lymphatic filariasis in eastern mediternean region

Overview on Lymphatic Filariasis in Overview on Lymphatic Filariasis in EMRO Region, Present situation and EMRO 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, disfiguring Filariasis is a disabling, disfiguring infection caused by parasitic worm infection 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 Egypt Bancroftian 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. The shows clear visible signs of the disease. The mummified body of Natsef-Amun, a priest at mummified body of Natsef-Amun, a priest at Karnak in the times of Ramses XI proven after Karnak in the times of Ramses XI proven after 3000 years by autopsy to have LF worms in the 3000 years by autopsy to have LF worms in the groin.groin.

in Thebes (now Luxor city), Egypt. To the back (north) ofthe 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 of Early stage: erysipelas with no line of

demarcationdemarcation Late stages: dilatation of lymphatic vessels Late stages: dilatation of lymphatic vessels

followed by their dysfunction, accumulation followed by their dysfunction, accumulation of fluid in tissues and increased risk of of fluid in tissues and increased risk of infection (lymphoedema)infection (lymphoedema)

Skin becomes infected---thickening of Skin becomes infected---thickening of lower limb--- elephantiasislower limb--- elephantiasis

Thickening of scrotum ( hydrocele)Thickening of scrotum ( hydrocele)

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, sexual family stress care giving, shame, sexual disability.disability.

Psychological: depression, hopelesness, Psychological: depression, hopelesness, sucidial tendenciessucidial tendencies

Economic: loss of work, loss of family Economic: loss of work, loss of family income, costly treatmentincome, costly treatment

DiagnosisDiagnosis Thick blood smears for detection of Thick blood smears for detection of

Microfilaremia Under microscopyMicrofilaremia Under microscopy Blood specicmen should be collected Blood specicmen should be collected

at late night from 10 PM to 2 AM in at late night from 10 PM to 2 AM in the morning.the morning.

Not highly sensitive, sensitivity Not highly sensitive, sensitivity reaches only 60%, needs trained reaches only 60%, needs trained technicians.technicians.

DiagnosisDiagnosis Recently a highly sensitive and specific method of Recently a highly sensitive and specific method of

detection has been introduced.detection has been introduced. The development of an immunochromatographic The development of an immunochromatographic

card test (ICT) with high sensitivity and specificity card test (ICT) with high sensitivity and specificity for detecting W. bancrofti infection has simplified for detecting W. bancrofti infection has simplified diagnosis, and test kits are commercially available. diagnosis, and test kits are commercially available. The test requires 100 μl of finger-prick blood The test requires 100 μl of finger-prick blood drawn at any time, day or night. It is a rapid drawn at any time, day or night. It is a rapid antigen test that is highly specific for detection of antigen test that is highly specific for detection of female adult worms in lymphatic system female adult worms in lymphatic system

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

Situation of LF in countries of Situation 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 as Classification 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 into The 23 countries in the Region can be divided into threethree groups groups depending on the status of transmission of lymphatic filariasis:depending on the status of transmission of lymphatic filariasis:

1. Countries with 1. Countries with ongoing transmissionongoing transmission which need an which need an intervention programme to interrupt transmission: Egypt, Sudan intervention programme to interrupt transmission: Egypt, Sudan and Republic of Yemen;and Republic of Yemen;

2. Countries with a 2. Countries with a past history of lymphatic filariasis past 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 Saudi Islamic Republic of Iran, Oman, Pakistan, Somalia and Saudi Arabia;Arabia;

3. Countries with 3. Countries with no record or past historyno record or past history of lymphatic filariasis of lymphatic filariasis transmission: the remaining 14 countries transmission: the remaining 14 countries

Countries with a Countries with a past history of lymphatic filariasis past history of lymphatic filariasis transmissiontransmission or for which the information is not clear: or for which the information is not clear:

OmanOmanA study done in oman in 2001 found antigenemia A study done in oman in 2001 found antigenemia

prevalence rate of 2.4% among Indian emigrants living in prevalence rate of 2.4% among Indian emigrants living in OmanOman

In a decade with surveillance of the disease they found 15 In a decade with surveillance of the disease they found 15 cases with elephentiasis, other with positive cases with elephentiasis, other with positive microfilaremia or antibody test.microfilaremia or antibody test.

