheTeports of the working groups of the second GAEL^The-rrreeting
discussed the critical issues through a consultative process that involved
representation from the endemic countries, regional PRGs and other partners. A
chairman of the GAELF was appojnied., a new enlarged and collegial secretariat was
created and an additional Task Force for Communications including preparation of the
Cairo meeting, was established. Specific Terms of Reference of the Chairman, the
enlarged secretariat and the two Task Forces were drawn up and are available at
pages 41-44 of the Annual Report 2002 of the Global Programme to Eliminate
Lymphatic Filariasis. A report of the Liverpool meeting was circulated to all Alliance
members and is available on the Global Alliance website. The ad-hoc secretariat was
charged to recommend to the next meeting of the GTKELF in Ma.rch_.2Q04 in Cairo,
Egypt, an efficient working mechanism which would successfully overcome the
challenges facing the Alliance in advocacy and the mobilization of the resources
necessary to scale-up.
All the reports of the three above-mentioned meetings and the Annual Reports are
available for consultation at the web site of the GAELF: www filariasis.org.
The brief history outlined here gives a sense of the great dynamism of the global effort
to eliminate this disease during its first years. The endemic countries that initiated LF
elimination programmes have achieved spectacular progress. From 2 million people
cove_rei^MDA_in--12-countries in 2000, close to a 130 million people in 38 countries
have been reached in 2003, with very good coverage in the vast majority of the
implementation units.
3
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by MDaX the end of pooi"9 if and acl,ieve lhe poets ol covering 3S0 mill-
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coSthe pr°9ramme is Presently, competttonSTundSsts ad°eS
n°W Seem to be Practical
TH6;’'0" °f,
malana^supported by (he
and the
against fllV/AIDS,
of
V
X-
i
!
E Gtoi? S^SSSJIsls m terms ol
mam implementing agenc- nf tho^r ’ aF ° ,-es' ^S'^a31 Officeranci Hr a
h
“»’ reiislwSg2"'
appomtmen, o,
Recommendations
conducf
boards^
requiremente.Wedo "noTShZ?
phance meetings wi» take p£
" ‘0 eXeCUte the Emendations of Globai
C0Untries and 01b3r
®J™nation of LF. A Fesid<MPLtS
t0^rd the
A'!'ance_me£ikig_
----- —memance shall be appointed at each
P- by the A,Bance ,he
2
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4
the Alliance itself. This Group should be composed of two country
SSS PRGs'Zd
R6SiQf1aL13RGof the
/
donors non-governmental organizations and WHO. The Representative
up to the next Alliance meeting. A discussion forum will be created on the
ofethfs G?oupe
“ t0 enSUre C°n.tinUity and discussion b^een members
3.
9™">S >tet^guKecLs^cornm.tment and resources to
S^SSeXTlhey shoSSSaS^ftSS^
SoJ
in the Business Session as the Chair to lead the EG The EG may estobhsh
ZZ°m'nate|the membershiP °f ad hoc I ask Forces (e.g. for advocacy
fundraising, planning and communication0)
ovnort r
'
essentia, tor the ate’ttve »ork”£ EG a^t" antoX’
people will continue to be provM by Pertnens SuppM S’
'tes»
’<“o
a budget between US$J,5jQ 1.8 million for a two-year perioo wSe re eSt,™ted that
GAELF Secretariat
February 12, 2004
See next page for a Summary Table of Proposed GAELF Changes
5
*x.
CURRENT GAELF STRUCTURE
Transitional structure agreed at Liverpool 2002
\
PROPOSED CHANGES
For approval at GAELF3 in Cairo, ^rch 2004
Full Members
«>prese„,lng tey GAELF
J P'
■%
eCZ?”Xe“ELFS-"-sUS„
j
Purpose; Provide feedback on member
recommendations and priorities for the
Alliance to work on over the next two years
5-person Secretariat
•
--------------- -----
i
J
st:“s2z’Krraskfov':s
Meet 2 or more times per year
IPCPS onSspecific^askfeOUIfS 38 necsssarV,o
I
Planning e^1
L
I
I communicate and,planning
i Two Lasl< Fo.ccs
5
1. Advocac;/ * Fg.
undra-si.ig
2. Communication
D. s ba n d bot h TUT^rfTs k Fm-.~eTs-----------s at the Cairo-]
I ^ies'm>’Se “OrC""a"0" «
I
!
I
CK
of |
sup^Tru^e
provided by a
GAELF Partner institution
I on C?T'^8 UP WH0 res^ces to
concentrate
j
G'obr',/ Programme activities
I Cha'rmanrGteteT7i!i^--- ------ ------I Appoint
nee
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RF_DIS_7_B_SUDHA.pdf
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