The PacELF programme: will mass drug administration be enough?

The Pacific Programme to Eliminate Lymphatic Filariasis is a regional, mass drug administration-based campaign in 22 countries and territories with the aim of eliminating filariasis transmission and alleviating the suffering caused by Wuchereria bancrofti. The challenges to filariasis elimination campaigns based on mass drug-administration alone are reviewed in this article. These challenges together with the previous successes of mosquito control campaigns in eliminating filariasis from regions in the Pacific argue for inclusion of entomology components in the control of filariasis and the monitoring of filariasis elimination programs.     

Management of filariasis using prediction rules derived from data mining

The present paper demonstrates the application of CART (classification and regression trees) to control a mosquito vector (Culex quinquefasciatus) for bancroftian filariasis in India. The database on filariasis and a commercially available software CART (Salford systems Inc. USA) were used in this study. Baseline entomological data related to bancroftian filariasis was utilized for deriving prediction rules. The data was categorized into three different aspects, namely (1) mosquito abundance, (2) meteorological and (3) socio-economic details. This data was taken from a database developed for a project entitled "Database management system for the control of bancroftian filariasis" sponsored by Ministry of Communication and Information Technology (MC&IT), Government of India, New Delhi. Predictor variables (maximum temperature, minimum temperature, rain fall, relative humidity, wind speed, house type) were ranked by CART according to their influence on the target variable (month). The approach is useful for forecasting vector (mosquito) densities in forthcoming seasons.     

Data base management system for lymphatic filariasis--a neglected tropical disease

Background

Researchers working in the area of Public Health are being confronted with large volumes of data on various aspects of entomology and epidemiology. To obtain the relevant information out of these data requires particular database management system. In this paper, we have described about the usages of our developed database on lymphatic filariasis.

Methods

This database application is developed using Model View Controller (MVC) architecture, with MySQL as database and a web based interface. We have collected and incorporated the data on filariasis in the database from Karimnagar, Chittoor, East and West Godavari districts of Andhra Pradesh, India.

Conclusion

The importance of this database is to store the collected data, retrieve the information and produce various combinational reports on filarial aspects which in turn will help the public health officials to understand the burden of disease in a particular locality. This information is likely to have an imperative role on decision making for effective control of filarial disease and integrated vector management operations.     

Comparison of Three Quality of Life Instruments in Lymphatic Filariasis: DLQI,WHODAS 2.0, and LFSQQ

Background

The Global Program to Eliminate Lymphatic Filariasis aims to interrupt transmission of lymphatic filariasis and manage morbidity in people currently living with the disease. A component of morbidity management is improving health-related quality of life (HRQoL) in patients. Measurement of HRQoL in current management programs is varied because of the lack of a standard HRQoL tool for use in the lymphatic filariasis population.

Methodology/Principal Findings

In this study, the psychometric properties of three health status measures were compared when used in a group of lymphatic filariasis patients and healthy controls. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), the Dermatology Life Quality Index (DLQI), and the Lymphatic Filariasis Quality of Life Questionnaire (LFSQQ) were administered to 36 stage II and stage III lymphatic filariasis subjects and 36 age and sex matched controls in Kerala, India. All three tools yielded missing value rates lower than 10%, suggesting high feasibility. Highest internal consistency was seen in the LFSQQ (α = 0.97). Discriminant validity analysis demonstrated that HRQoL was significantly lower in the LF group than in controls for the WHODAS 2.0, DLQI, and LFSQQ, but total HRQoL scores did not differ between stage II and stage III lymphedema subjects. The LFSQQ total score correlated most strongly with the WHODAS 2.0 (r = 0.91, p<0.001) and DLQI (r = 0.81, p<0.001).

Conclusions/Significance

The WHODAS 2.0, DLQI, and LFSQQ demonstrate acceptable feasibility, internal consistency, discriminate validity, and construct validity. Based on our psychometric analyses, the LFSQQ performs the best and is recommended for use in the lymphatic filariasis population.     

