SEMINAR ON NATIONAL FILARIA CONTROL PROGRAMME (NFCP)

PRESENTED BY ARUN.JV

INTRODUCTION
Filariasis has been a major public health problem in India next only to malaria. The disease was recorded in India as early as 6th century B.C. by the famous Indian physician, Susruta in his book Susruta Samhita. In 7thcentury A.D., Madhavakara described signs and symptoms of the disease in his treatise Madhava Nidhana which hold good even today.

INTRODUCTION cont
In 1709, Clarke called elephantoid legs in Cochin as Malabar legs. The discovery of microfilariae (MF) in the peripheral blood was made first by Lewis in 1872 in Calcutta (Kolkata).

FILARIASIS
Filariasis is caused by several round, coiled and threadlike parasitic worms belonging to the family filaridea. These parasites after getting deposited on skin penetrate on their own or through the opening created by mosquito bites to reach the lymphatic system. The disease is caused by the nematode worm, either Wuchereria bancrofti or Brugia malayi and transmitted by ubiquitous mosquito species Culex quinquefasciatus and Mansonia annulifera/M.uniformis respectively.

FILARIASIS
Brugian filariasis

Bancroftian filariasis

FILARIA VECTORS

Culex quinquefasciatus transmits filariasis in India. Culex breeds in polluted water. Common breeding sites are wet pit latrines, septic tanks, barrow pits, cess pools, drains, disused wells, paddy fields, etc.

TRANSMISSION OF LYMPHATIC FILARIASIS

The adult produces millions of very small immature larvae known as microfilariae, which circulate in the peripheral blood with marked nocturnal periodicity. The worms usually live and produce microfilariae for 5-8 years.

 In India, 99.4% of the cases are caused by the species - Wuchereria bancrofti whereas Brugia malayi is responsible for 0.6% of the problem.

Wuchereria bancrofti

Brugia malayi

MAGNITUDE OF DISEASE
Indigenous cases have been reported from about 250 districts in 20 states/Union Territories. Cases of filariasis have been recorded from Andhra Pradesh, Assam, Bihar, Chhattisgarh, Goa, Jharkhand, Karnataka, Gujarat, Kerala, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh, West Bengal, Pondicherry, Andaman & Nicobar Islands, Daman & Diu, Dadra & Nagar Haveli and Lakshadweep.

 B. malayi is prevalent in the states of Kerala, Tamil Nadu, Andhra Pradesh, Orissa, Madhya Pradesh, Assam and West Bengal. The single largest tract of this infection lies along the west coast of Kerala, comprising the districts of Trichur, Ernakulum, Alleppey, Quilon and Trivandrum, stretching over an area of 1800 sq km. The infection in the other six states is confined to a few villages. Surveys undertaken recently in Kerala and a few villages in other states revealed either a reduction of foci or complete elimination of the parasite as well as the vector(s) in many villages which were known to be endemic for B. malayi infection four decades back

ECONOMIC LOSS :

About 1.2 billion man-days are lost due to filariasis every year leading to an economic loss of Rs. 3500 crore

NATIONAL FILARIA CONTROL PROGRAMME

National filarial control programme was started in 1955. After pilot project in Orissa from 1949 to 1954, the National Filaria Control Programme (NFCP) was launched in the country in 1955 with the objective of delimiting the problem, to undertake control measures in endemic areas and to train personnel to manage the programme.

Pilot project in Orissa:

mass drug administration with diethylcarbamazine (DEC) recurrent antilarval measures Residual insecticidal spray as anti-adult measure.

Recommendations of assessment committee.

(a) proper environmental sanitation (b) antilarval measures by the application of oil.

Under the NFCP the following avtivities are being undertaken

Delimitation of the programme in unsurveyed areas. Adoption of antilarval and anti-mosquito measures. Detect and treat positive cases of filariasis. Install underground drainage system to prevent mosquito breeding.