As the WHO recommended in 2003 the authorities in Oman As the WHO recommended in 2003 the authorities in Oman to start transmission survey in school children using ICT to start transmission survey in school children using ICT cards in suspected endemic focalities, a study was cards in suspected endemic focalities, a study was conducted in 2004 on secondary school children. Eight conducted in 2004 on secondary school children. Eight endemic districts were studied with a minimum 250 endemic districts were studied with a minimum 250 students examined with ICT card testing. Of the 2745 students examined with ICT card testing. Of the 2745 tested, none of the students tested positive for circulating tested, none of the students tested positive for circulating W. bancrofti antigen.(8) W. bancrofti antigen.(8)

Countries with a Countries with a past history of lymphatic filariasis past history of lymphatic filariasis transmissiontransmission

Kingdom of Saudi ArabiaKingdom of Saudi ArabiaLymphatic filariasis was first reported in a few chronic cases from Lymphatic filariasis was first reported in a few chronic cases from two areas, Asir and Jizan, in the 1970s. During the 1990s, several two areas, Asir and Jizan, in the 1970s. During the 1990s, several

expatriates, mostly Indians, were found to be LF positive. A study expatriates, mostly Indians, were found to be LF positive. A study was conducted on 302 indian expatriates found the total prevalence was conducted on 302 indian expatriates found the total prevalence

of antigenemia 10.6% and of those positively tested with the card of antigenemia 10.6% and of those positively tested with the card test 31.3% had microfilaremia and could be a source of infection to test 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 cases In 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 34 Jizan (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 with However, 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 suspected they could not be used to conduct school surveys in suspected endemic areas. endemic areas.

Countries with a Countries with a past history of lymphatic filariasis past history of lymphatic filariasis transmissiontransmission

Kingdom of Saudi ArabiaKingdom of Saudi Arabia In 2010 with a representative of the vector control In 2010 with a representative of the vector control

program from Saudi Arabia, the actions done for program 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 suspected Doing questionnaire surveys in the three suspected region (Aseer, Jazan and Mecca), survey in all region (Aseer, Jazan and Mecca), survey in all hospitals in three regions for hydrocele operation in hospitals in three regions for hydrocele operation in the past two years, Incomplete screening of the 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 techniques Suggestion for doing more sophisticated techniques for confirmation of diagnosis with ICT card positive for confirmation of diagnosis with ICT card positive results, and lastly that all activities for screening results, and lastly that all activities for screening were suspended in 2005.were suspended in 2005.

Countries with a Countries with a past history of lymphatic past history of lymphatic filariasis transmissionfilariasis transmission

Islamic Republic of IranIslamic Republic of Iran Although it is a country with uncertain situation Although it is a country with uncertain situation

about Lymphatic Filariasis no studies were done about Lymphatic Filariasis no studies were done in this domain. A recent study published in this domain. A recent study published demonstrated that there are no reported Iranian demonstrated that there are no reported Iranian cases with LF yet the vector of the disease (Culex cases with LF yet the vector of the disease (Culex quinquefasciatus, Diptera culcidae) is present all quinquefasciatus, Diptera culcidae) is present all over the country. With the immigration of people over the country. With the immigration of people from Endemic countries Lymphatic Filariasis is a from Endemic countries Lymphatic Filariasis is a public health threat for Iran. This study also public health threat for Iran. This study also showed a case reported of an Indian immigrant showed 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 with active The goal of initial assessment is to identify areas with active

transmission of transmission of W bancrofti W bancrofti rather than to identify all rather than to identify all infected persons.infected persons.

Because implementation of the programme is likely to be Because implementation of the programme is likely to be organized within the locally defined administrative organized within the locally defined administrative boundaries, a decision must be made by the health boundaries, a decision must be made by the health authorities on the administrative unit or level at which mass authorities on the administrative unit or level at which mass treatment will be implemented (e.g. village, district, town, treatment will be implemented (e.g. village, district, town, city bloc). The presence of microfilaraemia or antigenaemia city bloc). The presence of microfilaraemia or antigenaemia at a level higher than 1 % among residents within a given at a level higher than 1 % among residents within a given administrative unit will be reason for initiation of mass administrative unit will be reason for initiation of mass treatment to all persons at risk of infection. treatment to all persons at risk of infection.