Successful Control of Lymphatic Filariasis in the Republic of Korea

A successful experience of lymphatic filariasis control in the Republic of Korea is briefly reviewed. Filariasis in the Republic of Korea was exclusively caused by infection with Brugia malayi. Over the past several decades from the 1950s to 2006, many investigators exerted their efforts to detection, treatment, and follow-up of filariasis patients in endemic areas, and to control filariasis. Mass, combined with selective, treatments with diethylcarbamazine to microfilaria positive persons had been made them free from microfilaremia and contributed to significant decrease of the microfilarial density in previously endemic areas. Significant decrease of microfilaria positive cases in an area influenced eventually to the endemicity of filariasis in the relevant locality. Together with remarkable economic growth followed by improvement of environmental and personal hygiene and living standards, the factors stated above have contributed to blocking the transmission cycle of B. malayi and led to disappearance of this mosquito-borne ancient disease in the Republic of Korea.     

Combining Attractants and Larvicides in Biodegradable Matrices for Sustainable Mosquito Vector Control

BackgroundThere is a global need for cost-effective and environmentally friendly tools for control of mosquitoes and mosquito-borne diseases. One potential way to achieve this is to combine already available tools to gain synergistic effects to reduce vector mosquito populations. Another possible way to improve mosquito control is to extend the active period of a given control agent, enabling less frequent applications and consequently, more efficient and longer lasting vector population suppression.Conclusions/significanceCollectively, our data demonstrate the potential for the effective use of wax emulsions as slow release matrices for mosquito attractants and control agents. The results indicate that the combination of an oviposition attractant with larvicides could synergize the control of mosquito disease vectors, specifically Cx. quinquefasciatus, a nuisance pest and circumtropical vector of lymphatic filariasis and encephalitis.     

Multiple Resistances and Complex Mechanisms of Anopheles sinensis Mosquito: A Major Obstacle to Mosquito-Borne Diseases Control and Elimination in China

Malaria, dengue fever, and filariasis are three of the most common mosquito-borne diseases worldwide. Malaria and lymphatic filariasis can occur as concomitant human infections while also sharing common mosquito vectors. The overall prevalence and health significance of malaria and filariasis have made them top priorities for global elimination and control programmes. Pyrethroid resistance in anopheline mosquito vectors represents a highly significant problem to malaria control worldwide. Several methods have been proposed to mitigate insecticide resistance, including rotational use of insecticides with different modes of action. Anopheles sinensis, an important malaria and filariasis vector in Southeast Asia, represents an interesting mosquito species for examining the consequences of long-term insecticide rotation use on resistance. We examined insecticide resistance in two An. Sinensis populations from central and southern China against pyrethroids, organochlorines, organophosphates, and carbamates, which are the major classes of insecticides recommended for indoor residual spray. We found that the mosquito populations were highly resistant to the four classes of insecticides. High frequency of kdr mutation was revealed in the central population, whereas no kdr mutation was detected in the southern population. The frequency of G119S mutation in the ace-1 gene was moderate in both populations. The classification and regression trees (CART) statistical analysis found that metabolic detoxification was the most important resistance mechanism, whereas target site insensitivity of L1014 kdr mutation played a less important role. Our results indicate that metabolic detoxification was the dominant mechanism of resistance compared to target site insensitivity, and suggests that long-term rotational use of various insecticides has led An. sinensis to evolve a high insecticide resistance. This study highlights the complex network of mechanisms conferring multiple resistances to chemical insecticides in mosquito vectors and it has important implication for designing and implementing vector resistance management strategies.     

Lymphatic filariasis elimination in the Pacific: PacELF replicating Japanese success

Japan successfully eliminated lymphatic filariasis and other parasitic diseases through community-driven, integrated nationwide campaigns undertaken during the 1960s and 1970s. The campaigns also created a cadre of experienced clinicians, scientists and public health workers with excellent technical and operational knowledge and a positive attitude towards filariasis elimination. These factors, and the humanitarian desire to improve health in neighbouring nations, influenced Japan to support filariasis control efforts overseas, starting in the 1970s and continuing through to the inception of the Pacific Programme to Eliminate Lymphatic Filariasis (PacELF) in 1999. The unique community-driven, self-help approach of Japan to disease control and health improvement profoundly influenced the activities of PacELF. PacELF is demonstrating that the successful national disease-elimination model in Japan can be extended to the regional level.     

