Lymphatic Filariasis in Eastern Mediternean Region

Overview on Lymphatic Filariasis inOverview on Lymphatic Filariasis in
EMRO Region, Present situation andEMRO Region, Present situation and
Prospects for eliminationProspects for elimination
Dr.Khaled Mahmoud Abd Elaziz SalehDr.Khaled Mahmoud Abd Elaziz Saleh
Professor of Public health and Preventive medicine,Professor of Public health and Preventive medicine,
Faculty of Medicine, Ain Shams University, EgyptFaculty of Medicine, Ain Shams University, Egypt

Filariasis is a disabling, disfiguringFilariasis is a disabling, disfiguring
infection caused by parasitic worminfection caused by parasitic worm
called Wuchereria Bancrofticalled Wuchereria Bancrofti
(Bancroftian Filariasis)(Bancroftian Filariasis)

Historical background of Lymphatic filariasisHistorical background of Lymphatic filariasis
 Bancroftian filariasis has been endemic in EgyptBancroftian filariasis has been endemic in Egypt
for centuries with all the clinical manifestations.for centuries with all the clinical manifestations.
 The statue of a Pharaoh, created 4000 years ago,The statue of a Pharaoh, created 4000 years ago,
shows clear visible signs of the disease. Theshows clear visible signs of the disease. The
mummified body of Natsef-Amun, a priest atmummified body of Natsef-Amun, a priest at
Karnak in the times of Ramses XI proven afterKarnak in the times of Ramses XI proven after
3000 years by autopsy to have LF worms in the3000 years by autopsy to have LF worms in the
groin.groin.

in Thebes (now Luxor city),
Egypt. To the back (north) of
the mountain is the Valley of the
Kings where the tomb of
Tutankhamen was found. Replicas
of illustrations possibly depicting
elephantiasis can be seen on the
right side second layer limestone
wall of the funeral temple along
the middle terrace (Fig. 1a). with
the following explanation: ‘Very
fine painted limestone reliefs from
Terrace of Queen Hatshepsut’s
temple at EL-Deir Bahari which
record a trading expedition to
Punt, a locality near the sea and
South of Egypt. The center block
depicts the prince of Punt and his
wife, the latter obviously suffering
from elephantiasis (Fig. 1d),

 Clinical pictureClinical picture
 Early stage: erysipelas with no line ofEarly stage: erysipelas with no line of
demarcationdemarcation
 Late stages: dilatation of lymphaticLate stages: dilatation of lymphatic
vessels followed by their dysfunction,vessels followed by their dysfunction,
accumulation of fluid in tissues andaccumulation of fluid in tissues and
increased risk of infectionincreased risk of infection
(lymphoedema)(lymphoedema)
 Skin becomes infected---thickening ofSkin becomes infected---thickening of
lower limb--- elephantiasislower limb--- elephantiasis


 Burden of diseaseBurden of disease
 Physical: disfigurmentPhysical: disfigurment
 Social: isolation, loss of social support,Social: isolation, loss of social support,
family stress care giving, shame,family stress care giving, shame,
sexual disability.sexual disability.
 Psychological: depression,Psychological: depression,
hopelesness, sucidial tendencieshopelesness, sucidial tendencies
 Economic: loss of work, loss of familyEconomic: loss of work, loss of family
income, costly treatmentincome, costly treatment

 DiagnosisDiagnosis
 Thick blood smears for detection ofThick blood smears for detection of
Microfilaremia Under microscopyMicrofilaremia Under microscopy
 Blood specicmen should be collectedBlood specicmen should be collected
at late night from 10 PM to 2 AM inat late night from 10 PM to 2 AM in
the morning.the morning.
 Not highly sensitive, sensitivityNot highly sensitive, sensitivity
reaches only 60%, needs trainedreaches only 60%, needs trained
technicians.technicians.

 DiagnosisDiagnosis
 Recently a highly sensitive and specific methodRecently a highly sensitive and specific method
of detection has been introduced.of detection has been introduced.
 The development of an immunochromatographicThe development of an immunochromatographic
card test (ICT) with high sensitivity andcard test (ICT) with high sensitivity and
specificity for detecting W. bancrofti infectionspecificity for detecting W. bancrofti infection
has simplified diagnosis, and test kits arehas simplified diagnosis, and test kits are
commercially available. The test requires 100 μlcommercially available. The test requires 100 μl
of finger-prick blood drawn at any time, day orof finger-prick blood drawn at any time, day or
night. It is a rapid antigen test that is highlynight. It is a rapid antigen test that is highly
specific for detection of female adult worms inspecific for detection of female adult worms in
lymphatic systemlymphatic system

Global population at risk for LymphaticGlobal population at risk for Lymphatic
FilariasisFilariasis

Situation of LF in countries ofSituation of LF in countries of
EMRO regionEMRO region
Eastern Mediterranean region has an estimated at-risk population
of 12.6 million people, accounting for approximately 1% of the global
disease burden.