MDA interruption of transmissionMDA interruption of transmission The primary goal in the communities where filariasis is The primary goal in the communities where filariasis is

endemic is to eliminate microfilariae from the blood of endemic is to eliminate microfilariae from the blood of infected individuals so that transmission of the infection by infected individuals so that transmission of the infection by the mosquito can be interrupted.the mosquito can be interrupted.

A single dose of the drug commonly used for treatment of A single dose of the drug commonly used for treatment of intestinal parasites, albendazole, is 99% effective against the intestinal parasites, albendazole, is 99% effective against the micro filariae when simultaneously administered with micro filariae when simultaneously administered with Diethyl Carbamazine (DEC). Both DEC and albendazole kill Diethyl Carbamazine (DEC). Both DEC and albendazole kill adult worms in infected patients. The use of albendazole has adult worms in infected patients. The use of albendazole has a second major beneficial effect for individuals infected with a second major beneficial effect for individuals infected with gastrointestinal parasites in addition to lymphatic filariasis.gastrointestinal parasites in addition to lymphatic filariasis.

Interruption of Transmission

Post MDA surveillance Post MDA surveillance National elimination programmes do not end after National elimination programmes do not end after

MDA has been discontinued. Programme staff and MDA has been discontinued. Programme staff and resources must be maintained in order to continue resources must be maintained in order to continue surveillance and evaluation activities and manage surveillance and evaluation activities and manage the morbidity components of the programme. In the morbidity components of the programme. In fact, countries cannot verify elimination of LF fact, countries cannot verify elimination of LF directly after MDA has been stopped: directly after MDA has been stopped: approximately 5 years of post-MDA surveillance approximately 5 years of post-MDA surveillance data are required in order to confirm the sustained data are required in order to confirm the sustained absence of transmission. absence of transmission.

Post MDA surveillance Post MDA surveillance

A series of A series of two post-MDA surveillancetwo post-MDA surveillance surveys should be conducted to evaluate surveys should be conducted to evaluate whether recrudescence has occurred. Each whether recrudescence has occurred. Each survey should be conducted approximately survey should be conducted approximately 2–3 years following the previous survey and 2–3 years following the previous survey and should use a similar should use a similar design as the original design as the original TAS TAS

Verification of absence of transmissionVerification of absence of transmission A dossierA dossier should present systematically the evidence for absence of should present systematically the evidence for absence of

LF 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, particularly as geographical and economic features of the country, particularly as

they relate to risk of LF transmission; • the health system, they relate to risk of LF transmission; • the health system, emphasizing the adequacy of the health system to detect cases of emphasizing the adequacy of the health system to detect cases of infection and provide treatment; • geographical distribution, feeding infection and provide treatment; • geographical distribution, feeding behaviour, density and competence of the vector mosquitoes; • behaviour, density and competence of the vector mosquitoes; • immigration patterns to and from LF-endemic areas (including other immigration patterns to and from LF-endemic areas (including other countries); • occurrence of LF in neighboring countries and the status countries); • occurrence of LF in neighboring countries and the status of filariasis control or elimination efforts in those countries.of filariasis control or elimination efforts in those countries.

2-History of lymphatic filariasis2-History of lymphatic filariasis • • A detailed description, including maps of historic foci of LF A detailed description, including maps of historic foci of LF

transmission, as documented by both government and research efforts. transmission, as documented by both government and research efforts. This should include a review of data on prevalence and intensity of LF This should include a review of data on prevalence and intensity of LF infection in humans and vector mosquitoes.infection in humans and vector mosquitoes.

• • Evidence for the absence of LF transmission in areas considered to be Evidence for the absence of LF transmission in areas considered to be nonendemic. Information should be provided on how non-endemic areas nonendemic. Information should be provided on how non-endemic areas were defi ned and on surveillance in these areas to provide assurance that were defi ned and on surveillance in these areas to provide assurance that they remain non-endemicthey remain non-endemic..

