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Leda Mercado-Hernandez, M.D., M.P.H.* and Virgilio M. Go, M.D., M.H.A.**
(*Medical Specialist III, Program Coordinator for the Filariasis Control Program, Project Development and Research Division, Communicable Disease Control Service, Department of Health and **Medical Specialist IV, Provincial Coordinator, Provincial Health Office of Marinduque) ABSTRACT A total of 1,349 night blood smears were examined from inhabitants coming from the five villages of Boac, Marinduque. Results of these smears gave a microfilaria rate of 13.6%. This blood survey out that microfilaria rates were higher in the interior villages where there are banana, pakil, pandan plants and flowing streams. In the majority of the five villages under study, higher microfilaria rates were found among males than among females. Higher microfilaria rates were also found among older age groups than among the younger age groups. However, there were also cases among very young children (5-9 years old). Examinations of the Giemsa stained blood smears revealed the presence of microfilariae, which conformed, with the characteristics of Wuchereria bancrofti. This study had also shown the existence of chronic stages of filariasis among the subjects, which pointed out, that the disease might have been existing in these areas for quite a long time. (Phil J Microbiol Infect Dis 1997; 26(4):147-152) Keywords: Filariasis, epidemiology, prevalence, Wuchereria bancrofti
INTRODUCTION Filariasis is one of the major parasitic infections of mankind, which is widely spread throughout the tropics and subtropics infecting an estimated 250 million people (WHO, 1974). It remains to be an important public health problem in the Philippines since it was first discovered by a foreign researcher some 85 years ago among the indigenous population. The disease is spotty in distribution and endemic in 42 out of the 75 provinces (data from the 1960 national prevalence survey) where the environment favors the propagation of specific insect vectors of the parasite, however, only 18 provinces have control programs to date. The ten highest affected provinces were as follows, Sulu, Albay, Sorsogon, Camarines Sur, Camarines Norte, Surigao del Norte, Surigao del Sur, Samar, Catanduanes and Masbate. In the Philippines, the disease is caused by Wuchereria bancrofti, which is essentially rural in its distribution and common in areas where there are extensive plantations of abaca, banana, pandanus, gabi and other axilled plants. Another filarial parasite found in the country is the Brugia malayi causing Brugian filariasis and is seen in Palawan, some areas in Leyte and Davao. The primary vector for Bancroftian filariasis is the Aedes poecilius while the Anopheles flavirostris and Culex quinquefasciatus are incriminated as the secondary vectors. The Mansonia bonnea and Mansonia uniformis are the vectors for the Brugian filariasis. Marinduque has never been considered endemic for the disease. However, in 1989, there was a suspicion that filariasis may exist in the province due to observation of unusual occurrence of orchids and scrotal enlargement in the three barangays of Boac, Marinduque. Local health authorities attempted to document the existence of the disease through a limited survey. This study was undertaken in an attempt to shed light on the existence of filariasis in a previously non-endemic area. This paper will also include determination of the infecting species, microfilaria rate, intensity of infection, number of persons with obstructive disease and will touch on the education and treatment.
MATERIALS AND METHODS Study Area Marinduque is an island province located south of Manila between Bondoc Peninsula at the southeastern portion of Luzon and Mindoro Island. It is bounded in the north by Tayabas Bay in the northeast by Mompong Pass, in the southeast by Tayabas Strait and south by Sibuyan Sea; it has a land area of 959.2 sq. km. This island province is divided into six (6) municipalities with Boac as its capital, Sta. Cruz, Gasan, Mogpog, Torrijos and Buenavista. Each municipality is subdivided into 218 villages. The climate of Marinduque can be categorized as Type IV according to the classification of PAGASA. The type IV climate has a rainfall more or less evenly distributed throughout the year with no clear boundary between dry and wet seasons. Most of the hilly and mountainous land is located in central part of the interior area and is covered with forest dominated by dipterocrop species. The study was undertaken in five villages in the Municipality of Boac. These villages are located in the hilly/mountainous areas in the interior part of Boac, which are covered with trees, fruits and crops such as banana, pakil, pineapple, coffee, corn, root crops and vegetables. Barangay Bantay is the nearest village while Barangay Bayufi is the farthest village from the main town of Boac, Marinduque. Jeepneys are always available from the main town to some parts of Barangay Bantay even during rainy days. In the four other villages, overland travel is limited during rainy days due to the mountainous terrain. Only horses and a vehicle, which they call “weapons carrier,” can pass through. Residents of these villages earn their living by selling palay, corn, coconut and banana while some residents especially those living in the mountain side are