As India sets a fresh deadline to eliminate lymphatic filariasis, a look at why the national programme is crawling
Sonal Matharu | February 10, 2016 | Odisha
When Kointa Swain suffered from a spell of high fever, shivering and loss of appetite for the first time, she was 30-years-old. As the fever ‘attacks’ kept recurring, she visited the district hospital near her village, Kapileswarpur in Odisha. The doctors gave her medicines for malaria which gave her temporary relief. Kointa, now 67, is sitting in the freshly painted verandah of her house with her son, Pramod Kumar Swain, and telling us how with every fever attack soon after the first, her right leg below the knee swelled more and more. “Each time a layer of skin used to peel off and her leg would bleed,” Pramod says.
Kointa lifts her peach-coloured sari up till her knees to show the leg. It is swollen more than twice the normal size. The rough skin folding at the ankle has a long, deep cut which Kointa got when she fell, a common occurrence with such a heavy foot, and injured herself. She feels that malaria, which she acquired 37 years ago, caused lymphatic filariasis, a crippling ‘neglected tropical disease’ that had gripped many others in her village.
Her village in this coastal district of Puri lines houses on both sides of a single, straight concrete road. Beyond the houses are the fields where water collects and mosquitoes breed. Culex mosquitoes, which are the carriers of lymphatic filariasis in endemic areas, find a mention on the fresh fluorescent posters in orange, pink and peach colours pasted on the walls of the brick houses. But these posters that inform people in Odiya language about the symptoms of this communicable disease mean little for the younger people here. The village has not seen any new cases of lymphatic filariasis in the last eight to ten years leaving behind only a few elderly with disproportionate limbs.
Kapileswarpur is an example how sustained efforts by the government and civil society have stopped the transmission of lymphatic filariasis, commonly known as filaria or elephantiasis. It is caused by thread-like worms that attach to the lymph nodes of a person’s lower limbs, breasts or male genital organs and start growing. The worms can stay dormant in a person’s body for five to eight years, growing into adults and starting to reproduce and multiply. If a mosquito bites somebody after biting an infected person, it can transfer the microfilaria or the baby worms, spreading the disease. As the worms become active the affected area swells disproportionately making the skin rough, thick and prone to infections. Once transmission of microfilaria is stopped, the adult parasites eventually die.
Lymphatic filariasis, which can be classified in seven stages, is mostly concentrated in the coastal pockets and the entire community can be at risk. It is one of the seven most common neglected tropical diseases in the world and is endemic in 73 countries affecting 120 million people. In India, which has been running a national lymphatic filariasis control programme since 1955, the disease still exists in the rural, marginalised and poor populations across 20 states.
“Lymphatic filariasis is a slow-progressing disease. There are no sudden outbreaks of the disease and people do not die of it. But it cripples them for life. Also, it is found in poor pockets across the world; that is why it has attracted very little attention and is called a neglected tropical disease,” says Nandini Pillai, programmes and operations officer, Global Network for Neglected Tropical Diseases (GNNTD), a Washington DC-based advocacy group.
In December, when over 2.5 lakh health workers and volunteers visited 14,736 villages for supplying and administering drugs to the lymphatic filariasis endemic districts of Odisha, Puri was left out.
“Puri has had several rounds of annual drug administration drives. A survey will now be conducted there to check whether the disease transmission rate has come down to below one percent or not,” said Dr MM Pradhan, joint director, national vector borne disease control programme, Odisha.
While there are pockets in the country which are successfully reducing microfilaria transmission rates, the union government is struggling to altogether wipe out the disease across the country. The national health policy, 2000, set an ambitious target of eliminating lymphatic filariasis by 2015, five years before the global target of 2020. As per the world health organisation (WHO), a country can be declared lymphatic filariasis free if the microfilaria transmission rate is less than one percent.
According to global estimates, the microfilaria transmission can drop to below one percent if the drugs are given once a year for five years to about 65 percent of population living in an endemic region. After more than 11 rounds of drug administration in India, lymphatic filariasis remains active in 250 districts.
As India now approaches the global deadline of lymphatic filariasis elimination, it is considering a relook at its existing strategies of targeting the disease. There are 31 ‘hot-spot’ districts in Karnataka, West Bengal, Odisha, Gujarat and Kerala amongst others where the microfilaria transmission rates are refusing to drop.
Lymphatic filariasis can be diagnosed with a microscopic examination but the task is not as simple. The worms are active only during the night. To detect their presence in the blood, the patients have to be tested at night in a dark room. That is why, at any given time, it is difficult to assess the scale of the spread of Lymphatic filariasis in a region.
“The person may be infected as a child, but the symptoms may start showing when he or she is an adult. The worms can stay dormant in the body for a long time,” says Shailesh Vaite, national advisor (India), GNNTD.
One tablet of chewable deworming tablet Albendazole and weight-wise dose of diethylcarbamazine citrate (DEC) are being given under the national programme since 2006. Though Albendazole is donated by the pharmaceutical company GlaxoSmithKline and DEC is procured cheap, administering them is a challenge. “People feel that since they are not showing any symptoms, they should not eat the medicines. They collect the medicine from the health centre and throw them,” says Pramod Kumar Barick from Kapileswarpur.
The government data reflects this gap in drug distribution and intake. The coverage of annual mass drug administration has always been above 92 percent since 2007 in Gujarat, for instance; yet the microfilaria transmission is at 0.97 – the second highest after Karnataka – in 2014. (The states may show a below one percent microfilaria transmission rates, but this is an average of the endemic districts within states. All districts put together may have more than one percent microfilaria transmission.)
