SEMINAR ON NATIONAL FILARIA CONTROL PROGRAMME (NFCP)

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 SusrutaSamhita. In 7thcentury A.D., Madhavakara described signs and symptoms of the disease in his treatise MadhavaNidhana which hold good even today. 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 thread-like 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 Wuchereriabancrofti or Brugiamalayi and transmitted by ubiquitous mosquito species Culex quinquefasciatus andMansonia annulifera/M.uniformis respectively. The disease manifests often in bizarre swelling of legs, and hydrocele and is the cause of a great deal of social stigma. Brugian filariasis: Lymphadenitis (swollen and painful lymphnode) occurs episodically, most commonly affecting one inguinal lymph node at a time. The infection lasts for several days and usually heals spontaneously. Characteristically, elephantiasis involves the leg below the knee but occasionally it affects the arm below the elbow. Genital lesions or chyluria (milky colour urine) do not occur in brugianfilariasis. Bancroftian filariasis: The lymphatic vessels of the male genitalia are most commonly affected in bancroftianfilariasis, producing episodicfuniculitis (inflammation of the spermatic cord), epididymitis and orchitis. Hydrocele is the most common sign of chronic bancroftianfilariasis, followed by lymphoedema, elephantiasis and chyluria. The swelling involves the whole leg, the whole arm, the scrotum, the vulva or the breast. Due to damaged lymphatic system, patients with lymphoedema have frequent attacks of infection causing high fever and severe pain. Patients may be bed-ridden for several days and normal routine activities become difficult. Such attacks not only cause acute physical suffering but also directly impede the earning capacity of the individual. Lymphatic filariasis is estimated to be one of the leading causes of disability worldwide. Elimination of the disease is an important tool for poverty alleviation and economic development.

FILARIA VECTORS Culex quinque fasciatus 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. Lymphatic filariasis is transmitted through mosquito bites. The persons having circulating microfilariae are outwardly healthy but transmit the infection to others through mosquitoes. In India, 99.4% of the cases are caused by the species Wuchereriabancrofti whereas Brugiamalayi is responsible for 0.6% of the problem. LIFE CYCLE OF FILARIA PARASITE Man is the definitive host i.e. where the mature adult male and female parasites mate and produce microfilariae whereas the mosquito is the intermediate host. The adult parasites are usually found in the lymphatic system of man. They give birth to as many as 50,000 microfilariae per day, which find their way into blood circulation. The life span of microfilaria is not exactly known which preferably may survive up to a couple of months. The parasite cycle in the mosquito begins when the microfilariae are picked up by the vector mosquitoes during their feeding on the infected person (microfilaria carrier). The microfilaria in mosquito develops into three stages and under optimum conditions of temperature and humidity; the duration of the cycle in the mosquito (extrinsic incubation period) is about 10-14 days. When the infective mosquito feeds on other human host, the infective larvae are deposited at the site of mosquito bite from where the infective larvae get into lymphatic system. In the human host, the infective larvae develop into adult male and female worms. The adult worms survive for about 5-8 years or sometimes as long as 15 years or more.

In filariasis, the life cycle of the parasite is relatively long. In contrast to malaria parasite, it does not multiply in the mosquito vector. The infective larvae transmitted by mosquito do not

multiply in the human host. Prolonged exposure is required to develop patent infection in man. The incubation interval is one year or more. Therefore, the parasite never causes epidemics.

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. The North-Western States/UTs namely Jammu & Kashmir, Himachal Pradesh, Punjab, Haryana, Chandigarh, Rajasthan, Delhi and Uttaranchal and North-Eastern States namely Sikkim, Arunachal Pradesh, Nagaland, Meghalaya, Mizoram, Manipur and Tripura are known to be free from indigenously acquired filarial infection. The disease is endemic in 250 districts in 20 states and UTs.According to recent estimates about 600 million people are exposed to the risk of infection. BURDEN OF DISEASE : Lymphatic filaria is prevalent in 18 states and union territories. Bancroftianfilariasis is widely distributed while brugianfilariasis caused by Brugiamalayi is restricted to 6 states - UP, Bihar, Andhra Pradesh, Orissa, Tamil Nadu, Kerala, and Gujarat. The WHO has estimated that 600 million people are at risk of infection in South east Asia and 60 million are actually infected in the region (WHO). There are about 454 million people (75.6%) at the risk of infection with 48 million (80%) infected with parasite are contributed only by India. 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: The first pilot project for the control of bancroftianfilariasis was undertaken in a group of villages in Orissa from 1949 to 1954 through the conventional methods, namely mass drug administration with diethylcarbamazine (DEC) recurrent antilarval measures Residual insecticidal spray as anti-adult measure.