Delimitation of lymphatic filariasis transmission risk areas: a geo-environmental approach

Background

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) depends upon Mass Drug Administration (MDA) to interrupt transmission. Therefore, delimitation of transmission risk areas is an important step, and hence we attempted to define a geo-environmental risk model (GERM) for determining the areas of potential transmission of lymphatic filariasis.

Methods

A range of geo-environmental variables has been selected, and customized on GIS platform to develop GERM for identifying the areas of filariasis transmission in terms of "risk" and "non-risk". The model was validated through a 'ground truth study' following standard procedure using GIS tools for sampling and Immuno-chromotographic Test (ICT) for screening the individuals.

Results

A map for filariasis transmission was created and stratified into different spatial entities, "risk' and "non-risk", depending on Filariasis Transmission Risk Index (FTRI). The model estimation corroborated well with the ground (observed) data.

Conclusion

The geo-environmental risk model developed on GIS platform is useful for spatial delimitation purpose on a macro scale.     

A possible case of spontaneous Loa loa encephalopathy associated with a glomerulopathy

Background

There is a danger that mass drug administration campaigns may fail to maintain adequate treatment coverage to achieve lymphatic filariasis elimination. Hence, additional measures to suppress transmission might be needed to ensure the success of the Global Program for the Elimination of Lymphatic Filariasis.

Discussion

Vector control successfully eliminated lymphatic filariasis when implemented alone or with mass drug administration. Challenges to lymphatic filariasis elimination include uncertainty of the exact level and duration of microfilarial suppression required for elimination, the mobility of infected individuals, consistent non-participation of some infected individuals with mass drug administration, the possible development of anti-filarial drug resistance and treatment strategies in areas co-endemic with loasis. Integration of vector control with mass drug administration can address some of these challenges. The potential benefits of vector control would include: (1) the ability to suppress filariasis transmission without the need to identify all individual 'foci of infection'; (2) minimizing the risk of reestablishment of transmission from imported microfilaria positive individuals; and (3) decreasing the risk of dengue or malaria transmission where, respectively, Aedes or Anopheles are lymphatic filariasis vectors.

Summary

With adequate sustained treatment coverage, mass drug administration should meet the criteria for elimination of lymphatic filariasis. However, it may be difficult to sustain sufficiently high mass drug administration coverage to achieve lymphatic filariasis elimination in some areas, particularly, where Aedes species are the vectors. Since vector control was effective in controlling and even eliminating lymphatic filariasis transmission, integration of vector control with mass drug administration will ensure the sustainability of transmission suppression and thereby better ensure the success of national filariasis elimination programs. Although trials of some vector control interventions are needed, proven vector control strategies are ready for immediate integration with mass drug administration for many important vectors. Vector control is the only presently available additional lymphatic filariasis control measure with the potential for immediate implementation.     

Chicory (Cichorium intybus) and wormwood (Artemisia absinthium) extracts exhibit strong larvicidal activity against mosquito vectors of malaria,dengue fever,and filariasis

Vector-borne diseases transmitted by mosquitoes cause globally important diseases such as malaria, dengue fever, and filariasis. The incidence of these diseases can be reduced through mosquito control programs but these control programs currently rely on synthetic insecticides that can impact the environment, and has selected widespread mosquito resistance. Environment friendly and biodegradable natural insecticides discovered in plants offer an alternative approach to mosquito control. Here, we investigated extracts from root or aerial parts of Chicory (Cichorium intybus) and wormwood (Artemisia absinthium) against the early 4th instar larvae of Anopheles stephensi (malaria vector), Aedes aegypti (dengue fever vector), and Culex quinquefasciatus (filariasis vector). The root and aerial parts extracts of A. absinthium and C. intybus at 200, 100, 50, 25 and 12.5?ppm caused significant mortality of the tested mosquito species. Root extracts exhibited higher larvicidal activity that aerial part extracts. The highest larvicidal activity was recorded in methanol extract of roots of C. intybus with LC50?=?66.16, 18.88 and LC¬90?=?197.56, 107.16?ppm for An. stephensi; LC50?=?78.51, 40.15 and LC90?=?277.31, 231.28?ppm for Ae. aegypti and LC50?=?103.99, 64.56 and LC¬90?=?314.04, 247.54?ppm for Cx. quinquefasciatus. These results reveal potent mosquito larvicidal activity against vectors of malaria, dengue fever, and filariasis is present in extracts of chicory and wormwood.     