33. Interventions. Interventions • • A detailed description of all measures to control or A detailed description of all measures to control or interrupt transmissionin each focus. This description should include details interrupt transmissionin each focus. This description should include details of screening, testing and treatment of patients who test positive, MDA and of screening, testing and treatment of patients who test positive, MDA and ancillary measures, such as environmental and economic improvement, ancillary measures, such as environmental and economic improvement, vector control and other relevant interventions, other vector-borne diseases vector control and other relevant interventions, other vector-borne diseases (e.g. malaria). • Review of case management for filarial disease.(e.g. malaria). • Review of case management for filarial disease.

4.4. Assessment of interventionsAssessment of interventions • • A detailed description of surveys and studies conducted to A detailed description of surveys and studies conducted to

evaluate theimpact of the interventions (e.g. microfilaraemia evaluate theimpact of the interventions (e.g. microfilaraemia surveys). This chapter would include data from sentinel sites and surveys). This chapter would include data from sentinel sites and surveys for antigenaemia, as recommended by WHO, as well as surveys for antigenaemia, as recommended by WHO, as well as other surveys or evaluations that have been conducted before the other surveys or evaluations that have been conducted before the GPELF was established. It also would include any sampling GPELF was established. It also would include any sampling undertaken as part of the decision to stop MDA or other undertaken as part of the decision to stop MDA or other interventions. • Details should be provided on sampling methods interventions. • Details should be provided on sampling methods and procedures that were used to assess baseline prevalence, and procedures that were used to assess baseline prevalence, monitor the programme and assessstopping points for MDA.monitor the programme and assessstopping points for MDA.

• • Review of any data collected on the impact of interventions on Review of any data collected on the impact of interventions on filarial disease. filarial disease.

5. Surveillance5. Surveillance • • AA full review of any surveillance activities full 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 a description including TAS, other active surveillance activities,and a description of case follow-up activities completed for each positive case detected.of case follow-up activities completed for each positive case detected.

• • Review of data collected through post-MDA surveys, such as the Review of data collected through post-MDA surveys, such as the TAS. • Review of the filariasis case reports through routine disease TAS. • Review of the filariasis case reports through routine disease surveillance or other systems for case detection.surveillance or other systems for case detection.

• • Demonstration that any positive cases detected following MDA Demonstration that any positive cases detected following MDA representedisolated events not traceable to an area of active representedisolated 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 LF transmission.6. Additional data that support the absence of LF transmission. 7. Bibliography7. Bibliography • • Published and any available unpublished studies on Published and any available unpublished studies on

LF, its geographical LF, its geographical distribution and control, including theses and distribution and control, including theses and dissertations dissertations

Situation in SudanSituation in Sudan 1-Incomplete Mapping in parts of Sudan as Darfour, Blue Nile, and 1-Incomplete Mapping in parts of Sudan as Darfour, Blue Nile, and

South Kordofan.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 health in Among the challenges that face the Sudanese ministry of health in

elimination of lymphatic filariasis:elimination of lymphatic filariasis: 1- Definition of areas with coendemic diseases with LF as 1- Definition of areas with coendemic diseases with LF as

onchocerceria, they need to be clearly defined to allow targeted onchocerceria, they need to be clearly defined to allow targeted implementation.implementation.

2- Funds are needed to complete mapping of NTDs throughout 2- Funds are needed to complete mapping of NTDs throughout Southern Sudan in order to have sound prevalence data to guide mass Southern Sudan in order to have sound prevalence data to guide mass drug administration where needed.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 (the coverage By 2007, the basic criteria of pre-TAS were met (the coverage rate was >77% for 5 MDA rounds, the Mf prevalence in sentinel rate was >77% for 5 MDA rounds, the Mf prevalence in sentinel

and spot check sites was less than 1%). In 2008, TAS-1 was and spot check sites was less than 1%). In 2008, TAS-1 was implemented in two EUs, the mainland and Socotra Island, based implemented in two EUs, the mainland and Socotra Island, based on the old WHO guidelines. While the Mainland met the criteria on the old WHO guidelines. While the Mainland met the criteria

for stopping MDA, Socotra failed TAS (the antigen prevalence for stopping MDA, Socotra failed TAS (the antigen prevalence was 1.8%) and was subjected to further MDA rounds. In 2012, was 1.8%) and was subjected to further MDA rounds. In 2012,

based on the results of TAS-2 Socotra met the criteria for based on the results of TAS-2 Socotra met the criteria for stopping MDA. To respond to a Regional Program Review stopping MDA. To respond to a Regional Program Review