The pilot study revealed that each of the above methods had its own drawback but a project using all the three methods concurrently was appropriate for the control of filariasis. Whenever the disease was found the survey and control units were established.An assessment committee was appointed in 1961 to note the progress made against malaria.It was found that the insect vector culexfatigens has become resistant to all the available insecticides. Recommendationsof assessment committee. (a)proper environmental sanitation (b)antilarval measures by the application of oil. This has an implication for the nurses working in the community to educate the people on promotion of good environmental hygiene. 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.

The emphasis was shifted to reduce the problem of filariasis and stop the transmission through intensive antilarval and anti-parasitic measures.

 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 atCalicut ,Rajahamudry(AP) and Varanasi(UP) under the National Institute of communicable diseases ,Delhi. At the state level 12 headquarters bureaux are functioning. In June1978 ,the operational component of NFCP was merged with the urban malaria scheme for maximum utilization of available resources.The training and research components ,however continue to be with the Director ,National institute of Communicable diseases ,Delhi. National filarial control programme is being implemented through 206 filaria control units ,199filaria 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. The organophosphorus compounds like temephos and fenthion and drugs are supplied by the Centre.

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.

Home based management of lymphedema cases and upscaling of hydrocele operations in identified CHCs /district hospitals/medical colleges. 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. The microfilaria survey in all the implementation units is being done through night blood survey before MDA.The survey is done in 4 sentinal and 4 random sites collecting total 4000 slides (500 from each site).There is definite evidence of microfilaria reduction in the MDA districts.However the coverage of population with MDA should be above 80% persistently for 5-6 years,which would reduce microfilaria load in the community and there by interrupt the transmission. 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. Home based management of cases who already have the disease and hydrocelectomy operations in identified CHCs and hospitals.

Annual Mass Drug Administration with single dose of DEC was taken up as a pilot project covering 14 endemic districts of Maharashtra State viz. Solapur, Chandrapur, Gadchiroli, Nagpur, Bhandara, Wardha, Godia, Yeotmal, Amaravati, Jalgaon, Nandurbar, Thane, Sindhudurga, &Nanded. during Jun 2004. 1.58 Crore selected population was covered under MDA in 2004 and extended to 2.68 Crore population in 18 districts for the year 2005. Four newly added districts for the campaign are Ratnagiri, Latur, Osmanabad, & Akola. This strategy is to be continued 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. Annual mass drug administration (MDA) of single dose of antifilaria drug for 5 years or more to the eligible population (except pregnant woman,children below 2 years of age and seriously ill persons)to interrupt transmission of disease. To achieve elimination of lymphatic filariasis,during 2004 the Govt. of India launched annual MDA with single dose of DEC tablets in addition to scaling-up home based foot care and hydrocele operation.The co-administration of DEC+Albendazole has been upscaled to cover population at risk. 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 i. 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.

ii.

iii.

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

Parasite control with DEC is often relatively cheap when compared with vector control. The drug is safe and effective for human lymphatic filariasis. There is basic difference between individual

and community treatment of filariasis. In the first case, it is usually the patient who is in need of help and therefore he or she is more likely to comply with the treatment. In a community, on the other hand, only a small proportion of the population is suffering from acute clinical filariasis at any one time and therefore a few people feel the need for help. During a largescale treatment programme, the key to success is the ability of the peripheral (village/subCentre) level team involved in MDA to communicate effectively with the community. Once the mutual confidence is builtup, the communication with people becomes easy and the treatment objectives and nature of possible reactions would be explained to them. The success of the strategy also depends on the speed of control measures put forth in order to prevent parasite becoming reestablished within a stipulated period of time.