Transmission dynamics of lymphatic filariasis: density-dependence in the uptake of Wuchereria bancrofti microfilariae by vector mosquitoes

Gaining a better understanding of parasite infection dynamics in the vector mosquito (Diptera: Culicidae) population is central to improving knowledge regarding the transmission, persistence and hence control of lymphatic filariasis. Here, we use data on mosquito feeding experiments collated from the published literature to examine the available evidence regarding the functional form of the first component of this parasite-vector relationship for Wuchereria bancrofti (Filarioidea: Onchocercidae) causing Bancroftian filariasis, i.e. the rate of microfilariae (mf) uptake from the blood of infected humans by the feeding mosquito vector. Using a simple logarithmic regression model for describing the observed relationships between the mean numbers of mf ingested per mosquito and parasite load in humans in each study, and a linear mixed-effects meta-analytical framework for synthesizing the observed regressions across studies, we show here for the first time clear evidence for the existence of density-dependence in this process for all the three major filariasis transmitting mosquito vectors. An important finding of this study is that this regulation of mf uptake also varies significantly between the vector genera, being weakest in Culex, comparatively stronger in Aedes and most severe and occurring at significantly lower human mf loads in Anopheles mosquitoes. The analysis of the corresponding mf uptake prevalence data has further highlighted how density-dependence in mf uptake may influence the observed distributions of mf in vector populations. These results show that whereas strong regulation of mf uptake, especially when it leads to saturation in uptake at low human parasite intensities, can lead to static distributions of mf per mosquito with host parasite intensity, a weaker regulation of mf ingestion can give rise to changes in both mean mf loads and in the frequency distribution of parasites/mosquito with increasing human parasite intensity. These findings highlight the importance of considering local vector infection dynamics when attempting to predict the impacts of community-based filariasis control. They also emphasize the value of developing and applying robust meta-analytic methods for estimating functional relationships regarding parasitic infection from population ecological data.     

Geographic and ecologic heterogeneity in elimination thresholds for the major vector-borne helminthic disease,lymphatic filariasis

Background

Large-scale intervention programmes to control or eliminate several infectious diseases are currently underway worldwide. However, a major unresolved question remains: what are reasonable stopping points for these programmes? Recent theoretical work has highlighted how the ecological complexity and heterogeneity inherent in the transmission dynamics of macroparasites can result in elimination thresholds that vary between local communities. Here, we examine the empirical evidence for this hypothesis and its implications for the global elimination of the major macroparasitic disease, lymphatic filariasis, by applying a novel Bayesian computer simulation procedure to fit a dynamic model of the transmission of this parasitic disease to field data from nine villages with different ecological and geographical characteristics. Baseline lymphatic filariasis microfilarial age-prevalence data from three geographically distinct endemic regions, across which the major vector populations implicated in parasite transmission also differed, were used to fit and calibrate the relevant vector-specific filariasis transmission models. Ensembles of parasite elimination thresholds, generated using the Bayesian fitting procedure, were then examined in order to evaluate site-specific heterogeneity in the values of these thresholds and investigate the ecological factors that may underlie such variability

Results

We show that parameters of density-dependent functions relating to immunity, parasite establishment, as well as parasite aggregation, varied significantly between the nine different settings, contributing to locally varying filarial elimination thresholds. Parasite elimination thresholds predicted for the settings in which the mosquito vector is anopheline were, however, found to be higher than those in which the mosquito is culicine, substantiating our previous theoretical findings. The results also indicate that the probability that the parasite will be eliminated following six rounds of Mass Drug Administration with diethylcarbamazine and albendazole decreases markedly but non-linearly as the annual biting rate and parasite reproduction number increases.

Conclusions

This paper shows that specific ecological conditions in a community can lead to significant local differences in population dynamics and, consequently, elimination threshold estimates for lymphatic filariasis. These findings, and the difficulty of measuring the key local parameters (infection aggregation and acquired immunity) governing differences in transmission thresholds between communities, mean that it is necessary for us to rethink the utility of the current anticipatory approaches for achieving the elimination of filariasis both locally and globally.