 Classification of countries in Eastern Mediternean Region asClassification of countries in Eastern Mediternean Region as
regards status of infection with Lymphatic filariasisregards status of infection with Lymphatic filariasis
 The 23 countries in the Region can be divided intoThe 23 countries in the Region can be divided into threethree groupsgroups
depending on the status of transmission of lymphatic filariasis:depending on the status of transmission of lymphatic filariasis:
 1. Countries with1. Countries with ongoing transmissionongoing transmission which need anwhich need an
intervention programme to interrupt transmission: Egypt, Sudanintervention programme to interrupt transmission: Egypt, Sudan
and Republic of Yemen;and Republic of Yemen;
 2. Countries with a2. Countries with a past history of lymphatic filariasispast history of lymphatic filariasis
transmissiontransmission or for which the information is not clear: Djibouti,or for which the information is not clear: Djibouti,
Islamic Republic of Iran, Oman, Pakistan, Somalia and SaudiIslamic Republic of Iran, Oman, Pakistan, Somalia and Saudi
Arabia;Arabia;
 3. Countries with3. Countries with no record or past historyno record or past history of lymphatic filariasisof lymphatic filariasis
transmission: the remaining 14 countriestransmission: the remaining 14 countries

Countries with aCountries with a past history of lymphatic filariasispast history of lymphatic filariasis
transmissiontransmission or for which the information is not clear:or for which the information is not clear:
OmanOman
A study done in oman in 2001 found antigenemiaA study done in oman in 2001 found antigenemia
prevalence rate of 2.4% among Indian emigrants living inprevalence rate of 2.4% among Indian emigrants living in
OmanOman
In a decade with surveillance of the disease they found 15In a decade with surveillance of the disease they found 15
cases with elephentiasis, other with positivecases with elephentiasis, other with positive
microfilaremia or antibody test.microfilaremia or antibody test.
As the WHO recommended in 2003 the authorities in OmanAs the WHO recommended in 2003 the authorities in Oman
to start transmission survey in school children using ICTto start transmission survey in school children using ICT
cards in suspected endemic focalities, a study wascards in suspected endemic focalities, a study was
conducted in 2004 on secondary school children. Eightconducted in 2004 on secondary school children. Eight
endemic districts were studied with a minimum 250endemic districts were studied with a minimum 250
students examined with ICT card testing. Of the 2745students examined with ICT card testing. Of the 2745
tested, none of the students tested positive for circulatingtested, none of the students tested positive for circulating
W. bancrofti antigen.(8)W. bancrofti antigen.(8)

transmissiontransmission
Kingdom of Saudi ArabiaKingdom of Saudi Arabia
Lymphatic filariasis was first reported in a few chronic cases from twoLymphatic filariasis was first reported in a few chronic cases from two
areas, Asir and Jizan, in the 1970s. During the 1990s, severalareas, Asir and Jizan, in the 1970s. During the 1990s, several
expatriates, mostly Indians, were found to be LF positive. A studyexpatriates, mostly Indians, were found to be LF positive. A study
was conducted on 302 indian expatriates found the total prevalencewas conducted on 302 indian expatriates found the total prevalence
of antigenemia 10.6% and of those positively tested with the cardof antigenemia 10.6% and of those positively tested with the card
test 31.3% had microfilaremia and could be a source of infection totest 31.3% had microfilaremia and could be a source of infection to
others.others.
In 2002, based on a questionnaire survey, a total of 51 clinical casesIn 2002, based on a questionnaire survey, a total of 51 clinical cases
(15–20 years of age) with elephantiasis or hydrocele, although(15–20 years of age) with elephantiasis or hydrocele, although
amicrofilaraemic, were identified from 3 areas Asir (44 cases),amicrofilaraemic, were identified from 3 areas Asir (44 cases),
Jizan (4 cases) and Mecca (3 cases). Subsequently, a total of 34Jizan (4 cases) and Mecca (3 cases). Subsequently, a total of 34
laboratory technicians were trained to perform the ICT card test.laboratory technicians were trained to perform the ICT card test.
However, due to a technical problem encountered at that time withHowever, due to a technical problem encountered at that time with
the Binax ICT cards showing false positive results after 10 minutes,the Binax ICT cards showing false positive results after 10 minutes,
they could not be used to conduct school surveys in suspectedthey could not be used to conduct school surveys in suspected
endemic areas.endemic areas.

transmissiontransmission
Kingdom of Saudi ArabiaKingdom of Saudi Arabia
 In 2010 with a representative of the vector controlIn 2010 with a representative of the vector control
program from Saudi Arabia, the actions done forprogram from Saudi Arabia, the actions done for
diagnosis of LF in Saudi Arabia were:diagnosis of LF in Saudi Arabia were:
 Doing questionnaire surveys in the three suspectedDoing questionnaire surveys in the three suspected
region (Aseer, Jazan and Mecca), survey in allregion (Aseer, Jazan and Mecca), survey in all
hospitals in three regions for hydrocele operation inhospitals in three regions for hydrocele operation in
the past two years, Incomplete screening ofthe past two years, Incomplete screening of
secondary school children with ICT card testing,secondary school children with ICT card testing,
Suggestion for doing more sophisticated techniquesSuggestion for doing more sophisticated techniques
for confirmation of diagnosis with ICT card positivefor confirmation of diagnosis with ICT card positive
results, and lastly that all activities for screeningresults, and lastly that all activities for screening
were suspended in 2005.were suspended in 2005.