One of the main reasons for "non-compliance" to the MDA programme is the occurrence of sideeffects reported by consumers. DEC is reported to be safe, and does not produce any chronic toxicity. However, people harboring filarial infection are likely to experience side-effects as a consequence of the interaction between the drug and the parasite, particularly if mF counts are high. In others, the symptoms are usually nonspecific and self-limiting. There is no evidence yet that this message has reached the community at large. The people's awareness on MDA widely varies between different community settings. An intensive information, education, communication and advocacy campaign involving professional bodies will be highly useful to achieve the desired community compliance.

Medicated salt regimens in India: Based on the encouraging results obtained in pilot trials in the Uttar Pradesh and Andhra Pradesh, the distribution of 0.1% DEC medicated salt to general public for one year was implemented in Lakshadweep, comprising a population of 25,000 during 1976-77 which reduced MF rate by 80% and circulating MF by about 90%. The DEC medicated salt project with 0.2% concentration was concluded at Karaikal; Pondicherry which gave significant reduction in microfilaraemia. DEC pilot project was taken up during 1989 in selected villages of Kalakuchi Health District of Tamil Nadu. 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: A. Control Mosquito larvicidal spraying operation, pistia removal and anti parasitic (DEC) treatment. B. 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 Filaria Cases(kerala)

Year 200102 200203

Persons Examined 971658 1003222

Cases detected MF 13142 13848 Disease 2374 2527

Hydrocele Operations 1642 2666

200304 200405 200506 20062007 20072008 200809 up to May

1055505 1086526 1045770 925331 1049923 194855

13292 10311 8270 5588 4705 825

1396 1776 1024 623 655 216

2287 4232 3615 3056 4250 133

A workshop to develop the vision, objectives and strategies for the approach paper to the twelfth five year plan was held at the on 15th September 2011 at the State Health Resource Centre, Thycaud, Thiruvananthapuram. 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. Kerala has to become serious about control of plastics as plastic waste has become the single most important location of waste water where mosquito breeds. Ayurveda and Homeopathy have to take up identified hotspots and establish that interventions using the strategies in their stream of medicine have brought down incidence. The group considered the lack of an effective public health act a major lacuna in the control of communicable disease. Kerala should have an effective public health act soon. 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. This advance information must be mopped up by surveillance workers/Malaria inspectors/DMOs so as to facilitate the villagers to extend full cooperation in getting actual spray inside of human dwelling with the objective of full coverage of targeted population.

Role of NGOs 1. Non Governmental Organizations (NGOs), Community Based Organisations (CBOs), Faith Based Organisations (FBOs) can play an important role in LF elimination. 2. 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. 3. A list of NGOs, DBOs, FBOs and enterprising Panchayats with the possible areas of partnership should be prepared. The possible areas of partnership for an active role of voluntary organisations for Elimination of Lymphatic Filariasis (ELF) in India are identified in the following three specific areas i. ii. iii. iv. 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.

The private health sector represents a substantial resource, especially in urban areas. Private medical practitioners can also be motivated through the professional organizations. These organizations can also identify areas in which the support of private physicians could best be utilised in mass drug administration and in morbidity (disability) management. The private sector, industrial houses and private educational institutions are also important groups for organizing mass treatment campaigns for their employees. Large industries provide health services to their employees and their families and sometimes also provide health services to the industrial township or rural area where they are located. An inventory of private establishments will enhance planning for drug distribution.

The following mid-course corrections are suggested which would facilitate the present control/elimination strategy:

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 co-ordinated 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.

BIBLIOGRAPHY Book 1.Park.K Parks Textbook of preventive and social medicine.21stedition,Banarsidas Bhanotpublishers.pp- 814-818 2.Lucita Mary Nursing:Practice and public health administration.2ndedition.Elseiver publishers.pp-262-325 3.Basavanthappa.BT Text book of community health Nursing2ndedition.Jaypee publishers.pp321-330 4.Gulani.kk Textbook of community health nursing2ndedition.Kumar publishers Pp 256-262

Net reference www.nrhm.org www.authorstream.com www.arogyakeralam.org www.mohfw.org