?

FILARIASIS

F I L A R I A S I S

At the end of the session, the student should be able to:

General Objective: Understand the DOH program for the prevention and control of Filariasis

Specific Objectives: Discuss the National Filariasis Elimination Program to include the following:
Etiology, mode of transmission, symptoms and pathogenesis of the disease Epidemiology & prevalence of Filariasis in the Philippines Goal, objectives and strategies of the program

Introduction
One of the Neglected Tropical Diseases (NTDs) Chronic and parasitic infection Worlds 2nd leading cause of permanent longterm disability Over 120M have been infected with over 1/3 being seriously incapacitated and disfigured, affecting their productivity and lifestyle

Source: WHO.Lymphatic filariasis. Retrieved from World Health Organization website: http://www.who.int/gho/neglected_diseases/lymphatic_filariasis/en/

World Data
1.4 billion people in 73 countries are at risk
65% living in the South-East Asia Region 30% in the African Region 5% in other tropical areas

120 million people are infected

25 million men having genital disease 15 million people having lymphedema.

Elimination of lymphatic filariasis can contribute in achieving the Millennium Development Goals
Source: WHO.Lymphatic filariasis. Retrieved from World Health Organization website: http://www.who.int/gho/neglected_diseases/lymphatic_filariasis/en/

ETIOLOGY

The

PARASITE

SUSPECT NO.1:

SUSPECT NO.2:

Wuchereria bancrofti

Brugia malayi

The

PARASITE

In the Philippines, 2 species of filaria are known:

W. bancrofti - predominant organism

- nocturnal

B. malayi

- reported from 7 provinces

- noctural subperiodic

4 provinces Davao Oriental, Palawan, Eastern Samar and Surigao del Sur have both species
Nocturnal: MF scarce in the peripheral blood by day, peak at night (10pm-2am) Nocturnal subperiodic: MF present all the time, peak (5-11pm)

(Kron, 2000)

Distribution of Filariasis in the Philippines

PINK: Wuchereria bancrofti BLUE: Brugia malayi YELLOW: both GREEN: Undefined species

(Kron, 2000)

The
Wuchereria bancrofti
Bancroftian filariasis Chronic disfiguring disease: Lymphedema Elephantiasis Hydrocoele

PARASITE
Brugia malayi

Malayan filariasis Chronic infection (also): Lymphedema Elephantiasis

Disease
Vectors

Aedes poicilius Anopheles minimus flavirostris

Mansonia uniformis Mansonia bonnea

Wuchereria bancrofti
Sheath in Giemsa Nuclei Tail Terminal nuclei
Appearance

Brugia malayi
Pink Irregularly spaced and overlapping Single row of nuclei that reaches tails ends 2 nuclei which bulge the cuticle Kinky

Unstained Regulary spaced, separately situated Single row of nuclei that does not reach tails ends None Smoothly curved

The POP QUIZ: Identify.

PARASITE

The

VECTOR

axil

The Vector

Vector Aedes poicilius

Breeding Site Water-filled leaf axils of abaca, banana, taro.

W. bancrofti Anopheles minimus

flavirostiris Mansonia uniformis B. malayi Mansonia bonnea

Clear mountain streams

Swampy and forested areas

The Vector

Pop quiz:

The Vector
Aedes sp. Mansonia sp.

Breeds in the AXILS OF PLANTS Prefers FRESH WATER SWAMPS like abaca, banana, pandanus, gabi, with an extensive growth of giant biga pandanus & other aquatic plants. Night biters (10pm-2am) Endophilic1 and partially exophilic Night biters (5-11pm) Exophagic2 and exophilic3

Dopulation density is related to Density is related to rainfall patterns rainfall patterns

Table 2. Characteristics of Anopheles sp. and Mansonia sp. 1Endophilic: An endophilic mosquito is a mosquito that tends to inhabit/rest indoors. 2Exophagic: An exophagic mosquito is a mosquito that feeds outdoors. 3Exophilic: An exophilic mosquito tends to inhabit/rest outdoors.