Countries with aCountries with a past history of lymphaticpast history of lymphatic
filariasis transmissionfilariasis transmission
Islamic Republic of IranIslamic Republic of Iran
 Although it is a country with uncertain situationAlthough it is a country with uncertain situation
about Lymphatic Filariasis no studies were doneabout Lymphatic Filariasis no studies were done
in this domain. A recent study publishedin this domain. A recent study published
demonstrated that there are no reported Iraniandemonstrated that there are no reported Iranian
cases with LF yet the vector of the disease (Culexcases with LF yet the vector of the disease (Culex
quinquefasciatus, Diptera culcidae) is present allquinquefasciatus, Diptera culcidae) is present all
over the country. With the immigration of peopleover the country. With the immigration of people
from Endemic countries Lymphatic Filariasis is afrom Endemic countries Lymphatic Filariasis is a
public health threat for Iran. This study alsopublic health threat for Iran. This study also
showed a case reported of an Indian immigrantshowed a case reported of an Indian immigrant
with Lymphatic Filariasis in Iran.(11)with Lymphatic Filariasis in Iran.(11)

MDA (Mass drug administration)MDA (Mass drug administration)
programprogram

Strategies needed for elimination of Lymphatic Filariasis

 Initial assessmentInitial assessment
 The goal of initial assessment is to identify areas withThe goal of initial assessment is to identify areas with
active transmission ofactive transmission of W bancroftiW bancrofti rather than torather than to
identify all infected persons.identify all infected persons.
 Because implementation of the programme is likely toBecause implementation of the programme is likely to
be organized within the locally defined administrativebe organized within the locally defined administrative
boundaries, a decision must be made by the healthboundaries, a decision must be made by the health
authorities on the administrative unit or level at whichauthorities on the administrative unit or level at which
mass treatment will be implemented (e.g. village,mass treatment will be implemented (e.g. village,
district, town, city bloc). The presence ofdistrict, town, city bloc). The presence of
microfilaraemia or antigenaemia at a level higher than 1microfilaraemia or antigenaemia at a level higher than 1
% among residents within a given administrative unit% among residents within a given administrative unit
will be reason for initiation of mass treatment to allwill be reason for initiation of mass treatment to all
persons at risk of infection.persons at risk of infection.

 MDA interruption of transmissionMDA interruption of transmission
 The primary goal in the communities where filariasis isThe primary goal in the communities where filariasis is
endemic is to eliminate microfilariae from the blood ofendemic is to eliminate microfilariae from the blood of
infected individuals so that transmission of the infectioninfected individuals so that transmission of the infection
by the mosquito can be interrupted.by the mosquito can be interrupted.
 A single dose of the drug commonly used for treatmentA single dose of the drug commonly used for treatment
of intestinal parasites, albendazole, is 99% effectiveof intestinal parasites, albendazole, is 99% effective
against the micro filariae when simultaneouslyagainst the micro filariae when simultaneously
administered with Diethyl Carbamazine (DEC). Bothadministered with Diethyl Carbamazine (DEC). Both
DEC and albendazole kill adult worms in infectedDEC and albendazole kill adult worms in infected
patients. The use of albendazole has a second majorpatients. The use of albendazole has a second major
beneficial effect for individuals infected withbeneficial effect for individuals infected with
gastrointestinal parasites in addition to lymphaticgastrointestinal parasites in addition to lymphatic
filariasis.filariasis.

 Post MDA surveillancePost MDA surveillance
 National elimination programmes do not endNational elimination programmes do not end
after MDA has been discontinued. Programmeafter MDA has been discontinued. Programme
staff and resources must be maintained in orderstaff and resources must be maintained in order
to continue surveillance and evaluation activitiesto continue surveillance and evaluation activities
and manage the morbidity components of theand manage the morbidity components of the
programme. In fact, countries cannot verifyprogramme. In fact, countries cannot verify
elimination of LF directly after MDA has beenelimination of LF directly after MDA has been
stopped: approximately 5 years of post-MDAstopped: approximately 5 years of post-MDA
surveillance data are required in order to confirmsurveillance data are required in order to confirm
the sustained absence of transmission.the sustained absence of transmission.

 Post MDA surveillancePost MDA surveillance
 A series ofA series of two post-MDA surveillancetwo post-MDA surveillance
surveys should be conducted to evaluatesurveys should be conducted to evaluate
whether recrudescence has occurred. Eachwhether recrudescence has occurred. Each
survey should be conducted approximatelysurvey should be conducted approximately
2–3 years following the previous survey and2–3 years following the previous survey and
should use a similarshould use a similar design as the originaldesign as the original
TASTAS

 Verification of absence of transmissionVerification of absence of transmission
 A dossierA dossier should present systematically the evidence for absenceshould present systematically the evidence for absence
of LFof LF transmission for the entire country.transmission for the entire country.
 Dossier contentsDossier contents
 1.1. General descriptionGeneral description
 The general description should focus on:The general description should focus on:
 •• geographical and economic features of the country, particularlygeographical and economic features of the country, particularly
as they relate to risk of LF transmission; • the health system,as they relate to risk of LF transmission; • the health system,
emphasizing the adequacy of the health system to detect cases ofemphasizing the adequacy of the health system to detect cases of
infection and provide treatment; • geographical distribution,infection and provide treatment; • geographical distribution,
feeding behaviour, density and competence of the vectorfeeding behaviour, density and competence of the vector
mosquitoes; • immigration patterns to and from LF-endemicmosquitoes; • immigration patterns to and from LF-endemic
areas (including other countries); • occurrence of LF inareas (including other countries); • occurrence of LF in
neighboring countries and the status of filariasis control orneighboring countries and the status of filariasis control or
elimination efforts in those countries.elimination efforts in those countries.