4 rural research cum training centres were established,one each in Andhra Pradesh,Maharashtra,Madhya Pradesh ,and in uttar Pradesh 3 regional research cum training centres situated at Calicut ,Rajahamudry(AP) and Varanasi(UP) under the National Institute of communicable diseases ,Delhi. At the state level 12 headquarters bureaux are functioning.

 National filarial control programme is being implemented through 206 filaria control units ,199 filaria clinics and 27 survey units primarily in filarial endemic urban towns.In rural areas anti filarial medicines and morbidity management through primary health care system.

NATIONAL GOAL The National Health Policy 2002 aims at Elimination of Lymphatic Filariasis by 2015.

The elimination is defined as lymphatic filariasis ceases to be public health problem, when the number of microfilaria carriers is less than 1 percent and the children born after initiation of ELF are free from circulating antigenaemia(presence of adult filarial worm in human body)

Central Assistance
During Fourth Five Year Plan the NFCP was 100 per cent centrally sponsored programme. But in Fifth Five Year Plan, only material and equipment were supplied by the Centre from its share and the entire operational cost was borne by the States. However, from 1978 onward the Central assistance was further reduced by sharing the cost of material and equipment on 50:50 basis. Up to Seventh Five Year Plan the NFCP budget was separate and the same was merged with budget of Urban Malaria Scheme during Eighth Five Year Plan continuing the sharing the cost of material and equipment on 50:50 basis.

FILARIA CONTROL STRATERGY

Vector control through anti larval operations Source reduction Detection and treatment of microfilaria carriers Morbidity management IEC

Anti-mosquito and anti-larval measures :

Anti-larval measures with temephos in prescribed dosage in water storage tanks every week and application of Mineral larvidcidal oils on water surface are practiced. The larvicide under use includetemephos, Fenthion and MLO. The selection of breeding places for treatment with a particular larvicide is done judiciously. Recurrent antilarval measures at weekly intervals. Environmental methods including source reduction by filling ditches, pits, low lying areas, deweeding, desilting, etc. Biological control of mosquito breeding through larvivorous fish.

 The line listing of lymphedema and hydrocele cases were initiated till 2004 by door to door survey in filarial endemic districts.Initiation has also been taken to demonstrate the simple washing of foot to maintain hygiene for prevention of secondary bacterial and fungal infection in chronic lymph edema cases,so that the patients get relief from frequent acute attacks.

Home based management of lymphedema cases and upscaling of hydrocele operations

Mass drug administration (MDA)

DEC dosage schedule: The DEC dosage adopted in the programme is 6mg/kg body wt. per day for 12 days. The strategy for achieving the goal of elimination is by Annual Mass Drug Administration of DEC for 5 years or more to the population excluding children below two years, pregnant women and seriously ill persons in affected areas to interrupt transmission of disease.

 During 2008 around 121 million population in selected districts of Tamil Nadu,Karnataka,Kerala and Andhra Pradesh were covered with co administration of single dose of DEC+Albendazole.Rest the districts were covered with DEC alone.The MDA coverage was 82.75% in 2007 and 85.9% in 2008.

Objectives of MDA
To review the progress of activities of single dose DEC mass administration in the selected districts. To make independent assessment of the programme implementation with respect to process and outcome indicators. To recommend midcourse corrections and suggest necessary steps for further course of action.

The Basic Principle of Revised Strategy for the Single Dose Mass DEC Administration
Interruption of disease transmission Treatment of problems associated with lymphoedema (disability prevention and control)

 One of the main reasons for "non-compliance" to the MDA programme is the occurrence of side-effects reported by consumers. DEC is reported to be safe, and does not produce any chronic toxicity.

Medicated salt regimens in India

The DEC medicated salt project with 0.2% concentration was concluded at Karaikal; Pondicherry which gave significant reduction in microfilaraemia.

B.malayi control
The pilot project under the auspices of NICD in Kerala has revealed that the vectors of B.malayi are amenable to indoor residual spray of HCH at a dose of 0.2 g/m2 per round, three rounds a year. Integrated vector control approach for control of this infection was being implemented by VCRC Pondicherry in Cherthala of Alapuzhadistrict, Kerala.