The Vector

ABACA

as breeding site of Aedes mosquitos

Mode of Transmission & Pathogenesis

The Life Cycle

Mode of Transmission
Lymphatic filariasis is transmitted through bite of infected mosquito which harbors the L3 larva

Incubation Period
PRE-PATENT PERIOD
inoculation of infective larvae to the appearance of detectable microfilariae (Mf) in blood approx. 12 months

INCUBATION PERIOD: 6-16 months

Pathogenesis
Adult worms live in afferent lymphatics or sinuses of lymph nodes which cause inflammatory damage to the lymphatics Results to lymphatic dilatations and thickening of the vessel walls. Infiltration of plasma cells, eosinophils, and macrophages in and around the infected vessels along with endothelial and connective cell proliferation Tortuosity of the lymphatics and damaged or incompetent lymph valves Lymphedema and chronic statis changes with hard or brawny edema

Clinical Manifestations

CHYLURIA

Types of Clinical Manifestations

1. LYMPHATIC FILARIASIS presence of adult worms 2. OCCULT FILARIASIS - immunohyperresponiveness
Clinical Spectrum
None Asymptomatic Microfilaremia Filarial Fever Chronic Pathology TPE

OCCULT FILARIASIS Lymphatic

NO classical manifestation Due to immunologic hyperresponsiveness to filarial antigens derived from microfilaria. It is seen more in males. Patient may present with paroxysmal cough and wheezing, low grade fever, scanty sputum with occasional haemoptysis, adenopathhy and increased eosinophilia. X-ray shows diffused nodular mottling and interstitial thickening.

Stages in Lymphatic Filariasis

Asymptomatic amicrofilariaemic
Asymptomatic microfilariaemic Stage of Acute Manifestation Stage of Obstructive (Chronic) Lesions

Stages in Lymphatic Filariasis Lymphatic

A. Asymptomatic Amicrofilariaemia
ABSENCE of Mf or clinical manifestations Some degree of exposure to infective larvae

B. Asymptomatic Microfilariaemia
Blood positive for Mf Asymptomatic for years Carriers: Important SOURCE OF INFECTION in the community

Lymphatic
C. Stage of ACUTE manifestations
1st month and years Recurrent episodes of acute inflammation in lymph glands and blood vessels Manifestations: Filarial fever (ADL-DLA), Lymphangitis, Lymphadinitis, Epididimo orchitis

D. Stage of CHRONIC OBSTRUCTIVE lesions

10-15 years d/t fibrosis & obstruction of lymph vessels permanent structural changes

ADL

Hydrocoele

Scrotum

Penis

Breast

Arms

Legs

Chyluria & Hematuria

Laboratory Diagnosis
1. Demonstration of Microfilariae in the peripheral blood Blood Smear (wet/thick)
std method for diagnosing active infection best time for blood collection: 8pm-4am provocative test (DEC) for daytime sampling stained with Giemsa or H&E

(Belizario & de Leon, 2004; www.cdc.gov).

Filariasis in the Philippines

abaca

Filariasis in the Philippines

First discovered in the Philippines in 1907 by foreign workers Prevalence rate has declined:
9.7 cases per 1,000 population (1998), to 7.7 per 1,000 in endemic areas (2002)

Morbidity rate has also dropped:

from 1.5% in 1997 to 0.5% in 2010

Figure 1. Morbidity rate, Filariasis, 1997-2010

Degree of Endemicity (WHO)

ENDEMICITY LOW

MICROFILARIAL RATE <5%

MODERATE

5%-10%

HIGH

>10%

Categories of Endemicity in RP
Category

ENDEMIC
Areas

- established as endemic areas for Filariasis, with validated recent reports of endemicity - identified as endemic in 1960 survey excluding provinces in category 1, without report of endemicity to date.

Category

2 3

PROBABLYENDEMIC Areas

Category

NON-ENDEMIC Areas

- without validated report of endemicity up to present.

(WHO, 2005)

A place is considered endemic, by DOH criteria, if one case of filariasis is detected (deformity survey, positive ICT), specifically: An ENDEMIC BARANGAY has one case of filariasis, An ENDEMIC MUNICIPALITY has one endemic barangay An ENDEMIC PROVINCE has one endemic municipality.

Filariasis in the Philippines

189 endemic municipalities in 39 provinces in 10 regions

Of the 645,232 cases reported, 56% were in Mindanao (DOH, 2008). 76% of the filariasis endemic areas are poor municipalities.