 2-History of lymphatic filariasis2-History of lymphatic filariasis
 •• A detailed description, including maps of historic foci of LFA detailed description, including maps of historic foci of LF
transmission, as documented by both government and researchtransmission, as documented by both government and research
efforts. This should include a review of data on prevalence andefforts. This should include a review of data on prevalence and
intensity of LF infection in humans and vector mosquitoes.intensity of LF infection in humans and vector mosquitoes.
 •• Evidence for the absence of LF transmission in areasEvidence for the absence of LF transmission in areas
considered to be nonendemic. Information should be provided onconsidered to be nonendemic. Information should be provided on
how non-endemic areas were defi ned and on surveillance inhow non-endemic areas were defi ned and on surveillance in
these areas to provide assurance that they remain non-endemicthese areas to provide assurance that they remain non-endemic..
 33. Interventions. Interventions •• A detailed description of all measures toA detailed description of all measures to
control or interrupt transmissionin each focus. This descriptioncontrol or interrupt transmissionin each focus. This description
should include details of screening, testing and treatment ofshould include details of screening, testing and treatment of
patients who test positive, MDA and ancillary measures, such aspatients who test positive, MDA and ancillary measures, such as
environmental and economic improvement, vector control andenvironmental and economic improvement, vector control and
other relevant interventions, other vector-borne diseases (e.g.other relevant interventions, other vector-borne diseases (e.g.
malaria). • Review of case management for filarial disease.malaria). • Review of case management for filarial disease.

4.4. Assessment of interventionsAssessment of interventions
 •• A detailed description of surveys and studiesA detailed description of surveys and studies
conducted to evaluate theimpact of the interventionsconducted to evaluate theimpact of the interventions
(e.g. microfilaraemia surveys). This chapter would(e.g. microfilaraemia surveys). This chapter would
include data from sentinel sites and surveys forinclude data from sentinel sites and surveys for
antigenaemia, as recommended by WHO, as well asantigenaemia, as recommended by WHO, as well as
other surveys or evaluations that have been conductedother surveys or evaluations that have been conducted
before the GPELF was established. It also wouldbefore the GPELF was established. It also would
include any sampling undertaken as part of the decisioninclude any sampling undertaken as part of the decision
to stop MDA or other interventions. • Details should beto stop MDA or other interventions. • Details should be
provided on sampling methods and procedures thatprovided on sampling methods and procedures that
were used to assess baseline prevalence, monitor thewere used to assess baseline prevalence, monitor the
programme and assessstopping points for MDA.programme and assessstopping points for MDA.
 •• Review of any data collected on the impact ofReview of any data collected on the impact of
interventions on filarial disease.interventions on filarial disease.

 5. Surveillance5. Surveillance •• AA full review of any surveillance activitiesfull review of any surveillance activities
undertaken since MDA and other interventions were stopped,undertaken since MDA and other interventions were stopped,
including TAS, other active surveillance activities,and aincluding TAS, other active surveillance activities,and a
description of case follow-up activities completed for eachdescription of case follow-up activities completed for each
positive case detected.positive case detected.
 •• Review of data collected through post-MDA surveys, such asReview of data collected through post-MDA surveys, such as
the TAS. • Review of the filariasis case reports through routinethe TAS. • Review of the filariasis case reports through routine
disease surveillance or other systems for case detection.disease surveillance or other systems for case detection.
 •• Demonstration that any positive cases detected following MDADemonstration that any positive cases detected following MDA
representedisolated events not traceable to an area of activerepresentedisolated events not traceable to an area of active
transmission. If an area ofpotential transmission was discovered,transmission. If an area ofpotential transmission was discovered,
evidence should be presented that subsequent interventions (e.g.evidence should be presented that subsequent interventions (e.g.
MDA) were successful.MDA) were successful.
 6. Additional data that support the absence of LF6. Additional data that support the absence of LF
transmission.transmission.
 7. Bibliography7. Bibliography •• Published and any available unpublishedPublished and any available unpublished
studies on LF, its geographicalstudies on LF, its geographical distribution and control, includingdistribution and control, including
theses and dissertationstheses and dissertations