Group recommendation, TAS was implemented (in 2013) in two Group recommendation, TAS was implemented (in 2013) in two EUs (Mainland & Socotra) based on the new WHO guidelines EUs (Mainland & Socotra) based on the new WHO guidelines

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 country was revealed that the distribution of filariasis in the country was highly focal.highly focal. -Implementation of national public health -Implementation of national public health program in 1950-1965 to eliminate the disease.program in 1950-1965 to eliminate the disease.

Between 1985 and 1991, Ministry of Health surveillance teams Between 1985 and 1991, Ministry of Health surveillance teams took blood samples from 324 552 individuals who lived in took blood samples from 324 552 individuals who lived in 314 villages and towns in the Nile delta area314 villages and towns in the Nile delta area. . The crude The crude microfilaremia rates for the 314 villages examined ranged microfilaremia rates for the 314 villages examined ranged from 0 to 23% The observed distribution of filariasis in the from 0 to 23% The observed distribution of filariasis in the southern Nile delta is prominently focal, with clusters of southern Nile delta is prominently focal, with clusters of high endemicity in the governorate of Qalyubiya. Individual high endemicity in the governorate of Qalyubiya. Individual foci of high prevalence exist also in the govemorates of foci of high prevalence exist also in the govemorates of Giza, Monufiya and Dakhaliya Giza, Monufiya and Dakhaliya

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

Twin pillar of LF eliminationTwin pillar of LF elimination 1- Interruption of transmission: mass 1- Interruption of transmission: mass

treatment of at risk population by a single treatment of at risk population by a single dose for 4-6 yearsdose for 4-6 years

2-Morbidity relief: control of suffering: 2-Morbidity relief: control of suffering: care of the diseased (lymphoedema, acute care of the diseased (lymphoedema, acute inflammatory attacks, and hydrocele inflammatory attacks, and hydrocele repair) active hygiene & elevation of the repair) active hygiene & elevation of the affected part in addition to physiotherapy. affected part in addition to physiotherapy. For hydrocele the treatment is surgey.For hydrocele the treatment is surgey.

MDA Program in EgyptMDA Program in EgyptThe programme depended on the well developed network of rural The programme depended on the well developed network of rural

health centers, which are part of the MOHP infrastructure. It also health centers, which are part of the MOHP infrastructure. It also included a training component for physicians and nurses working included a training component for physicians and nurses working at the rural health centres of the target villages and participating at 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 and distribution of pamphlets and posters, and short radio and television broadcasts for the dissemination of information about television broadcasts for the dissemination of information about the LF elimination programme in order to create public the 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 2000 The MOHP estimated that the overall MDA coverage rate in 2000 and 2001 reached 96.6% of the target population and 96.8% in and 2001 reached 96.6% of the target population and 96.8% in 20022002. .

Reports and Studies reporting success of the Reports 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 issued In 2003 the World health organization has issued

a document that marks the great achievement a document that marks the great achievement and success in the MDA program. The and success in the MDA program. The document was titled " The global elimination of document was titled " The global elimination of LF, The story of Egypt LF, The story of Egypt

In this document the emphasis on the role of In this document the emphasis on the role of social mobilization and it was addressed as one social mobilization and it was addressed as one of the key factors in the success of the mass of 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 situationLast MDA march 2013MDA stopped in 167 villagesMDA 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 millionMDA 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 the the proportion of individuals in an IU who actually ingested the medicinesmedicines""