National Filaria Control Programme in kerala

Filariasis is prevalent in the entire coastal belt and in some pockets of Kerala. About 6.3 million people are exposed to the risk Filarisis and 2.8 million people are protected by NFCP. The programme was launched in the State during 1955-56. Now it is implemented through 16 NFCP units, 2 Filaria Survey Units and the Filaria control works at Cherthala. Attached to the Filaria Units, 11 Filaria clinics are functioning. The Filaria Survey Unit at Thrissur was shifted to Thiruvananthapuram in May 95 and continues to function as main central unit at Valiyathura in Thiruvananthapuram.

Activities
Control Mosquito larvicidal spraying operation, pistia removal and anti parasitic (DEC) treatment. Assessment Entomological and parasitological (filaria survey)

Monitoring Agency
The State Headquarters Bureau of Filariasis under the Assistant Director (Filaria) attached to the Directorate of Health Services is monitoring and assessing the work at the State level

Achievements of National Filaria Control Programme

Cases detected Year Persons Examined Hydrocele Operations

MF

Disease

200102

971658

13142

2374

1642

200203

1003222

13848

2527

2666

200304

1055505

13292

1396

2287

200405

1086526

10311

1776

4232

200506

1045770

8270

1024

3615

20062007

925331

5588

623

3056

20072008

1049923

4705

655

4250

200809 up to May

194855

825

216

133

A workshop to develop the vision, objectives and strategies for the approach paper to the twelfth five year plan
The filaria elimination strategies were also discussed. Kerala should aim to eliminate filariasis through active case detection and through effective implementation of MDA campaign. Rehabilitation of patients including surgery and artificial aids should also be done effectively. An effective waste management and source reduction for mosquito is a necessary condition for reduction of incidence of communicable diseases.

Expected Community Participation

Involvement of Panchayats in successful indoor residual insecticide spray is an essential aspect of the programme. Panchayats/villages/local bodies/village heads/BDOs/MahilaMandals, religious groups etc. are to be informed about the spray schedule at least before a fortnight.

Role of NGOs
Non Governmental Organizations (NGOs), Community Based Organisations (CBOs), Faith Based Organisations (FBOs) can play an important role in LF elimination. These organisations should be invited to discussions when the annual strategic plan is prepared, so that they can identify areas of interest for their participation, which could be incorporated in the national plan. A list of NGOs, DBOs, FBOs and enterprising Panchayats with the possible areas of partnership should be prepared.

 Mapping of areas through morbidity surveys. Social Mobilization for drug compliance. Supporting mass drug administration and management of adverse reactions. Morbidity Management at community level

MID-COURSE CORRECTIONS
A geographically identified risk area or PHC should be made an intervention unit. Vector control should be a component in the LF elimination campaign. It is not wise to depend only on MDA. A single strip of two tablets, one each of DEC and Alb in blister pack could be used in the programme. Programme managers should be encouraged to adopt the principle of 'directly-observed treatment'. DEC-fortified salt and vector control as an adjunct should be introduced in all residual foci, including the areas where other intervention measures are weak. An intensive information, education, communication and advocacy campaign involving professional bodies is crucial.

NURSES ROLE
Active detection of cases through surveys.the coordinated effort of peripheral level workers has to be ensured. Supply of DEC tablets as per the government policies and explaining the benefits.Removing the misconception of the people regarding adverse effects of DEC is essential. Health education and promotion of IEC activities about the disease,vector control,environmental sanitation,removing social stigma of disease etc Ensuring adequate treatment for identified cases. Co-ordinating the efforts of NGOs and non voluntary organizations in filarial control activities.

CONCLUSION
Elimination of filariasis using annual MDA is one of the most economical and beneficial disease control strategies undertaken so far in public health programmes. Now, the whole world is looking at the progress of the LF elimination programme in India as the population living at risk of infection is high, and hence the height of its achievement will greatly have a bearing at the global level.