LF elimination programmes are good investments in health and poverty reduction. Increases in productivity and earning potential are important outcomes realized in areas where LF is eliminated. Gains in labour productivity come directly from the prevention of acute attacks, hydrocele, and lymphoedema, conditions which severely decrease worker productivity. Savings on medical treatment from the elimination of LF represent another significant gain for individuals and health systems.
TOGO: First African country to be validated
In the eight districts which were endemic for lymphatic filariasis (LF) in Togo, 6 to 9 rounds of annual MDA were conducted from 2000 to 2009 with the combination of ivermectin and albendazole and coordinating with the ongoing MDA for onchocerciasis control as a platform.
The reported treatment coverage in the districts was consistently high throughout the 10 years of MDA resulting in the complete decline in microfilaria in selected sites and a successful transmission assessment survey.
The results of the five-year post-MDA surveillance did not show any sign of recurrence of the disease following the stopping of MDA. Importantly, Togo implemented successful morbidity management and disability prevention programmes to help address the impact of the disease on those infected.
As the two pillars of the programme were successfully addressed, the country was approved in 2016 by the WHO-AFRO NTD Regional Programme Review Group to have achieved the elimination of LF as public health problem.
Strong and diverse partnerships, integration to existing health interventions and innovative approaches were the key determinants of success in Togo which is on the way to becoming the first sub-Saharan African country to be validated free of LF by the WHO.
PERSONS REQUIRING MASS DRUG ADMINISTRATION
2010 2015 2016
1.2m 0 0
MDA no longer required. Elimination being validated
The Bangladesh Filarial Elimination Programme (FEP) launched in 2001, with an estimated 70 million people at risk. FEP scaled-up MDA across 19 districts requiring MDA with support from MOH, UKAid (CNTD) and USAID (FHI360) so that by 2009, all endemic districts were receiving MDA. Partners’ support primarily focused on MDA advocacy and TAS. Scale-down of MDA started in 2012 following completion of TAS. In 2016, the final district passed TAS, resulting in a total population of 33 million no longer requiring MDA across the country. TAS has also been completed in 15 districts considered to be ‘low endemic’ and not requiring MDA at the start of the programme, confirming absence of transmission in these areas, and a further 37 million people not at risk of infection. In addition to ongoing TAS, FEP is conducting post-transmission surveillance with support from CDC, Atlanta in selected districts.
Since 2012, morbidity management activities have been scaled up across Bangladesh, with training conducted for community health workers and patient case/estimate mapping in the 19 endemic districts between 2013 and 2016. Over 8,000 community health workers were trained, and over 43,000 lymphoedema and hydrocele patients were reported. Lymphoedema management is provided in these districts through community clinics, and hydrocele surgery has been made available through intensive camps with a total of 14,900 surgeries provided to date (2003-2016). Additionally, patient searching was conducted in the 15 low-endemic districts, including the peri-urban areas of Dhaka, to ensure all patients have access to care. Health worker training is ongoing, with retraining of community health workers in seven districts conducted in 2017. With support from CNTD, quality of training evaluations, health facility assessments and access to care surveys will be conducted in 2017 to provide evidence to support FEPs ongoing activities and elimination efforts.
PERSONS REQUIRING MASS DRUG ADMINISTRATION
2010 2015 2016
36.34m 3.21m 0
33.1 million persons no longer require MDA
CHINA – A Case Study of Success
In China before control strategies were implemented, 330 million people were at risk of becoming infected with LF, with over 30 million cases documented. In the early 1950s, China targeted five diseases as a means of improving agricultural and industrial productivity, one of which was LF. The Chinese government was worried about the negative impact of the chronic clinical cases of LF (lymphoedema and hydrocele) and the repeated acute attacks of inflammation, after finding that approximately 80% of these occurred in people in the labour force. In the early 1980s, they estimated that 17.28 million days of labour were lost each year.
A cost-benefit analysis on an LF control programme in Zhejiang Province, China calculated a cost-benefit ratio of 1 to 5.7, implying that one Yuan spent on filariasis control produced 5.7 Yuan in benefits.
AFRICA – A Positive Economic Rate of Return
For the African LF programme, the economic rate of return would be approximately 27%. LF elimination programmes in Africa are likely to produce increases in health status, quality of life, and the productive potential of workers.
Epidemiological modelling was used to estimate both the costs of implementing LF mass drug administration (MDA) activities in the context of ongoing onchocerciasis activities and outcomes associated with the MDA activities. The population at risk was assumed to be 314 million residents in areas with known active LF transmission. On average, acute attacks were assumed to reduce a worker’s labour productivity by 2% per year, hydrocele and lymphoedema by 20% per year. Productivity was measured using the marginal productivity of agricultural labour.
LF was found to cost Africa US$1.3 billion per year from LF disability: 6% (US$78 million) from acute attacks 11% (US$140 million) from lymphoedema 83% (US$1.1 billion) from hydrocele. The LF programme would cost from US$0.20 - $0.50 per person per year. By 2029, the number of men with hydrocele would fall from almost 20 million to less than 4 million, the number of people with lymphoedema from about 4 million to less than 1 million, and the incidence of acute attacks would almost disappear.
But until programmes are fully funded in Africa, the return on investment will be unrealized.