engaged in "kaingin." Most of dwellings in Barangay Bantay are located near the road, which are made of wood, bamboo while few are made of concrete materials. Majority of the houses from Barangays Binunga, Bayuti, Boi and Canat are made of bamboo with roof of thatched palm leaves with very wide windows. Almost all of the houses are not screened and very few people use mosquito nets. There is no electricity on the four villages except in some areas in Barangay Bantay, which are supplied by a private electric company. There is also no waste disposal system and very few households have toilets especially in Barangays Bayuti, Boi and Canat. Methodology Surveys were conducted in the three villages namely Barangays Boi, Bayuti and Canat due to preliminary survey done by the local health workers revealing the probable existence of the filariasis. Two adjacent villages, namely Barangays Binunga and Bantay, were also included in the study, because they have the same environment as the three villages mentioned above. A systemic random sampling was employed using households as the sampling units. A spot map was also used in getting the samples. The proposed project was explained to the Barangay Captain, RHU staff and Barangay Health Workers. As soon as approval was obtained, the households that were selected in each village were given notice by the Barangay Health Workers and by the Barangay officials, In each village, people were asked to gather at the barangay hall at 6:00 o' clock in the evening for registration. Lectures on the medical importance of the disease, its life cycle and symptomatology were presented. Clinical histories and physical examinations were done on all subjects. Blood smears were taken from the sampled subjects from age 2 and above starting from 8:00 pm to 2:00 am. Specimens of 20 ul were taken from finger punctures from each subject. Blood smears from villagers who were present but not included in the samples were also taken; however results were not included in the study. Fresh blood smears were examined for
microfilaria in the microscope and all positive slides were shown to the villagers. The slides were also stained with Giemsa and microfilariae were also counted per slide. Those individuals found to be positive for microfilaria were asked to return the next morning for treatment. RESULTS The study areas consisting of five villages were covered thoroughly in the blood survey over period of four weeks. A total of 1,349 subjects were included in the study. Five hundred fifty eight or 41.4% were from Barangay Bantay, 261 (19.3%) from Barangay Binunga, 226 (16.8%) from Barangay Canat, 222 (16.5%) from Barangay Boi, and 82 (6.1%) from Barangay Bayuti (Table 1). Of the total number of subjects, 645 (47.8%) were female while 704 (52.2%) were male (Table 2). Distribution and Prevalence The distribution of filariasis by villages is shown in Table 1 and Figure 1. A total of 184 specimens were positive out of 1,349 fresh blood smears stained and examined in all five villages. It was identified that the infecting parasite responsible for the disease in all the five villages was that of the Wuchereria bancrofti type. The microfilaria rates ranged from 7.5% to 25.6%. The lowest microfilaria rate was found in Barangay Bantay while the highest rate was found in Barangay Bayuti.
Table 1. Prevalence of microfilaria by barangay, Marinduque, 1992 Municipality Bantay Bayuti Binunga Bio Canat Total Number Examined 558 82 261 222 226 1349 % 41.4 6.1 19.3 16.5 16.8 100.0 Number Positive 42 21 41 43 37 184 % 22.8 11.4 22.3 23.4 20.1 100.0 % Positive 7.5 25.6 15.7 19.4 16.4 13.6
Figure 1. Prevalence of microfilaria by barangay and sex, Marinduque, Philippines, 1992
Barangay Bayuti Of the 82 subjects (48 males and 34 females) in this village, 21 were found to be positive for microfilaria or a microfilaria rate of 25.6%. Out of the 48 males, 15 were positive (31.3%) and
of the 34 females, six (17.6%) were positive. This village had the highest prevalence of microfilaria from among the five villages. Barangay Boi A total of 222 person (136 males and 86 females) were examined covering almost half of the whole population of the village. Of these, 43 or 19.4% subjects were positive for microfilaria. The microfilaria rate for males was 22.1% (30/136) while for females, it was 15.1% (13/86). This barangay ranked second among the villages with high infection rate. Barangay Canat Thirty four percent (123 males and 103 females) of the total population of this village had been examined and 37 persons were found positive for microfilaria. Of the 123 males, 20 (16.3%) were positive while 17 (16.5%) females out of 103 were positive. This village ranked the third highest in prevalence among the villages being studied. Barangay Binunga A total of 261 (136 males and 125 females) persons were examined for the presence of microfilaria and 41 subjects were positive. Among the male subjects, the prevalence rate was 21.3% (29/136) while in females it was 9.6% (12/125). This place has a microfilaria rate of 15.7%, which makes it fourth highest among the villages Barangay Bantay This village yielded the lowest microfilaria rate of 7.5%, A total of 42 out of 558 persons examined were found to be positive for microfilaria. Out of the 261 male subjects examined, the microfilaria rate was 10.7%. Among the 297 female subjects, the microfilaria rate was 4.7%.
