TOWARDS ELIMINATING LYMPHATIC FILARIASIS

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Dr Chavada V K, Assistant Professor, Dept of Community Medicine, Saveetha Medical College, Chennai, India Recent years have seen dramatic changes in our understanding and approaches to the control of lymphatic filariasis. No longer must we lament yesteryear’s cumbersome, inadequate means for diagnosing these infections, the inadequate tools for treating them, an insufficient understanding of how to alleviate the associated suffering and disfigurement, an inadequate strategy for controlling or stopping the spread of infection in endemic areas, an insufficient level of knowledge of the parasite and the principles of pathogenesis necessary for further future discoveries, or an insufficient appreciation by the world community of the burden that lymphatic filariasis exacts on affected individuals and Communities. Certainly, our understanding today is far from perfect and much remains to be defined. However, it is now quite clear that advances during the past decade have so transformed our understanding and ability to deal with lymphatic filariasis that a new sense of optimism is sweeping through the health community focused on prospects not only for successfully controlling this infection, but even for eliminating it. Indeed, after an International Task Force for Disease Eradication identified lymphatic filariasis as one of only six diseases it considered eradicable or potentially eradicable with the tools currently available. Technical Considerations The most important of the “principal indicators of eradicability” are really more technical than biological. Of greatest importance is that effective tools must be available, first to interrupt transmission and then to monitor the effects of such intervention with an accuracy sufficient to detect levels of persistent or re-emergent infections that could result in resumption of transmission.. For lymphatic filariasis most of these ‘technical’ considerations also favour success of elimination efforts, as indicated below. Available intervention (treatment) tools: excellent To interrupt transmission of lymphatic filariasis it is necessary either to eliminate (or reduce to very low levels) the microfilaraemia in humans or to control the mosquito vector effectively. Since efforts at vector control have proven expensive and difficult to sustain in the past, and since drugs for very effective control of microfilaraemia are now available, the focus of efforts to interrupt transmission has now shifted to treating infections in humans. Two dramatic advances have recently come about in our understanding of how to use available microfilaricidal drugs most effectively. The first is that single-dose, onceyearly, treatment is extremely effective in decreasing microfilaraemia. Indeed, a single dose of diethylcarbamazine (DEC), essentially the only drug used for treating lymphatic filariasis since its introduction in 1947, is now recognized to give long-term reductionsin microfilaraemia levels (~90% reduction of pre-treatment levels even one year after treatment) that are equivalent to those induced by the’ standard’ 12 or 14-day course of DEC recommended by WHO for the past 30 years. Importantly, it was also discovered that ivermectin, the new microfilaricide whose availability has completely transformed

the drugs used for these programmes are themselves ‘inexpensive’ (US $0. while either drug alone can decrease microfilaraemia by ~90% even one year after administration. once-yearly. Thus. once-yearly treatment (Fiji. personnel and infrastructure necessary for its delivery and for the assessment of its effects. . indicates that utilisation of such salt for between 4 months and 4 years leads to dramatic reduction in microfilaraemia and subsequent interruption of transmission.01–0. Indeed. Samoa) is that the additional costs to health ministries have ranged between US $0.08 per person per year even for these ‘standalone’filariasis elimination programmes. the two drugs given together effect reductions of 98–99%still one year after they are administered. the actual experience in countries already having an infrastructure able to ‘sensitize’ the population and deliver one-dose. the development of assays to detect circulating antigen released by living adult parasites and remaining at stable levels in the circulation both days and night has opened up many avenues related to surveillance and monitoring that were almost completely closed before. First. Subsequent studies have shown that this combination-effect is not limited just too DEC-plus ivermectin but is also found for ivermectin-plusalbendazole In addition to these new once-yearly treatment tools there is an alternative public health strategy for reducing microfilaraemia that utilized-fortified salt as a replacement for normal table/cooking salt.The second major conceptual advance in our understanding of how-to reduce microfilaraemia came from the discovery that single doses of DEC and ivermectin when administered together were very much more effective than either drug alone. but a number of important but a number of important considerations point toward this conclusion. not just the costs of the treatment being delivered but all the training. especially. it may seem cavalier to term the costs of lymphatic filariasis elimination programmes as ‘inexpensive’. one in an ELISA format (especially suitable for laboratory analysis of samples collected in the field and the other in a card-test format (suitable for evaluation either in the laboratory or in the field.02 per patient per year for DEC.05 and 0. in China and India. There are two monoclonal antibody-based assays for detecting. single-dose treatment with either DEC or ivermectin became a feasible control strategy to reduce microfilaraemia. when given as a single dose in lymphatic filariasis effectively reduces microfilaraemiaby ~90% even one year after treatment. Available monitoring (diagnostic) tools: excellent It had never been an easy task to study lymphatic filariasis because the accurate diagnosis of active infection could be made essentially only by detecting microfilaria in the blood of infected individuals. Inc. Papua New Guinea. and just as safely as DEC . Circulating filarial antigen (CFA) now available.the treatment and control of onchocerciasis . and in most parts of the world the nocturnal periodicity of the parasite meant that such blood examinations had to be carried out between 10:00 PMand 02:00 AM. of course. Costs of control/elimination programmes: ‘inexpensive’ and easily ‘packaged’ True costs of control programmes comprise.Thus.. Thus. Thus. Large-scale experience. and equally safe . and zero cost for both albendazole [which is donated by its manufacturer SmithKline Beecham] and ivermectin [donated by its manufacturer Merck & Co. a time period evoking little enthusiasm from either the affected population or the responsible health worker. India.]).

the suffering of affected individuals must be alleviated. morbidity from the infection must be controlled.smartdoc. the spread of infection must be stopped.in/node/1478 . http://www.Defining the Strategy to Eliminate Lymphatic Filariasis as a Public Health Problem There are two major thrusts to the strategy for eliminating lymphatic filariasis. Second. First.. i. transmission must be interrupted. i.e..e.