When mass drug administration breaks the transmission cycle of a disease, it also helps break the cycle of poverty… A 2012 report found that India loses, on average, $1 billion to lymphatic filariasis, or L.F., which is the world’s second-largest cause of chronic disability ( and is economically debilitating as well) every year. However, the report estimated a return of $20-$60 for every dollar spent on treatment… One-third of the world’s lymphatic filariasis patients live in 15 Indian States and Union Territories, with Bihar, Kerala, Uttar Pradesh, Orissa and Assam being the most endemic. This disease is common among poor people who live in unhygienic conditions such as slums or in coastal regions where waterside housing and floating vegetation is common. Apart from disability, lymphatic filariasis causes stigma, isolation and psychological stress among affected individuals….
In communities across Africa, health workers are going house to house with medicine to combat lymphatic filariasis, or L.F., which is the world’s second-largest cause of chronic disability. They make sure the children are old enough, the women aren’t pregnant and no one is seriously ill. Then people take two pills while the health worker watches. She writes down their names in her ledger. What makes this remarkable is that most of the people being treated aren’t sick. They are participating in a strategy called mass drug administration, which treats everyone in an area where a disease is found – even if they aren’t sick or infected. Normally, it would be malpractice to treat people for a disease they don’t have. But some neglected tropical diseases will go on slowly killing and disabling people as long as some in the population are infected. Mass treatment is the way to break the cycle of transmission.
Mass drug administration has all but eliminated river blindness in the Americas, a disease that had put half a million people at risk of going blind. Researchers consider it a key strategy for eliminating other neglected tropical diseases. “There is no doubt in my mind that mass drug administration is going to improve the quality of life of a billion people,” said Alan Fenwick, a professor of tropical parasitology at Imperial College in London.
Mass drug administration is also being used to combat other neglected diseases that cause blindness, chronic illness and malnutrition. But its most promising application is against L.F., which infects more than 120 million in at least 72 countries. Most who are infected don’t show any symptoms, even as the disease wears on their kidneys and immune systems. Others have it much worse. Some people suffer severe swelling of their legs and scrotum. Ultimately, it can lead to elephantiasis. It becomes hard to walk and work. The greater the swelling, the greater the shame people feel, and the more isolated they become from their family and friends. Like many neglected diseases, L.F. doesn’t kill its victims quickly. Instead, it hacks away at their quality of life. Every year, people lose 5.9 million years of good health to this disease.
Recently, however, researchers reported a breakthrough in the fight against L.F. A paper for PLoS Neglected Tropical Diseases describes how Togo is set to become the first sub-Saharan African country to eliminate the disease. Here’s how Togo did it. First, health officials mapped the disease burden. To do so, they set up sampling sites across the country. At each site, they collected about two drops of blood from people’s fingertips. They tested this blood for infection. A small country on Africa’s west coast, Togo is divided into 35 health districts. They found L.F. in 7 of them.
In order for mass drug administration to work, at least 65 per cent of the community must take the pills. Treatment is voluntary, of course. But how to convince people to take the drugs, if they aren’t sick? “This is the trickiest part of the problem,” said Yao Sodahlon, the lead author of the paper on Togo’s success story and formerly the director of the Division of Clinical Laboratories in Togo’s Ministry of Health. “A very strong component of the program is to sensitise the community and let them know, even though you don’t feel sick, you may be harboring the parasite. And if you want to protect your community, take these pills.”
In Togo, health officials met with village heads and trained them to understand both the disease and the goal of the intervention. Along with the village head, people from civil society, such as the town crier, helped spread this information. They also handed out pamphlets, hung posters and ran advertisements on the radio with contact information for questions. Across all media, the message was consistent: If you take these drugs, your children will not know this disease.
But this only works in small villages, where neighbors distribute the drugs to neighbors. This is what Frank Richards, the director of the Carter Center’s lymphatic filariasis program, calls a “Girl Scout cookies” approach. “When it’s time to sell Girl Scout cookies, you call all your friends and neighbors,” Richards said. “Essentially, you’re visiting people you know. The word is out in these small communities what this is about. As soon as you move from rural villages where everyone knows each other, and where you know the people who are treating you, this works far less well.”
Mass drug administration is only ethical if the drugs have no dangerous side effects. But how do we figure out which drugs should be used to treat millions of people? Take the case of ivermectin, a drug for L.F. and river blindness. First, Merck scientists ran clinical trials. Once they knew it was safe and effective, they ran into another problem: distribution. To get the drugs to the people who need them the most, they partnered with the World Health Organization, the Carter Center, and the World Bank. They also teamed up with ministries of health, N.G.O.s, and community officials. Public-private partnerships select the drugs and get the program off the ground. But ultimately community members are empowered to treat each other.
This is another reason the community health worker is so critical. These drugs are safe, when used carefully. Children under the age of six, for example, cannot be treated with certain drugs, such as praziquantel for schistosomiasis, a parasitic worm infection. If a drug is given to a child who is too young, this can result in serious side effects. Recently, several children died during a mass drug administration in Zimbabwe, though the link, at present, is unclear.