Table 2. Prevalence of Microfilaria by age and sex all barangays, Boac, Marinduque, 1992 Males
Age Group No. exam, No. pos. % pos. No. exam.
No. pos. % pos. No. exam.
No. pos. % pos.
0-9 175 0 0.0 170 10-19 203 29 14.3 157 20-29 95 21 22.1 81 30-39 95 29 30.5 92 40-49 59 17 28.8 52 50-59 39 16 41.0 48 60-69 24 6 25.0 23 70-79 12 3 25.0 19 80-89 2 1 50.0 2 90 & over 0 0 0.0 1 All ages 704 122 17.3 645 Source: Prevalence survey conducted from May to June, 1992
5 17 7 11 8 6 5 3 0 0 62
2.9 10.8 8.6 12.0 15.4 12.5 21.7 15.8 0.0 0.0 9.6
345 360 176 187 111 87 47 31 4 1 1349
5 46 28 40 25 22 11 6 1 0 184
1.4 12.8 15.9 21.4 22.5 25.3 23.4 19.4 25.0 0.0 13.6
Age and Sex Distribution Except in Barangay Canat, males have higher microfilaria rate than females, 17.3% compared to 13.6%. Furthermore, it was observed that the prevalence of microfilaria generally increases as age advances and highest among the 50-54 age group. The youngest case was a six
year old female residing in Barangay Boi and the oldest case was an 80 year old male from Barangay Bantay. Intensity of Microfilaremia The intensity of microfilaremia in each of the five villages was studied. The 122 males positive for microfilaria had counts ranging from 1/20 ul blood to 319/20 ul blood while the 62 females positive for microfilaria had counts ranging from 1/20 ul to 128/20 ul. The highest microfilaria count of 319/20 ul was found in an 18 year old male from Barangay Boi while among females the highest microfilarial count of 128/20 ul was found in Barangay Binunga. It appears that the highest microfilarial counts were confined to the interior villages.
Table 3. Average microfilaria count by age and sex, 5 barangays, Boac, Marinduque, 1992
Source Prevalence survey conducted from May to June, 1992
Table 3 shows the average microfilaria count by age group and sex in the five villages. Barangay Boi has the highest median microfilarial count of 54 for both sexes and Barangay Canat had the lowest median microfilarial count of 32 in both sexes. The highest average microfilarial count of 173 belonging to the 70 years and over age group was found in Barangay Bantay. Among the females, the highest microfilarial count of 120/20 ul was also found in Barangay Bantay among the 70 years and over age group. The highest overall average microfilarial count was among males belonging to the 70 years and over, whereas among the females the highest average microfilarial count was 66 belonging to the 30-34 age group. For the total average microfilarial count, the males had 45 compared to 30 for females. Clinical Studies Physical examinations and clinical histories were conducted in all the patients. Seventy three percent of the 184 microfilaremic subjects had manifested the acute stage of filariasis like leg pain (31%), chills/fever (8.7%) and lymphadenopathy (63%). Twenty-six subjects (14%) manifested the chronic stage of filariasis (hydrocoele/elephantiasis). Hydrocoele was found in 25 males whose ages ranged from 16 to 80 years while one female patient was found to have elephantiasis of the breast. The rest of the positive subjects had no histories or could not remember if they had experienced any of the clinical manifestations of the disease. It is
interesting to note that among those examined but were negative for microfilariae, two had obstructive symptoms (Table 4). DISCUSSION The results from the survey showed that filariasis is a public health problem in Marinduque. Usually the infection is never considered and diagnosed in other parts of the country that have been labeled as non-endemic just like in Marinduque. The infection therefore is able to spread unrecognized until clinical manifestations of later stages of the disease appear. Vigilance, skill and a high index of suspicion among the health workers are needed to discover the disease in such cases. Field health workers in the province should be commended for having discovered the first cases of filariasis in the area.
