Lymphatic filaraisis as neglected tropical disease. The past and current efforts of Egypt in elimination. Egypt has now reached the elimination of lymphatic filaraisis as a public health problem. And joined 10 countries in that triumph around the world.

1. Neglected Tropical diseasesNeglected Tropical diseases
lymphatic filariasislymphatic filariasis
Dr.Khaled Mahmoud Abd Elaziz SalehDr.Khaled Mahmoud Abd Elaziz Saleh
Professor of Public health andProfessor of Public health and
Preventive medicine, Faculty ofPreventive medicine, Faculty of
Medicine, Ain Shams UniversityMedicine, Ain Shams University

2. Neglected Tropical diseasesNeglected Tropical diseases
affects more than 1 billionaffects more than 1 billion
people worldwide (morepeople worldwide (more
than one disease) yet thethan one disease) yet the
diseases remain neglected atdiseases remain neglected at
all levels.all levels.

3. Disease where povertyDisease where poverty
prevails, unsafe water, noprevails, unsafe water, no
access to health care, pooraccess to health care, poor
housing, malnutrition, poorhousing, malnutrition, poor
sanitation which all increasesanitation which all increase
vulnerability to infections.vulnerability to infections.

4. Neglect at community level:Neglect at community level:
NTD as Lymphatic filariaisis is feared disease with strong socialNTD as Lymphatic filariaisis is feared disease with strong social
stigma in rural areas. So theses disease are mostly hidden, out ofstigma in rural areas. So theses disease are mostly hidden, out of
sight poorly documented and unmentioned.sight poorly documented and unmentioned.
Neglect at the national levelNeglect at the national level
 Neglected tropical diseases tend to be hidden below the radar
screens of health services and politicians because they afflict
populations that are marginalized, with little political voice.
 Although frequently causing severe pain and life-long
disabilities, these diseases are generally not major
killers. Under resource-limited conditions, high mortality
diseases such as HIV/AIDS or tuberculosis are prioritized to the
detriment of neglected tropical diseases.

5. Neglect at international levelNeglect at international level
 Neglected tropical diseases do not travel
easily and thus do not pose an immediate
threat to Western society. Moreover, they
are tied to specific geographical and
environmental conditions.
 The development of new diagnostic tools
has been under funded largely because
neglected tropical diseases do not represent
a significant market.

6. --Lymphatic filariaisis is a major health problem inLymphatic filariaisis is a major health problem in
tropical and subtropical regions with at least 120tropical and subtropical regions with at least 120
million people are infected with the parasite inmillion people are infected with the parasite in
8080
-One of the oldest known diseases on Earth-One of the oldest known diseases on Earth
Some date this disease to 2000 BCSome date this disease to 2000 BC

7. Situation in EgyptSituation in Egypt
 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.
 An estimated 250.000 people infected and 2.5 millionAn estimated 250.000 people infected and 2.5 million
people at risk in 8 governorates in the Delta region (181people at risk in 8 governorates in the Delta region (181
villages) (sharkia, gharbia, menofia, Qalyoubia, Kafrvillages) (sharkia, gharbia, menofia, Qalyoubia, Kafr
elsheikh, Dakhlia, Assiut, Giza)elsheikh, Dakhlia, Assiut, Giza)

8. Statue of Imenhoutp II in EgyptianStatue of Imenhoutp II in Egyptian
museummuseum

9. 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),

10. Situation in EgyptSituation in Egypt
 MOH in the past had tried to eliminate theMOH in the past had tried to eliminate the
diseasedisease
 There was a resurgence of the disease in
the 1970s with changes in water levels and
agricultural practices after construction of
the Aswan High Dam, and prevalences
 rose to 40% in some areas

13.  Life cycleLife cycle
 In mosquitoes: few weeks the changeIn mosquitoes: few weeks the change
of MF in the infected blood to thirdof MF in the infected blood to third
stage larvae (infective stage)stage larvae (infective stage)
 Larva passes from chest muscles ofLarva passes from chest muscles of
mosquitoes to the mouth parts duringmosquitoes to the mouth parts during
blood feedingblood feeding
 Each MF is transferred to one Larva,Each MF is transferred to one Larva,
no multiplication in mosquitoesno multiplication in mosquitoes

14.  Life cycleLife cycle
 Humans: few months. Third stageHumans: few months. Third stage
larva passes to lymphatic vessels,larva passes to lymphatic vessels,
where it is changed to adult male andwhere it is changed to adult male and
female worm, the life span is 4-6 yearsfemale worm, the life span is 4-6 years
producing millions of wormsproducing millions of worms

15.  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


20.  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

21.  Failure of elimination in the pastFailure of elimination in the past
 Microfilaremia or antigenemia aboveMicrofilaremia or antigenemia above
1% in any locality considered endemic1% in any locality considered endemic
disease of the poor and present in ruraldisease of the poor and present in rural
areasareas
 Difficulty in diagnosis--- Night bloodDifficulty in diagnosis--- Night blood
smears (10PM & 2AM) to detect MFsmears (10PM & 2AM) to detect MF
in blood (thick blood smear) , needsin blood (thick blood smear) , needs
trained technician, sensitivity 60%trained technician, sensitivity 60%

22.  Failure of elimination in the pastFailure of elimination in the past
 Long selective treatment:Long selective treatment:
 6 tablets DEC (50mg) daily for 126 tablets DEC (50mg) daily for 12
days most people never complete thedays most people never complete the
course of treatmentcourse of treatment
 Causes ( disliked treatment pain in theCauses ( disliked treatment pain in the
testis) side effectstestis) side effects
 Only proven infected cases are treated.Only proven infected cases are treated.