With L.F., fortunately, ivermectin isn’t only safe. Ivermectin works on L.F. by breaking the transmission cycle of infecting mosquitos. But it also gets rid of common worms and scabies. This was a huge boost for the mass campaign. “People become really excited about the medicine,” said Richards. “Some of the kids being born were actually being named after the medicine, because they were felt to be good for fertility, or, for men, an aphrodisiac. This is because when you get a few good nights sleep and stop itching so much, you feel a lot better about other things.”
What about the expense of treating millions? It is actually not expensive. The drugs themselves are cheap, and usually donated. Merck announced in 1987 that it would donate Mectizan – its brand name for ivermectin – for as long as necessary to treat river blindness. It added L.F. treatment the following year. The other L.F. drug,albendazole, is donated by GlaxoSmithKline. It is also useful that the most prevalent neglected tropical diseases can be treated at the same time. In fact, there is overlap among seven diseases.
Because of drug donations and treatment overlap, the cost of mass drug administration is 50 cents per person annually. This is what makes mass drug administration “one of the best buys in public health,” according to Monica Parise, chief of the Parasitic Diseases Branch, Centers for Disease Control and Prevention.
When mass drug administration breaks the transmission cycle of a disease, it also helps break the cycle of poverty. These diseases cause chronic disability in communities where people live on less than $1.25 per day. This is a poverty trap. Tailors can’t see clearly enough to thread their needles. Fishermen are forced to flee infested waters. Children, who think urinating blood is normal, can’t concentrate in school.
“These are not killer diseases,” said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine. “They do everything but kill. But what they’re doing is robbing iron and energy. They occur in poverty and they cause poverty.” Consider L.F. in India. A 2012 report found that India loses, on average, $1 billion to the disease every year. However, the report estimated a return of $20-$60 for every dollar spent on treatment. But community involvement and low cost weren’t the only ingredients for the success of mass drug administration in Togo. A key component is surveillance. How can we tell that mass drug administration works, and when a disease disappears?
First, community health workers monitored how many people took the drugs. Since 2004, the numbers are better than expected. Coverage has exceeded 80 per cent, 10 percentage points better than the goal. Second, they also used a spot-check system. They chose several sites in districts where the disease was found. Then, they took blood samples from people at each site. After nine years of mass drug administration, the latest results show the disease is gone.
Now Togo is trying to ensure it doesn’t come back. It will continue surveillance until 2015. It will focus especially on its borders with neighboring countries where the disease still roams and mass drug administration campaigns are continuing. Once complete, the World Health Organization will verify that the disease has been stopped. Despite the success stories, mass drug administration is not enough. If we want to eradicate the world’s neglected diseases, we’ll need to change the environment that allows them to thrive. “These diseases are caused by poor water and sanitation,” said Fenwick. “And we need water and sanitation to reduce the transmission. Until we get that, we’re going to have to keep on treating.” n
(Jason Silverstein is a doctoral candidate in anthropology at Harvard, where he also works with the Hutchins Center for African and African American Research. Follow him on twitter @jason_reads).
Control Of Lymphatic Filariasis In India
The World Health Organization (WHO) classifies lymphatic filariasis (also known as elephantiasis) as a ‘neglected disease of the poor’. One-third of the world’s lymphatic filariasis patients live in 15 Indian States and Union Territories, with Bihar, Kerala, Uttar Pradesh, Orissa and Assam being the most endemic. This disease is common among poor people who live in unhygienic conditions such as slums or in coastal regions where waterside housing and floating vegetation is common. Apart from disability, lymphatic filariasis causes stigma, isolation and psychological stress among affected individuals.
Lymphatic filariasis is a tropical disease. It is transmitted by filarial parasites that are passed on to humans through mosquito bites. The larvae enter the lymphatic vessels and adult worms form ‘nests’ in the lymphatic system. Infection is usually acquired in childhood, but the painful and disfiguring visible manifestations of the disease occur later in life. Whereas acute episodes of the disease (filarial fever or acute dermatolymphangioadenitis) cause temporary disability, lymphatic filariasis leads to permanent disability.
Lymphatic filariasis is also economically debilitating with estimated losses to rural economies of $1 billion annually, mainly because patients are often the family’s primary bread winner. Most patients live in rural villages and are disabled by their swollen legs and suffer repeated episodes of fever. At the Government level, the National Filaria Control Programme aims to eliminate LF by 2015.
Meanwhile, the Global Alliance to Eliminate Lymphatic Filariasis (http://www.filariasis.org) is supporting a mass drug administration programme for over 473 million Indians who are at risk of infection. A single dose of diethylcarbamazine citrate (DEC) and albendazole tablets given together once a year for 5-6 years destroys parasites that circulate in the blood and interrupts disease transmission.
However, medication is aimed at prevention and has little effect on patients who already have swollen limbs. Morbidity control is not yet incorporated as a major part of the programme and although an estimated 23 million people are disabled due to lymphatic filariasis, the Indian government does not presently have any special programmes in place to combat disability and there are huge gaps in treatment provision.
In meeting the challenge of millions of patients disabled by lymphatic filariasis the author’s team adopted a pioneering role that sought to incorporate many elements, including:
- Poverty alleviation
- Morbidity control
- Integrative medicine
- Home-based treatment
- Ethical and evidence-based treatment.
– Dr KS Bose
– Wounds International