 Situation in SudanSituation in Sudan
 1-Incomplete Mapping in parts of Sudan as Darfour, Blue Nile,1-Incomplete Mapping in parts of Sudan as Darfour, Blue Nile,
and South Kordofan.and South Kordofan.
 2-Insecurity is present in the parts where mapping is needed.2-Insecurity is present in the parts where mapping is needed.
 3-Lack of Funding for Mapping of the disease.3-Lack of Funding for Mapping of the disease.
 4- Lack of supplies of ICT cards which will be offered by WHO.4- Lack of supplies of ICT cards which will be offered by WHO.
 Among the challenges that face the Sudanese ministry of healthAmong the challenges that face the Sudanese ministry of health
in elimination of lymphatic filariasis:in elimination of lymphatic filariasis:
 1- Definition of areas with coendemic diseases with LF as1- Definition of areas with coendemic diseases with LF as
onchocerceria, they need to be clearly defined to allow targetedonchocerceria, they need to be clearly defined to allow targeted
implementation.implementation.
 2- Funds are needed to complete mapping of NTDs throughout2- Funds are needed to complete mapping of NTDs throughout
Southern Sudan in order to have sound prevalence data to guideSouthern Sudan in order to have sound prevalence data to guide
mass drug administration where needed.mass drug administration where needed.

 Situation in YemenSituation in Yemen
 Successful MDA followed by TAS surveillanceSuccessful MDA followed by TAS surveillance
 By 2007, the basic criteria of pre-TAS were met (theBy 2007, the basic criteria of pre-TAS were met (the
coverage rate was >77% for 5 MDA rounds, the Mfcoverage rate was >77% for 5 MDA rounds, the Mf
prevalence in sentinel and spot check sites was less thanprevalence in sentinel and spot check sites was less than
1%). In 2008, TAS-1 was implemented in two EUs, the1%). In 2008, TAS-1 was implemented in two EUs, the
mainland and Socotra Island, based on the old WHOmainland and Socotra Island, based on the old WHO
guidelines. While the Mainland met the criteria for stoppingguidelines. While the Mainland met the criteria for stopping
MDA, Socotra failed TAS (the antigen prevalence wasMDA, Socotra failed TAS (the antigen prevalence was
1.8%) and was subjected to further MDA rounds. In 2012,1.8%) and was subjected to further MDA rounds. In 2012,
based on the results of TAS-2 Socotra met the criteria forbased on the results of TAS-2 Socotra met the criteria for
stopping MDA. To respond to a Regional Program Reviewstopping MDA. To respond to a Regional Program Review
Group recommendation, TAS was implemented (in 2013) inGroup recommendation, TAS was implemented (in 2013) in
two EUs (Mainland & Socotra) based on the new WHOtwo EUs (Mainland & Socotra) based on the new WHO
guidelinesguidelines

 Epidemiology of LF in EgyptEpidemiology of LF in Egypt
-Culex pipiens as the main vector of the disease and also-Culex pipiens as the main vector of the disease and also
revealed that the distribution of filariasis in the countryrevealed that the distribution of filariasis in the country
was highly focal.was highly focal. -Implementation of national public-Implementation of national public
health program in 1950-1965 to eliminate the disease.health program in 1950-1965 to eliminate the disease.
Between 1985 and 1991, Ministry of Health surveillanceBetween 1985 and 1991, Ministry of Health surveillance
teams took blood samples from 324 552 individualsteams took blood samples from 324 552 individuals
who lived in 314 villages and towns in the Nile deltawho lived in 314 villages and towns in the Nile delta
areaarea.. The crude microfilaremia rates for the 314 villagesThe crude microfilaremia rates for the 314 villages
examined ranged from 0 to 23% The observedexamined ranged from 0 to 23% The observed
distribution of filariasis in the southern Nile delta isdistribution of filariasis in the southern Nile delta is
prominently focal, with clusters of high endemicity inprominently focal, with clusters of high endemicity in
the governorate of Qalyubiya. Individual foci of highthe governorate of Qalyubiya. Individual foci of high
prevalence exist also in the govemorates of Giza,prevalence exist also in the govemorates of Giza,
Monufiya and DakhaliyaMonufiya and Dakhaliya

National program for elimination ofNational program for elimination of
lymphatic Filarisis in Egyptlymphatic Filarisis in Egypt

 Twin pillar of LF eliminationTwin pillar of LF elimination
 1- Interruption of transmission: mass1- Interruption of transmission: mass
treatment of at risk population by atreatment of at risk population by a
single dose for 4-6 yearssingle dose for 4-6 years
 2-Morbidity relief: control of2-Morbidity relief: control of
suffering: care of the diseasedsuffering: care of the diseased
(lymphoedema, acute inflammatory(lymphoedema, acute inflammatory
attacks, and hydrocele repair) activeattacks, and hydrocele repair) active
hygiene & elevation of the affectedhygiene & elevation of the affected
part in addition to physiotherapy. Forpart in addition to physiotherapy. For
hydrocele the treatment is surgey.hydrocele the treatment is surgey.