Table 4. Clinical manifestations among subjects positive for microfilaria by barangay, Boac, Marinduque, 1992 Number of Patients with Clinical Manifestations No. Leg Chills & Hydrocoele/ Barangay Positive Pains % Fever % LAD % Elephantiasis Bantay 42 14 33.3 2 4.8 31 73.8 10 Bayuti 21 10 47.6 1 4.8 15 71.4 2 Binunga 41 15 36.6 2 9.8 33 80.5 10 Boi 43 10 23.3 5 11.6 17 39.5 1 Canat 37 8 21.6 4 10.8 20 54.1 3 Total 184 57 31.0 16 8.7 116 63.0 26 Source: Prevalence survey conducted from May to June, 1992
% 23.8 9.5 24.4 2.3 8.1 14.1
Examining the slides with fresh blood was a lot easier compared to the stained specimen. Although it was time-consuming, it gave rise to a high percentage of participation among the residents in these villages because they were able to see the live microfilaria. Upon examining the stained specimen, Wuchereria bancrofti was found to be the infecting species causing filariasis in these areas. Although vector determination was not within the scope of the study, there are two possible vectors responsible for the disease namely, Aedes poecilius and Anopheles flavirostris. These two are considered mainly because of the presence of many axilled plants and slowflowing streams and the fact that malaria is one of the major causes of morbidity in Marinduque. The blood film surveys documented that prevalence rates and microfilaria rates are higher in the more interior villages. These may be due to the fact that in the interior villages, there were many axilled plants like banana, pandanus, gabi, pakil and flowing streams. As shown in the study, the highest microfilaria and prevalence rates were found in Barangay Bayuti which is the most interior and Barangay Bantay has the lowest which is the farthest village or the nearest to the main town of Boac. In Barangays Bantay, Bayuti, Binunga and Boi, males significantly showed higher microfilaria rates compared to females. It would be reasonable to attribute that the factor of occupation plays a contributory role. Majority of men the work in the fields that are in close proximity to the breeding sites of mosquitoes. Only in Barangay Canat was it shown that the females had a slightly higher prevalence rate of microfilaria. Review of the records of the positive female subjects both young and old in this village showed that most were either relatives living in the same household or one of their relatives in the family was also positive for the parasite. These point to the domestic environment as one possibly important site of transmission. Microfilaria rates were higher among adults than in children. This can be attributed to the cumulative process of the infection (Filariasis Survey in Jolo, Sulu, Vol. 3, Ser. 2, No. 2, OctDec, 1966.) The occurrence of microfilaremic cases among the very young children (5-9 yr.) could be ascribed to the biting habits of the mosquito vectors or that transmission is going on
within the house. It is also interesting to note that there were quite a number of microfilaremic cases at 10-14 age group in all the five villages. One possible explanation that could be ascribed was that children were exposed to the field earlier due to economic reasons. With this study, it was shown that there are subjects with chronic disease, which means that filariasis had existed in Marinduque for a long time already. That there were cases who have obstructive disease and at the same time are still positive for microfilaria means that there is reinfection or there is active transmission. In this kind of setting it is anticipated that there would be a relatively rapid increase in the transmission of the infection. CONCLUSION In conclusion, this study has proven the existence of filariasis in Marinduque and that the species responsible for the disease is the Wuchereria bancrofti type. RECOMMENDATION As this study shows, the reported filariasis in our country is not an accurate reflection of the disease because of underreporting, Therefore, control of the disease has been accorded much lower priority by health policy makers compared to control programs designed for diseases such as malaria, diarrhea and pneumonia. Consequently, the funds available for control of the disease have been limited. Health workers interested in this disease believe that there are more endemic areas to be discovered. As a first step to control the disease, the health education component of the program should be strengthened to make the public aware of filariasis. In view of this, we have the following recommendations: 1. Given the current state of knowledge in the area, an entomological survey must be done to know the vectors responsible for the disease in the area so that appropriate mosquito-control measures can be instituted. 2. Based on the results that men were found to be the more affected by the disease, health information on barrier protection like wearing of shirts with long sleeves and long pants must be disseminated. 3. Follow-up of cases after treatment and a repeat blood examination must be done. 4. Survey other municipalities in the province. 5. An intensive health education campaign must be conducted in the area. 6. The introduction and widespread use of bed nets should be done to decrease nocturnal transmission of filariasis
ACKNOWLEDGMENTS The study was made possible through the support of the Communicable Disease Control Service headed by Dr. Jesus Abella in collaboration with the Bureau of Research and Laboratory headed by Dr. Marietta Baccay and the Provincial Health Office headed by Dr. Efren Labay. The authors would like to acknowledge the technical assistance provided by Dr. Francisco Valeza and Dr. Benjamin Cabrera. The authors wish to express their appreciation to the research team, from BRL, Felix Avelino Jr. (Med. Tech.), from the Municipal Health Officer of Marinduque, Dr. Nimrod Villanueva, Eng. Nicolas Encluna, Anna Marie Hidalgo (HEPO), Digna Handusay (HEPO), Maximiano Mingi (PHN), Flora Malinao (RHM), Gloria Montemar (RHM), Amelia Magdurulan (Med. Tech.), Iluminado Ranosa (RSI), Tomas Hernandez (Malaria Canvasser), from CDCS, Mena Arroyo (Clerk) and two volunteers, Grace Osmilio and Helen Manrique. Special thanks to the statistician Herdie Hizon, for helping them in the consolidation and analysis of the data. The research team is also grateful for the help extended to them by the Barangay Health Workers and the Barangay Hall Officials.
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