Eliminating lymphatic filariasis: India's bold plan to finish 3 years ahead of global schedule
Sanghamitra Pati
Abstract
India’s race against time, to achieve the ambitious goal of completely eliminating lymphatic filariasis (LF) by 2027, is like a marathon runner tackling a long, grueling course requiring immense resilience and perseverance. This battle of epic proportions, is far from over, as LF has long been a neglected but potentially debilitating vector-borne tropical disease that has caused immense suffering and deprivation to millions of people worldwide since ancient times. It is caused by filarial nematodes transmitted through infected mosquito bites and has a heavy health-care burden threatening about 863 million people globally. The majority of LF infections are concentrated in India, Indonesia, Bangladesh, and Nigeria, collectively estimated to be around 70% of the global burden.[1] The impact of LF is much more than just chronic physical morbidity with economic losses – the affected individuals face social stigma and considerable psychological distress throughout their lives. An estimated 31 million people are infected by LF in India, with over 450 million at risk, making up 40% of the global human LF burden.[2] It is widespread in both rural and urban areas, and prevalent in 256 districts across 16 states and five union territories of India. Four states, namely Uttar Pradesh, Odisha, Telangana, and Bihar, are responsible for 60% of lymphedema cases, while 80% of hydrocele cases are reported from Uttar Pradesh, Odisha, Jharkhand, and Bihar.[3-5] Recognizing the importance of eliminating this debilitating disease, the World Health Organization (WHO) launched the Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000. While the GPELF program has made significant progress, with a 74% global reduction in the number of people infected with LF since its launch, complete LF elimination still remains a distant goal. India, being a signatory to the World Health Assembly resolution, initially aimed to eliminate filariasis by 2015, which was later aligned with the global target of 2020. The LF campaign in India provides an enabling environment for its elimination, including doorstep distribution of drugs with zero out-of-pocket expenditure. There are ample of capacity-building opportunities for human resources involved before the annual campaign. However, it is mainly limited by the lack of understanding of the rationale behind the drug distribution among the community, which leads to a gap between coverage and compliance. Here, it is worth noting that in recent times, direct observation of drug intake is increasing, which lacked previously. Nonetheless, a major challenge lies in providing drugs and consuming them in urban areas due to multiple challenges such as insufficient human resources, gated societies, unavailability of masses during daytime, and migration. The COVID-19 pandemic caused setback for achieving LF elimination, not only in India but also in other endemic regions worldwide.[6,7] The WHO has now reiterated its commitment to accelerate efforts for achieving the goal of complete LF elimination by 2030.[8] In view of this, the Ministry of Health and Family Welfare (MOHFW), Government of India, has launched an ambitious goal to eliminate LF by 2027, which is 3 years ahead of the global target. For beating the LF menace, a five-pronged strategy has been initiated by MOHFW, which includes: Mass Drug Administration (MDA) campaigns twice a year with National Deworming days (announced as February 10 and August 10); greater emphasis on early diagnosis and treatment for improving the morbidity management and disability prevention (MMDP) services; strengthening integrated vector control (IVC) and multisectoral coordinated efforts; evolving intersectoral convergence with allied departments; and leveraging on existing digital platforms developed for LF control and elimination. These strategies and policies being implemented for LF elimination capitalize on significant scientific successes achieved in the diagnosis and treatment of LF in the past few years. Combination therapy using two to three drugs in a single dose has been found to be more effective than monotherapy, and the MDA program currently uses diethylcarbamazine + albendazole, while ivermectin has been recommended for treating high-risk populations.[9] Administering MDA twice a year has several benefits, such as increased treatment coverage of the at-risk population and a greater reduction in the prevalence of LF through reduction of transmission of the disease. This MDA campaign aims to protect communities from negative consequences such as disability, economic insecurity, and social hardships. Ultimately, this can also reduce the burden of LF morbidity management on the health-care system. In addition, an increased frequency of contact between health workers and the community can lead to greater awareness and education about the disease and its treatment. However, despite past MDA rounds, suboptimal coverage and compliance have hindered the elimination of LF. Multisectoral coordinated efforts are essential for the success of the newly implemented LF elimination programs in India. This involves collaboration between the health sector, local governments, and community organizations to ensure the effective implementation of interventions, including IVC. The current guidelines suggest to inform and involve community leaders in pre-MDA as well as during MDA activities. Previous studies in sub-Saharan Africa have shown social mobilization and sensitization, willingness to ingest drugs (motivating through the information about MDA) and direct observation can be a game changer. Here, context-specific innovative community health education programs may be an important tool. In addition, we further need proof of transmission interruption through xenomonitoring, especially at sites with residual infection and at risk of resurgence of transmission. The inclusion of medical colleges can play a significant role in the early diagnosis and treatment of LF in India, as well as in the strengthening of MMDP services. Along with it, public health outreach programs such as community awareness campaigns, collaboration with government, nongovernmental organizations, and other stakeholders can help strengthen MMDP services. Examples such as Bihar’s involvement of 120 medical colleges in the MDA program and collaborations with Panchayati Raj Institutions, Self-Help Groups, and other departments to raise awareness about MDA[10] show how innovative public health strategies integrated with social awareness can be implemented to reach communities. To reach the key desired features of the newly implemented LF elimination program, the use of rapid diagnostic tests and point-of-care tests can facilitate early diagnosis and treatment, reducing the transmission of the disease.[11] In addition, ongoing research on the development of novel diagnostic tools such as nucleic acid-based assays can provide more accurate and sensitive diagnostics for LF, and other LF research involving epidemiological studies, clinical trials, and the development of new treatments and interventions could provide novel tools for deployment as part of a back-up plan for accelerated LF elimination, should the 2027 deadline for LF elimination in India needs to be revised. In conclusion, LF elimination is an ambitious goal for India; however, it is achievable with concerted efforts. Much like a jigsaw puzzle, all the pieces must come together to win the race against time and achieve the goal of completely eliminating LF by 2027. Robust strategies and policies need to be put into action for succeeding in this goal, involving collaborative efforts, and using innovative public health strategies integrated with social awareness. The collaborative efforts between various stakeholders, such as the health sector, administrative departments, local body governments, and community organizations, can help in winning the fight against LF. With the right strategies and policies in place, India can look forward to achieving complete LF elimination by 2027, and provide a beacon of hope for other countries affected by this disfiguring disease. Given India’s vast, diverse population and geography achieving complete LF elimination by 2027 calls for effective synergism between scientific research, public health policies, and innovative social awareness programs.