 MDA Program in EgyptMDA Program in Egypt
The programme depended on the well developed network of ruralThe programme depended on the well developed network of rural
health centers, which are part of the MOHP infrastructure. It alsohealth centers, which are part of the MOHP infrastructure. It also
included a training component for physicians and nurses workingincluded a training component for physicians and nurses working
at the rural health centres of the target villages and participatingat the rural health centres of the target villages and participating
in the implementation of MDA.in the implementation of MDA.
 Social mobilizationSocial mobilization included meetings with local village leaders,included meetings with local village leaders,
distribution of pamphlets and posters, and short radio anddistribution of pamphlets and posters, and short radio and
television broadcasts for the dissemination of information abouttelevision broadcasts for the dissemination of information about
the LF elimination programme in order to create publicthe LF elimination programme in order to create public
awareness and facilitate community participation.awareness and facilitate community participation.
 The first 3 rounds of MDA was applied in 2000-2002.The first 3 rounds of MDA was applied in 2000-2002.
The MOHP estimated that the overall MDA coverage rate in 2000The MOHP estimated that the overall MDA coverage rate in 2000
and 2001 reached 96.6% of the target population and 96.8% inand 2001 reached 96.6% of the target population and 96.8% in
20022002..

 Reports and Studies reporting success of theReports and Studies reporting success of the
National ProgrammeNational Programme
 Monitoring and EvaluationMonitoring and Evaluation of the Programme:of the Programme:
 In 2003 the World health organization has issuedIn 2003 the World health organization has issued
a document that marks the great achievementa document that marks the great achievement
and success in the MDA program. The documentand success in the MDA program. The document
was titled " The global elimination of LF, Thewas titled " The global elimination of LF, The
story of Egyptstory of Egypt
 In this document the emphasis on the role ofIn this document the emphasis on the role of
social mobilization and it was addressed as onesocial mobilization and it was addressed as one
of the key factors in the success of the massof the key factors in the success of the mass
administration programme in Egypt.administration programme in Egypt.

 Effect of yearly mass drug administration
with diethylcarbamazine and albendazole on
bancroftian filariasis in Egypt: a
comprehensive assessment LANCET 2006
Reda M R Ramzy, et al.
 MDA compliance rates were excellent (80%). In
Giza after MDA, prevalence rates of
microfilaraemia and Circulating filarial
antigenaemia fell from 11·5% to 1·2%, and from
19·0% to 4·8%, respectively (p0·0001).
Corresponding rates in Qalubyia fell from 3·1% to
0% and 13·6% to 3·1%, respectively (p0·0001)

MDA round
(Year
implemented)
Number of
Governorate District Village
MDA-1 (2000) 7 25 161
MDA-2 8 27 178*
MDA-3 8 27 179
MDA-4 8 27 181
MDA-5 (2004) 8 27 181
MDA-6 5 14 40†
MDA-7 (2006) 5 10 28‡

Egypt current situation
Last MDA march 2013
MDA stopped in 167 villages
MDA running in 29 villages in 5 governorates,
Menofia 13 , gharbia 2, elsharkia 5, Kafr
elshiekh 2, Giza 7
Total population treated almost half millionTotal population treated almost half million
MDA coverage 92.8%MDA coverage 92.8%

Epidemiological drug coverageEpidemiological drug coverage
 Epidemiological drug coverageEpidemiological drug coverage (programme coverage) is defined(programme coverage) is defined
as "as "the proportion of individuals in an IU who actually ingested thethe proportion of individuals in an IU who actually ingested the
medicinesmedicines""
No. people reported to have ingested the medicines
Total population in IU
X 100=
 To reduce the prevalence of Mf in infected individuals to the
threshold below which transmission is assumed to be no longer
sustainable, at least 65% of the total population in each IU must
ingest the medicines in at least five rounds of MDA.
Slide 47

 Post mass drug administration surviellancePost mass drug administration surviellance
Five annual MDA rounds were effective toFive annual MDA rounds were effective to
interrupt LF transmission in the majority ofinterrupt LF transmission in the majority of
endemic villages in Egypt and that 167 of 196endemic villages in Egypt and that 167 of 196
villages (85.2%) in 7 governorates (Menofia,villages (85.2%) in 7 governorates (Menofia,
Sharkia, Gharbia, Giza, Qalyoubia, Dakahlia andSharkia, Gharbia, Giza, Qalyoubia, Dakahlia and
Assuit) stopped MDA campaigns in 2005. TheseAssuit) stopped MDA campaigns in 2005. These
villages have implemented TAS-1, based on thevillages have implemented TAS-1, based on the
old WHO guidelines, and become eligible forold WHO guidelines, and become eligible for
TAS-2.TAS-2.

 Post mass drug administration surviellancePost mass drug administration surviellance
IIn December 2012,n December 2012, TAS-2TAS-2 was implemented inwas implemented in
two evaluation units (EU) comprising 28two evaluation units (EU) comprising 28
villages (MDA implementation units, IUs) invillages (MDA implementation units, IUs) in
Sharkia governorate. A total ofSharkia governorate. A total of 2,6842,684 samplessamples
were collected from school childrenwere collected from school children aged 6-7aged 6-7
yearsyears, tested by the ICT card test, and, tested by the ICT card test, and all wereall were
uniformly negativeuniformly negative. Such EUs encompass other. Such EUs encompass other
villages that stopped MDA in 2005 and thesevillages that stopped MDA in 2005 and these
received the last MDA round in 2013.received the last MDA round in 2013.