No. people reported to have ingested the medicines

Total population in IUX 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 to Five annual MDA rounds were effective to interrupt LF transmission in the majority of interrupt LF transmission in the majority of endemic villages in Egypt and that 167 of 196 endemic 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 and Sharkia, Gharbia, Giza, Qalyoubia, Dakahlia and Assuit) stopped MDA campaigns in 2005. These Assuit) stopped MDA campaigns in 2005. These villages have implemented TAS-1, based on the villages have implemented TAS-1, based on the old WHO guidelines, and become eligible for old 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 in was implemented in two evaluation units (EU) comprising 28 two evaluation units (EU) comprising 28 villages (MDA implementation units, IUs) in villages (MDA implementation units, IUs) in Sharkia governorate. A total of Sharkia governorate. A total of 2,6842,684 samples samples were collected from school children were collected from school children aged 6-7 aged 6-7 yearsyears, tested by the ICT card test, and , tested by the ICT card test, and all were all were uniformly negativeuniformly negative. Such EUs encompass other . Such EUs encompass other villages that stopped MDA in 2005 and these villages 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 of A Recent study (2015) was done with the aim of

surveillance for LF in an endemic village after 5 surveillance 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 was The aim of the study was to prove that there was no resurgence of the disease after stopping of no resurgence of the disease after stopping of MDA by 5 years.MDA by 5 years.

This study determined the status of lymphatic This study determined the status of lymphatic filariasis 5 years after cessation of MDA in filariasis 5 years after cessation of MDA in 3 3 sentinelsentinel Egyptian Egyptian villagesvillages in Menoufiya Gov in 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 pri mary-village C: Kafr El Bagour). A total of 1321 pri mary-school children in grade 1 (school children in grade 1 (n n = 632) and grade 2 (= 632) and grade 2 (n n = 689): the ICT and the ELISA test for IgG4 = 689): the ICT and the ELISA test for IgG4 antibody to the antibody to the Bm14 Bm14 recombinant filarial antigen. recombinant filarial antigen. Subjects in the household survey (75) were tested Subjects in the household survey (75) were tested by ICT card test only.by ICT card test only.

Research on Post MDA surveillanceResearch on Post MDA surveillance In conducting the study, they tested primary-school In conducting the study, they tested primary-school

children using the ICT test as recommended by WHO children using the ICT test as recommended by WHO and a new antibody detection tool, the and a new antibody detection tool, the Bm14 Bm14 CELISA. CELISA. Regarding the ICT test, no positive cases (either Regarding 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 results and 100% of the study subjects showed negative results

In conclusion, the study results provide evidence that 5 In conclusion, the study results provide evidence that 5 rounds of MDA with DEC and albendazole has rounds of MDA with DEC and albendazole has improved the various measures of filariasis endemicity improved 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 and demonstrates the success of the national programme to eliminate lym phatic filariasis in Egypt. programme to eliminate lym phatic filariasis in Egypt. Moreover, the transmission assessment survey has Moreover, the transmission assessment survey has provided satisfactory results concerning the elimination provided satisfactory results concerning the elimination status of the disease in these areas.status of the disease in these areas.

Recommendation for Egypt in 2015 by Recommendation for Egypt in 2015 by the regional programme review groupthe regional programme review group

1-To start Compiling the dossier for 1-To start Compiling the dossier for verification of elimination of lymphatic verification of elimination of lymphatic Filariasis in EgyptFilariasis in Egypt

2-To Apply for the ICT cards necessary for 2-To Apply for the ICT cards necessary for the TAS surveys in 2016. Mostly TAS2 and the TAS surveys in 2016. Mostly TAS2 and TAS3. TAS3.

3- WHO to support training in morbidity 3- WHO to support training in morbidity management and disability prevention for management and disability prevention for staff at governorate level (surveillance and staff at governorate level (surveillance and management).management).

Future prospects for Future prospects for challenges against challenges against

eliminationelimination

Challenges in ResearchChallenges in Research

Several gaps still exist in the understanding the Several 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 residual 1-Studies to understand the behaviour of residual microfilaraemia and antigenaemia in communities microfilaraemia and antigenaemia in communities where the threshold level of microfilaraemia has where the threshold level of microfilaraemia has been achieved through repeated MDA.been achieved through repeated MDA.