“Some pockets in Karnataka have low awareness about lymphatic filariasis. It is noted that these areas have poor social indicators like
literacy. Migration is also an important factor. In Gujarat due to rapid industrialisation, a lot of people who come from other states also get counted in the microfilaria survey, distorting the microfilaria transmission assessment data after mass drug administration,” says a senior health official with the union health ministry who did not wish to be named.
He explains that strategies like making people consume drugs in front of health workers like in tuberculosis and HIV/AIDS programmes are not possible for lymphatic filariasis. “In diseases like polio, measles or neonatal tetanus a particular age group is given medicines or vaccines. In lymphatic filariasis the entire community is to be given drugs. It is not feasible for a public health programme to have directly-observed treatment under lymphatic filariasis,” he says.
In January, Indian council of medical research (ICMR) director Dr Soumya Swaminathan announced at a press meet that the union government was soon going to add another drug, Ivermectin, to the existing combination of Albendazole and DEC. “The lymphatic filariasis elimination programme has been running for more than 10 years in the country but the microfilaria transmission rate has not fallen below one percent,” she said.
Admitting that the existing drugs do not kill the adult worms but can only kill the microfilaria, Dr Rashmi Arora, head, division of epidemiology and communicable diseases at ICMR, explains that Ivermectin is being introduced with the hope that the microfilaria transmission will go down at a faster rate. “Ivermectin can kill adult worms. Adding it in the annual drug administration drive has shown results globally. Two years of sustained administration of Ivermectin in Papa New Guinea has brought down the microfilaria transmission rates,” says Arora. The new drug, which cannot be given to children below the age of five, will be introduced in the ‘hot-spots’ if a pilot in Yadgir district of Karnataka, where transmission is high, is successful.
The proposal for adding this drug in the existing drug regimen is waiting the approval of the ethics committee at the ICMR headquarters. Once it gets the nod, it will go to the national ethics committee. “By April this year, it is expected that the drug will be introduced in Yadgir,” says Arora.
Other processes like request for requirement of the drug have already been placed before the drug controller general of India, raising the hopes of the government. But the scaling up of the drug to all 31 high-transmission districts may not happen before next year.
On one hand states like Odisha have taken work towards eliminating lymphatic filariasis on a campaign mode. On the other hand there are states like Bihar and Uttar Pradesh that remain problematic. The health official said that special attention is given to these two states to improve drug administration and to ensure that these are consumed by the people. Additional resources have also been assigned to these states. “Officials from the centre have been sent to all the states for constant monitoring of the programme. Intensified verification is being done whether people are consuming the medicines or not,” he said.
Once a district achieves a low microfilaria transmission rate, blood samples collected from the community have to be tested by special kits, called ICT cards, provided by WHO. This test, which is conducted six months after the drug administration, shows whether the transmission rate in the community is less than one percent or not.
The problem lies in the high demand for the ICT cards that are produced by only one company in the USA – Allere Binax – and supplied globally. The supply sometimes takes months to arrive. The states, meanwhile, have no option but to wait for the kits which delays their surveys and assessments. For instance, Puri was due to conduct the test in August 2015 but the ICT cards are arriving only in February 2016.
The health official says that though delays occur, it is not a major hurdle in the programme. “The kits are supplied through the WHO so the delivery is ensured. But none of the Indian companies that have attempted to produce these kits have received WHO validation,” he says.
The WHO validation process declaring a country lymphatic filariasis-free is itself a long process. Once a country eliminates lymphatic filariasis, it has to have a home-based plan of how people affected by it can have proper management of the affected limb. Once this morbidity management plan is in place, a dossier which has information on how the drugs were administered and how the post-drug assessment was conducted is submitted to the WHO. After reviewing it, the WHO sends its team of experts to the field and if they find any loopholes, the process may have to be repeated. “This entire process may take about three to four years,” says Shailesh Vaite of GNNTD.
But the government officials are hopeful. “India has never failed post-drug assessment. It is an evolving figure,” informs the official.
Meanwhile, officials in Odisha are confident that they are on the way to eliminating lymphatic filariasis by the new deadline which they have set for themselves – 2017. The state will conduct a survey in six months in all districts where drugs were administered to test whether the drive was effective or not.
“The fact that only older people are now affected with lymphatic filariasis in Kapileswarpur village shows that the government’s mass drug administration is working. People are taking the medicines and the coverage of drug administration is increasing,” Kelly Toves, communications officer, GNNTD.
Neglected tropical diseases affect one in six people around the world. India is endemic for at least 10 such diseases including lymphatic filariasis, yaws, leprosy and kala azar. Forty percent of lymphatic filariasis global burden is in India which is a signatory to the world health assembly resolution in 1997 for global elimination of lymphatic filariasis. Elimination of this disease from India is thus crucial for the entire South Asia.
After eliminating yaws in 2015, lymphatic filariasis is the next disease on the government’s radar, says the health official. Civil society advocates are also looking forward to 2020 when, according to them, India will achieve its next public health success. “Eliminating lymphatic filariasis is the next public health victory (after polio eradication) that India stands to achieve,” says Pillai.
Meanwhile, the government officials are cautious and say that constant monitoring even after the region is declared microfilaria transmission free is required. “Lymphatic filariasis cases will never stop occurring. The disease can be eliminated, not eradicated. Vector borne diseases can never be 100 percent eliminated,” says the health official quoted above.
(The story appears in the February 1-15, 2016 issue)
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