Regions 8,9,10 and CARAGA are the most highly affected regions (2008): Region 8 (Nor. Leyte, Nor. Samar, Ormoc City)
0.1 per 100,000 population

Region 9 (Zambonga del Sur)

less than 0.1 per 100,000 population

Region 10 (Bukidnon, Misamis Oriental)

0.2 per 100,000 population

CARAGA (Surigao del Sur, Bislig City, Surigao City)

1.1 per 100,000 population

Region Province IV-A Quezon Province IV-B Marinduque*, Mindoro Oriental, Mindoro Occidental, Palawan, Romblon* V Albay*, Camarines Norte, Camarines Sur, Catanduanes, Masbate, Sorsogon* VI Iloilo, Capiz, Aklan VII Negros Occidental, Negros Oriental** VIII Biliran*, E. Samar*, N. Samar, W. Samar*, N. Leyte, S. Leyte* IX Zamboanga del Norte, Zamboanga del Sur, Zamboanga, Sibugay X Bukidnon*, Misamis Occ., Misamis Or. XI Davao del Norte/del Sur, Davao Oriental, Compostela Valley* XII Saranggani, S. Cotabato, N. Cotabato*, Sultan Kudarat CARA Surigao del Sur/del Norte, Agusan del Sur*, Agusan del Norte, GA Dinagat Island* ARMM Maguindanao, Basilan, Sulu
* Filariasis-free ** Recently identified as endemic for filariasis

Proportion of symptomatic cases found positive (NEC, 2010)

Epidemiology
Host Factors Adults > Children, Males > females.
Conditions (specifically economic activities) that predispose adults and men to exposure to mosquito vectors

Region V (Bicol) hydrocele is a common presentation of filariasis

(Belizario)

Higher incidence in males due to their exposure in the field

Epidemiology
In the Philippines, 2 species of filaria are known:

W. bancrofti - predominant organism

- nocturnal

B. malayi

- reported from 7 provinces

- noctural subperiodic

4 provinces Davao Oriental, Palawan, Eastern Samar and Surigao del Sur have both species
Nocturnal: MF scarce in the peripheral blood by day, peak at night (10pm-2am) Nocturnal subperiodic: MF present all the time, peak (5-11pm)

(Kron, 2000)

Distribution of Filariasis in the Philippines

PINK: Wuchereria bancrofti BLUE: Brugia malayi YELLOW: both GREEN: Undefined species

(Kron, 2000)

National Filariasis Elimination Program

Progress of NFEP
Baseline data
Prevalence Rate (1997): 9.7% per 1,000 pop. Endemic in 43 provinces in 11 regions with a total population at risk of 30,000,000

Target Population
Individuals living in endemic municipalities in 44 provinces in 12 regions (30 million targeted for mass treatment or 1/3 of the total population of the country). However, 9 provinces have reached elimination level namely: Southern Leyte; Sorsogon; Biliran; Bukidnon; Romblon; Agusan Sur; Dinagat Islands; Cotabato Province; and COMVAL.

National Filariasis Elimination Program

VISION
Healthy and productive individuals and families for Filariasis-free Philippines

MISSION
Elimination of Filariasis as a public health problem thru a comprehensive approach and universal access to quality health services

GOAL
To eliminate Lymphatic Filariasis as a public health problem in the Philippines by year 2017

National Filariasis Elimination Program

8 STRATEGIES
Endemic Mapping Capability Building
Mass treatment

Support Control Monitoring and Supervision

Evaluation National Certification

International Certification

STRATEGY 1

ENDEMIC MAPPING
categorizing provinces based on prevalence of filariasis for tracking of cases & prioritization
3 COMPONENTS:
1. Deformity Survey 2. Cluster Mapping 3. Nocturnal Blood Survey

nocturnal blood survey

(WHO, 2005)

STRATEGY 2

CAPABILITY BUILDING
provide the community with the knowledge, skills & access to info, enabling them to perform effectively
empower them to plan & facilitate local programs on filariasis

STRATEGY 2

MASS TREATMENT
drugs are given to ALL residents >2 y/o living in an endemic area whether or not they are infected, for a minimun pd of 5 years
Target: 85% of total pop under this program should be taking the medications