 Research on Post MDA surveillanceResearch on Post MDA surveillance
 A Recent study (2015) was done with the aim ofA Recent study (2015) was done with the aim of
surveillance for LF in an endemic village after 5surveillance for LF in an endemic village after 5
years stopping of MDA in Al Menofia governorate.years stopping of MDA in Al Menofia governorate.
The aim of the study was to prove that there wasThe aim of the study was to prove that there was
no resurgence of the disease after stopping ofno resurgence of the disease after stopping of
MDA by 5 years.MDA by 5 years.
 This study determined the status of lymphaticThis study determined the status of lymphatic
filariasis 5 years after cessation of MDA infilariasis 5 years after cessation of MDA in 33
sentinelsentinel EgyptianEgyptian villagesvillages in Menoufiya Govin Menoufiya Gov
ernorate village A: Abo Sneita; village B: Garawan;ernorate village A: Abo Sneita; village B: Garawan;
village C: Kafr El Bagour). A total of 1321 primaryvillage C: Kafr El Bagour). A total of 1321 primary
school children in grade 1 (school children in grade 1 (nn = 632) and grade 2 (= 632) and grade 2 (nn
= 689): the ICT and the ELISA test for IgG4= 689): the ICT and the ELISA test for IgG4
antibody to theantibody to the Bm14Bm14 recombinant filarial antigen.recombinant filarial antigen.
Subjects in the household survey (75) were testedSubjects in the household survey (75) were tested

 Research on Post MDA surveillanceResearch on Post MDA surveillance
 In conducting the study, they tested primary-schoolIn conducting the study, they tested primary-school
children using the ICT test as recommended by WHOchildren using the ICT test as recommended by WHO
and a new antibody detection tool, theand a new antibody detection tool, the Bm14Bm14 CELISA.CELISA.
Regarding the ICT test, no positive cases (eitherRegarding the ICT test, no positive cases (either
schoolchildren or household members) were detected,schoolchildren or household members) were detected,
and 100% of the study subjects showed negative resultsand 100% of the study subjects showed negative results
 In conclusion, the study results provide evidence that 5In conclusion, the study results provide evidence that 5
rounds of MDA with DEC and albendazole hasrounds of MDA with DEC and albendazole has
improved the various measures of filariasis endemicityimproved the various measures of filariasis endemicity
and transmission in these 3 sentinel Egyptian villages,and transmission in these 3 sentinel Egyptian villages,
and demonstrates the success of the national programmeand demonstrates the success of the national programme
to eliminate lym-phatic filariasis in Egypt. Moreover,to eliminate lym-phatic filariasis in Egypt. Moreover,
the transmission assessment survey has providedthe transmission assessment survey has provided
satisfactory results concerning the elimination status ofsatisfactory results concerning the elimination status of
the disease in these areas.the disease in these areas.

 Recommendation for Egypt in 2015 byRecommendation for Egypt in 2015 by
the regional programme review groupthe regional programme review group
 1-To start Compiling the dossier for1-To start Compiling the dossier for
verification of elimination of lymphaticverification of elimination of lymphatic
Filariasis in EgyptFilariasis in Egypt
 2-To Apply for the ICT cards necessary for2-To Apply for the ICT cards necessary for
the TAS surveys in 2016. Mostly TAS2 andthe TAS surveys in 2016. Mostly TAS2 and
TAS3.TAS3.
 3- WHO to support training in morbidity3- WHO to support training in morbidity
management and disability prevention formanagement and disability prevention for
staff at governorate level (surveillance andstaff at governorate level (surveillance and
management).management).

Future prospects forFuture prospects for
challenges againstchallenges against
eliminationelimination

 Challenges in ResearchChallenges in Research
 Several gaps still exist in the understanding theSeveral gaps still exist in the understanding the
"epidemiology of elimination" of LF and there is a"epidemiology of elimination" of LF and there is a
need for research.need for research.
 1-Studies to understand the behaviour of residual1-Studies to understand the behaviour of residual
microfilaraemia and antigenaemia in communitiesmicrofilaraemia and antigenaemia in communities
where the threshold level of microfilaraemia haswhere the threshold level of microfilaraemia has
been achieved through repeated MDA.been achieved through repeated MDA.
 2-Rapid identification of high-prevalence areas and2-Rapid identification of high-prevalence areas and
development of strategies for dealing with them. 3-development of strategies for dealing with them. 3-
Development and standardization of cost-effectiveDevelopment and standardization of cost-effective
strategies to stop-MDA and post-MDA surveillancestrategies to stop-MDA and post-MDA surveillance
strategies. 4-Modelling of the outcome of MDAstrategies. 4-Modelling of the outcome of MDA
programmes of different duration and intensity. 5-programmes of different duration and intensity. 5-
Identification of target population groups for MDAIdentification of target population groups for MDA
and treatment strategies in urban areas.and treatment strategies in urban areas.