     

How Effective is Integrated Vector Management Against Malaria and Lymphatic Filariasis Where the Diseases Are Transmitted by the Same Vector?

Background

The opportunity to integrate vector management across multiple vector-borne diseases is particularly plausible for malaria and lymphatic filariasis (LF) control where both diseases are transmitted by the same vector. To date most examples of integrated control targeting these diseases have been unanticipated consequences of malaria vector control, rather than planned strategies that aim to maximize the efficacy and take the complex ecological and biological interactions between the two diseases into account.

Methodology/Principal Findings

We developed a general model of malaria and LF transmission and derived expressions for the basic reproductive number (R₀) for each disease. Transmission of both diseases was most sensitive to vector mortality and biting rate. Simulating different levels of coverage of long lasting-insecticidal nets (LLINs) and larval control confirms the effectiveness of these interventions for the control of both diseases. When LF was maintained near the critical density of mosquitoes, minor levels of vector control (8% coverage of LLINs or treatment of 20% of larval sites) were sufficient to eliminate the disease. Malaria had a far greater R₀ and required a 90% population coverage of LLINs in order to eliminate it. When the mosquito density was doubled, 36% and 58% coverage of LLINs and larval control, respectively, were required for LF elimination; and malaria elimination was possible with a combined coverage of 78% of LLINs and larval control.

Conclusions/Significance

Despite the low level of vector control required to eliminate LF, simulations suggest that prevalence of LF will decrease at a slower rate than malaria, even at high levels of coverage. If representative of field situations, integrated management should take into account not only how malaria control can facilitate filariasis elimination, but strike a balance between the high levels of coverage of (multiple) interventions required for malaria with the long duration predicted to be required for filariasis elimination.     

Mapping of lymphatic filariasis in Nepal

BACKGROUND: Human infection with Wuchereria bancrofti causes a disabling parasitic disease known as lymphatic filariasis, which is a major public health and socio-economic problem in many parts of the world. At the onset of the study, little was known of the distribution of filariasis and its current importance as a public health problem in Nepal. METHODS: Epidemiological mapping was undertaken to determine the prevalence of infection by Wuchereria bancrofti in 37 districts of Nepal between July to December 2001. The study population above 15 years of age was selected, and the immunochromatographic test (ICT Filariasis) was used to screen for circulating filarial antigen (CFA). RESULTS: The overall prevalence of lymphatic filariasis from a 4,488-sample population was 13% and 33/37 districts were found to be endemic. On the basis of geographical data, the highest number of cases was found at altitudes between 500-700 m; however, a substantial number of infected individuals were found in the highly populated Kathmandu valley, at altitudes between 900-1,500 metres where transmission appears to take place. Prevalence rates above 20% were found in 11 districts (with the highest rate of 40%), 6-19% were found in 15 districts, and 0.1-5% were in 7 districts.Information on people's knowledge, attitudes and behaviour towards filariasis was also collected by means of a structured questionnaire, which is presented and discussed in the study. CONCLUSIONS: This is the most extensive study of lymphatic filariasis undertaken to date in Nepal. The study indicates that the prevalence of infection is far greater that was previously reported and that lymphatic filariasis should be a much higher health priority than currently given.     

Control of malaria and filariasis vectors in South India

Community participation is increasingly seen as a major component of successful control programmes against parasitic diseases. One of the strongest exponents of this has been the Vector Control Research Centre (VCRC) in Pondicherry, South India (Fig. 1), who have successfully motivated and involved village communities in vector control activities with considerable success against malaria and filariasis vectors. Their largest single programme, the Filariasis Control Demonstration Project in Pondicherry Town, has now been handed to the Pondicherry State Government, while the VCRC's work on malaria and filariasis control is now expanding throughout other parts of India. As this article shows, much has been learnt from these projects, not just about control techniques but also about education, administration and decision-making.     