2-Rapid identification of high-prevalence areas and 2-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-effective Development and standardization of cost-effective strategies to stop-MDA and post-MDA surveillance strategies to stop-MDA and post-MDA surveillance strategies. 4-Modelling of the outcome of MDA strategies. 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 MDA Identification 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 in 7-Formulation of treatment strategies in

areas with co-infections of areas with co-infections of Wuchereria Wuchereria bancroftibancrofti and and Loa loaLoa loa. 8-Integration of MDA . 8-Integration of MDA with strategies to control other neglected with strategies to control other neglected tropical diseasestropical diseases

9-Advocacy for sustaining MDA in countries 9-Advocacy for sustaining MDA in countries where it is already being implemented and for where it is already being implemented and for starting it in countries where it has not yet starting it in countries where it has not yet been introduced. been introduced.

10- The TAS was determined to be a practical 10- The TAS was determined to be a practical and effective evaluation tool for stopping and effective evaluation tool for stopping MDA although its validity for longer-term MDA although its validity for longer-term post-MDA surveillance requires further post-MDA surveillance requires further investigation.investigation.

Challenges in Verification of Elimination in Challenges in Verification of Elimination in Egypt:Egypt:

Egypt is in the final chapter of the elimination Egypt is in the final chapter of the elimination process with the formulation of the dossier of process with the formulation of the dossier of verification of elimination. Yet there are challenges verification of elimination. Yet there are challenges in formulation of the dossier with some local studies in formulation of the dossier with some local studies reporting the positivity of the parasite in the Vector reporting the positivity of the parasite in the Vector around the country which would imply that the around the country which would imply that the transmission is still going in areas that were not in transmission 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 reporting A study was published in a local journal reporting the positivity of PCR for W. Bancrofti in mosquitoes the positivity of PCR for W. Bancrofti in mosquitoes in two districts in Sohag (Namely Tema and in two districts in Sohag (Namely Tema and Maragha Districts). Maragha Districts).

As a response of the MOHP, an epidemiological As a response of the MOHP, an epidemiological study will be done in those two districts to prove the study will be done in those two districts to prove the absence of the disease in humans in those two absence of the disease in humans in those two districts.districts.

Challenges in Verification of Elimination in Challenges in Verification of Elimination in Egypt:Egypt:

Egypt is in the final chapter of the elimination Egypt is in the final chapter of the elimination process with the formulation of the dossier of process with the formulation of the dossier of verification of elimination. Yet there are challenges verification of elimination. Yet there are challenges in formulation of the dossier with some local studies in formulation of the dossier with some local studies reporting the positivity of the parasite in the Vector reporting the positivity of the parasite in the Vector around the country which would imply that the around the country which would imply that the transmission is still going in areas that were not in transmission 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 reporting A study was published in a local journal reporting the positivity of PCR for W. Bancrofti in mosquitoes the positivity of PCR for W. Bancrofti in mosquitoes in two districts in Sohag (Namely Tema and in two districts in Sohag (Namely Tema and Maragha Districts). (35)Maragha Districts). (35)

As a response of the MOHP, an epidemiological As a response of the MOHP, an epidemiological study will be done in those two districts to prove the study will be done in those two districts to prove the absence of the disease in humans in those two absence 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 a Regarding LF Morbidity Management a

programme for morbidity management and programme for morbidity management and disability prevention (MMDP) was started in disability prevention (MMDP) was started in November 2011. Five MMDP centers were November 2011. Five MMDP centers were established in Tropical Disease Centers or established in Tropical Disease Centers or General Hospitals in 5 governorates. General Hospitals in 5 governorates. Furthermore, MMDP clinical guidelines were Furthermore, MMDP clinical guidelines were translated into Arabic and distributed to related translated into Arabic and distributed to related centers. A registry for clinical cases was centers. A registry for clinical cases was initiated; however, in depth specialized training initiated; however, in depth specialized training is still needed is still needed

Challenges in Vector Control:Challenges in Vector Control: An effective vector control component should An effective vector control component should

start by identifying the target mosquito vector start 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 the or use of polystyrene beads. Selection of the appropriate strategy depends largely on the appropriate strategy depends largely on the infrastructure and available resources. For infrastructure and available resources. For xenomonitoring, different methods for sampling xenomonitoring, different methods for sampling larvae and adult mosquitoes were discussed. The larvae and adult mosquitoes were discussed. The importance of xenomonitoring as a direct tool importance of xenomonitoring as a direct tool for monitoring interruption of LF transmission.. for monitoring interruption of LF transmission..

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lymphatic filariasis in eastern mediternean region

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