23.  Failure of elimination in the pastFailure of elimination in the past
 Long selective treatment:Long selective treatment:
 6 tablets DEC (50mg) daily for 126 tablets DEC (50mg) daily for 12
days most people never complete thedays most people never complete the
course of treatmentcourse of treatment
 Causes ( disliked treatment pain in theCauses ( disliked treatment pain in the
testis) side effectstestis) side effects

24.  Overcoming difficulties in the pastOvercoming difficulties in the past
 Better diagnosis (ICT) immunoBetter diagnosis (ICT) immuno
chromatography test:chromatography test:
 Pin prick test at any time, detectPin prick test at any time, detect
antigen of adult female worm, highlyantigen of adult female worm, highly
sensitive and specific (98%) and verysensitive and specific (98%) and very
easy to doeasy to do
 Better treatment: DEC and albandazoleBetter treatment: DEC and albandazole
treatment in Egypttreatment in Egypt

26. National program forNational program for
elimination of lymphaticelimination of lymphatic
Filarisis in EgyptFilarisis in Egypt

27. MDA (Mass drug administration)MDA (Mass drug administration)
programprogram

28.  MDA Program in EgyptMDA Program in Egypt
 Started in 2000Started in 2000
 Purpose: cut of the transmission cycle ofPurpose: cut of the transmission cycle of
the diseasethe disease
 DEC + albandazole given in 4-6 doses overDEC + albandazole given in 4-6 doses over
4-6 years in endemic areas to all the4-6 years in endemic areas to all the
residents (population)residents (population)
 Pregnant females & children under 2 yearsPregnant females & children under 2 years
are excludedare excluded
 Drugs are filarcidal kill MF 100% and toDrugs are filarcidal kill MF 100% and to
lesser extent adult worms:lesser extent adult worms:

29.  MDA Program in EgyptMDA Program in Egypt
 Success of this program dependedSuccess of this program depended
on the percentage of peopleon the percentage of people
accepting to take the drug to cut theaccepting to take the drug to cut the
transmission cycle.transmission cycle.
 WHO aimed at achieving globalWHO aimed at achieving global
elimination of LF as a public healthelimination of LF as a public health
problem by the year 2020.problem by the year 2020.

30.  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.

32. Slide 32

33. Eligibility criteria for a TransmissionEligibility criteria for a Transmission
assessment surveys TASassessment surveys TAS
Slide 33
In order for a national programme to start planningIn order for a national programme to start planning
a TAS, the following criteria must be met in each IU:a TAS, the following criteria must be met in each IU:
At least five roundsAt least five rounds of MDA were completed.of MDA were completed.
≥≥ 65% epidemiological drug coverage65% epidemiological drug coverage achieved at eachachieved at each
round.round.
Sentinel site:Sentinel site: prevalence of Mf < 1% or prevalence of Agprevalence of Mf < 1% or prevalence of Ag
< 2% after last effective round at all sites< 2% after last effective round at all sites
Spot-check site:Spot-check site: prevalence of Mf < 1% or prevalence ofprevalence of Mf < 1% or prevalence of
Ag < 2% after last effective round at all sitesAg < 2% after last effective round at all sites

34. 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 34

35. When should surveys be conducted?When should surveys be conducted?
Slide 35
 Baseline assessment: before first MDABaseline assessment: before first MDA
 Mid-term evaluation: at least 6 months after third MDAMid-term evaluation: at least 6 months after third MDA
(optional)(optional)
 Follow-up survey: at least 6 months after fifth effective MDAFollow-up survey: at least 6 months after fifth effective MDA
Mapping TAS
1 2 3 4 5
Mf and/or Ag
prevalence
(baseline)
Mf and/or Ag
prevalence
(follow-up)
Mf and/or Ag
prevalence
(optional)
Round of MDA

36.  Effect of yearly mass drug administration
with diethylcarbamazine and albendazole
on bancroftian filariasis in Egypt: a
comprehensive assessment
 LANCET 2006 Impact factor 26
Reda M R Ramzy, Maged El Setouhy, Hanan
Helmy, Ehab S Ahmed, Khaled M Abd
Elaziz, Hoda A Farid, William D Shannon,
Gary J Weil

37.  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)

38. Our results suggest that
after five rounds of MDA
filariasis is likely to
have been eliminated in
most endemic localities
in Egypt.

39. Egypt current situation
MDA stopped in 167 villages
MDA running in 29 villages in 5
governorates, Menofia, gharbia,
elsharkia, Kafr elshiekh, Giza
Last MDA march 2013
TAS1 was implemented in schools of all
endemic governorates

40. Post MDA surveillance
Should be repeated twice with interval 2-3
years in order to provide evidence that
recrudescence has not occurred and
therefore transmission can be considered
interrupted
Verification of elimination

41. The Success of Egypt in elimination was finally
documented by WHO in March 2018… joined ten
countries where official elimination has been reached

43. THANK YOU