Lymphatic Filariasis (Elephantiasis) Elimination: A public health success and development opportunity

BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis, launched following World Health Assembly Resolution 50.29 (WHA 50.29), has been facilitated in its progress by new research findings, drug donations, the availability of diagnostic tools, disability management strategies to help those already suffering and the development of partnerships. The strategy recommended by the World Health Organization of annual treatment with a two-drug combination has proved safe. DISCUSSION: Using different approaches in several countries the elimination of lymphatic filariasis (LF) has been demonstrated to be feasible during earlier decades. These successes have been largely overlooked. However, the programme progress since 2000 has been remarkable - upscaling rapidly from 2 million treatments in 2000 to approximately 60 million in 2002. Around 34 countries had active programmes at the end of 2002. It is anticipated that there will be further expansion - but this will be dependent on additional resources becoming available. The programme also provides significant opportunities for other disease control programmes to deliver public health benefits on a large scale. Few public health programmes have upscaled so rapidly and so cost-effectively (<$0.03/treatment in some Asian settings) - one country treating 9-10 million people in a day (Sri Lanka). The LF programme is arguably the most effective pro-poor public health programme currently operating which is based on country commitment and partnerships supported by a global programme and alliance. Tables are provided to summarize programme characteristics, the benefits of LF elimination, opportunities for integration with other programmes and relevance to the Millennium Development Goals. SUMMARY: Lymphatic filariasis elimination is an "easy-to-do" inexpensive health intervention that provides considerable "beyond filariasis" benefits, exemplifies partnership and is easily evaluated. The success in global health action documented in this paper requires and deserves further support to bring to fruition elimination of lymphatic filariasis as a public health problem and health benefits to poor people. A future free of lymphatic filariasis will reduce poverty and bring better health to poor people, prevent disability, strengthen health systems and build partnerships.     

The emerging story of disability associated with lymphatic filariasis: a critical review

Globally, 40 million people live with the chronic effects of lymphatic filariasis (LF), making it the second leading cause of disability in the world. Despite this, there is limited research into the experiences of people living with the disease. This review summarises the research on the experiences of people living with LF disability. The review highlights the widespread social stigma and oppressive psychological issues that face most people living with LF-related disability. Physical manifestations of LF make daily activities and participation in community life difficult. The findings confirm the need for the Global Programme to Eliminate Lymphatic Filariasis (GPELF) to support morbidity management activities that address the complex biopsychosocial issues that people living with LF-related disability face.     

Assessing the effects of disease-specific programs on health systems: An analysis of the Bangladesh Lymphatic Filariasis Elimination Program’s impacts on health service coverage and catastrophic health expenditure

This study presents a methodology for using tracer indicators to measure the effects of disease-specific programs on national health systems. The methodology is then used to analyze the effects of Bangladesh’s Lymphatic Filariasis Elimination Program, a disease-specific program, on the health system. Using difference-in-differences models and secondary data from population-based household surveys, this study compares changes over time in the utilization rates of eight essential health services and incidences of catastrophic health expenditures between individuals and households, respectively, of lymphatic filariasis hyper-endemic districts (treatment districts) and of hypo- and non-endemic districts (control districts). Utilization of all health services increased from year 2000 to year 2014 for the entire population but more so for the population living in treatment districts. However, when the services were analyzed individually, the difference-in-differences between the two populations was insignificant. Disadvantaged populations (i.e., populations that lived in rural areas, belonged to lower wealth quintiles, or did not attend school) were less likely to access essential health services. After five years of program interventions, households in control districts had a lower incidence of catastrophic health expenditures at several thresholds measured using total household expenditures and total non-food expenditures as denominators. Using essential health service coverage rates as outcome measures, the Lymphatic Filariasis Elimination Program cannot be said to have strengthened or weakened the health system. We can also say that there is a positive association between the Lymphatic Filariasis Elimination Program’s interventions and lowered incidence of catastrophic health expenditures.     

Diagnostic tools for filariasis elimination programs

The ambitious and exciting Global Programme to Eliminate Lymphatic Filariasis (GPELF) is largely based on a strategy of mass drug administration (MDA) of repeated rounds of antifilarial medications to endemic populations around the world. Diagnostic tools are important to GPELF because they affect decisions regarding where to distribute MDA, how to measure its effects, how to define targets and endpoints for stopping MDA, and how to monitor populations for possible resurgence of filariasis transmission following suspension of MDA. This article reviews available diagnostic tests for filariasis and their potential use as tools for different phases of filariasis elimination programs.