STRATEGY 3

MASS TREATMENT

Diethylcarbamazine

Citrate or DEC

(single dose based on 6 mg/kg body wt) +

Albendazole
(400mg) given single dose given once annually to people 2 yrs & above living in established endemic areas

mass treatment

STRATEGY 2

MASS TREATMENT
Other forms of management: SELECTIVE Treatment:
only those with (+) Mf in blood will be given DEC for 12 days

DISABILITY PREVENTION
home-based or community-based care for lymohedema & elephantiasis cases Giving of Disability Mgt Kit (topical antifungal creams, alcohol, soap Includes surgical mgt for hydrocoele

disability prevention

disability prevention

STRATEGY 4

SUPPORT CONTROL

Vector control
Polystyrene beads Insecticide-impregnated bed nets & curtains indoor spraying

STRATEGY 5

MONITORING & SUPERVISION

Monitoring
routine collection and analysis of data that pertain to the delivery of services use indicators as main measurement of effectiveness of the program

STRATEGY 6

EVALUATION
To establish infection: ANTIGEN RATE = no. of persons (+) in ICT x 100 total no. of persons examined

To characterize infection: Mf rate = no. of persons with microfilaria in blood x 100 total no. of persons examined Mf density = total no. of microfilariae x 16.7 (using uL of blood) total no. of persons MF Clinical rate = no. of persons with clinical manifestations x 100 total no. of persons examined

SCHEDULE
Annual Annual

INDICATOR
Process Indicator (% target population covered) % of population given mass treatment experiencing adverse reactions Outcome Indicators MF Rate MF Density

AREA
Per barangay Per barangay

Biennial

Per Sentinel Site

Random Spot Check To be scheduled

Outcome Indicators MF Rate MF Density

Resistance Monitoring Vector Surveillance

Any Sentinel Site To be identified

STRATEGY 6

EVALUATION
To establish the vectors of the disease in the endemic areas Local vector species Identification Man Biting Rate ave. no. of mosquitoes biting man/hr or captured mosquitoes/ man/hour House Resting Density No of mosquitoes collected in the house per man-hour Larval Index optional Annual Transmission Potential optional

Evaluation

May, 1985. Binosawan, Philippines. Larval survey of Aedes poicilieslarvae in leaf axil of abaca plant and in the field

STRATEGY 7

NATIONAL CERTIFICATION Local elimination:

cumulative incidence rate over five years of less than 1 new case per 1000 susceptible individuals

Categories & Conditions for National Categorization Cat.

Condition
Completion of Mass Treatment for 4 years and with Post-treatment Prevalence Rate of <1/1000
Previously endemic municipalities still found to be endemic after survey: Completion of Mass Treatment for 4 years and with Posttreatment Prevalence Rate of <1/1000 Previously endemic municipalities found to be non-endemic after survey: 5-year Cumulative Prevalence Rate of <1/1000 by background surveillance Previously non-endemic municipalities before and after mapping and with 5-year Cumulative Prevalence rate of <1/1000 by background surveillance

1 2
3

STRATEGY 8

INTERNATIONAL CERTIFICATION
Filariasis will be certified as eliminated in the Philippines by a WHO committee upon compliance with the ff: Cumulative Incidence Rate over 5 yrs of >1 new case per 1000 susceptible individuals measured yearly after completion of the Mass Treatment scheme in each endemic municipality in the country. Provision of the necessary documentation and satisfaction of the needed international requirements will warrant approval of the countrys application for International Certification of Elimination of Filariasis.

Progress of NFEP
Provinces that reach Elimination Stage:
Southern Leyte Sorsogon Biliran Bukidnon Romblon Agusan Sur Dinagat island Cotabato Province COMVAL

Declaration of Sorsogon as Filariais-Free Province

At the end of the session, the student should be able to:

Specific Objectives:
Discuss the National Filariasis Elimination Program to include the following: Etiology, mode of transmission, symptoms and pathogenesis of the disease Epidemiology & prevalence of Filariasis in the Philippines Goal, objectives and strategies of the program

General Objective: Understand the DOH program for the prevention and control of Filariasis

Thank you