 Challenges in ResearchChallenges in Research
 6-Quantification of the benefits of MDA.6-Quantification of the benefits of MDA.
 7-Formulation of treatment strategies in7-Formulation of treatment strategies in
areas with co-infections ofareas with co-infections of WuchereriaWuchereria
bancroftibancrofti andand Loa loaLoa loa. 8-Integration of MDA. 8-Integration of MDA
with strategies to control other neglectedwith strategies to control other neglected
tropical diseasestropical diseases
 9-Advocacy for sustaining MDA in countries9-Advocacy for sustaining MDA in countries
where it is already being implemented and forwhere it is already being implemented and for
starting it in countries where it has not yetstarting it in countries where it has not yet
been introduced.been introduced.
 10- The TAS was determined to be a practical10- The TAS was determined to be a practical
and effective evaluation tool for stoppingand effective evaluation tool for stopping
MDA although its validity for longer-termMDA although its validity for longer-term
post-MDA surveillance requires furtherpost-MDA surveillance requires further

 Challenges in Verification of Elimination inChallenges in Verification of Elimination in
Egypt:Egypt:
 Egypt is in the final chapter of the eliminationEgypt is in the final chapter of the elimination
process with the formulation of the dossier ofprocess with the formulation of the dossier of
verification of elimination. Yet there are challengesverification of elimination. Yet there are challenges
in formulation of the dossier with some local studiesin formulation of the dossier with some local studies
reporting the positivity of the parasite in the Vectorreporting the positivity of the parasite in the Vector
around the country which would imply that thearound the country which would imply that the
transmission is still going in areas that were not intransmission is still going in areas that were not in
the original map of the disease.the original map of the disease.
 A study was published in a local journal reportingA study was published in a local journal reporting
the positivity of PCR for W. Bancrofti in mosquitoesthe positivity of PCR for W. Bancrofti in mosquitoes
in two districts in Sohag (Namely Tema andin two districts in Sohag (Namely Tema and
Maragha Districts).Maragha Districts).
 As a response of the MOHP, an epidemiologicalAs a response of the MOHP, an epidemiological
study will be done in those two districts to prove thestudy will be done in those two districts to prove the
absence of the disease in humans in those twoabsence of the disease in humans in those two

 Challenges in Verification of Elimination inChallenges in Verification of Elimination in
Egypt:Egypt:
 Egypt is in the final chapter of the eliminationEgypt is in the final chapter of the elimination
process with the formulation of the dossier ofprocess with the formulation of the dossier of
verification of elimination. Yet there are challengesverification of elimination. Yet there are challenges
in formulation of the dossier with some local studiesin formulation of the dossier with some local studies
reporting the positivity of the parasite in the Vectorreporting the positivity of the parasite in the Vector
around the country which would imply that thearound the country which would imply that the
transmission is still going in areas that were not intransmission is still going in areas that were not in
the original map of the disease.the original map of the disease.
 A study was published in a local journal reportingA study was published in a local journal reporting
the positivity of PCR for W. Bancrofti in mosquitoesthe positivity of PCR for W. Bancrofti in mosquitoes
in two districts in Sohag (Namely Tema andin two districts in Sohag (Namely Tema and
Maragha Districts). (35)Maragha Districts). (35)
 As a response of the MOHP, an epidemiologicalAs a response of the MOHP, an epidemiological
study will be done in those two districts to prove thestudy will be done in those two districts to prove the
absence of the disease in humans in those twoabsence of the disease in humans in those two
districts.districts.

 Challenges in Morbidity relief in EgyptChallenges in Morbidity relief in Egypt
 Regarding LF Morbidity Management aRegarding LF Morbidity Management a
programme for morbidity management andprogramme for morbidity management and
disability prevention (MMDP) was started indisability prevention (MMDP) was started in
November 2011. Five MMDP centers wereNovember 2011. Five MMDP centers were
established in Tropical Disease Centers orestablished in Tropical Disease Centers or
General Hospitals in 5 governorates.General Hospitals in 5 governorates.
Furthermore, MMDP clinical guidelines wereFurthermore, MMDP clinical guidelines were
translated into Arabic and distributed to relatedtranslated into Arabic and distributed to related
centers. A registry for clinical cases wascenters. A registry for clinical cases was
initiated; however, in depth specialized traininginitiated; however, in depth specialized training
is still neededis still needed

 Challenges in Vector Control:Challenges in Vector Control:
 An effective vector control component shouldAn effective vector control component should
start by identifying the target mosquito vectorstart by identifying the target mosquito vector
then selection of the suitable control measures.then selection of the suitable control measures.
These include: long-lasting insecticidal nets,These include: long-lasting insecticidal nets,
indoor residual spraying, repellents, larvicides,indoor residual spraying, repellents, larvicides,
or use of polystyrene beads. Selection of theor use of polystyrene beads. Selection of the
appropriate strategy depends largely on theappropriate strategy depends largely on the
infrastructure and available resources. Forinfrastructure and available resources. For
xenomonitoring, different methods for samplingxenomonitoring, different methods for sampling
larvae and adult mosquitoes were discussed. Thelarvae and adult mosquitoes were discussed. The
importance of xenomonitoring as a direct toolimportance of xenomonitoring as a direct tool
for monitoring interruption of LF transmission..for monitoring interruption of LF transmission..

Lymphatic Filariasis in Eastern Mediternean Region

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (7)

Similar to Lymphatic Filariasis in Eastern Mediternean Region

Similar to Lymphatic Filariasis in Eastern Mediternean Region (20)

More from Khaled Abd Elaziz

More from Khaled Abd Elaziz (16)

Recently uploaded

Recently uploaded (20)

Lymphatic Filariasis in Eastern Mediternean Region