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by Fathima Razik Cader

"The remarkable advances in diagnosis, clinical understanding, treatment and control of Lymphatic Filariasis, the success of recent control programmes and increasing political commitment, led the 50th World Assembly in May 1997, to pass a Resolution identifying as a priority, the elimination of lymphatic filariasis as a public health problem. It urges members states to take advantage of these new findings to strengthen local filariasis control programmes, to integrate these control efforts with those directed at the control of other diseases, to strengthen the infrastructure necessary to effect control programmes and to mobilise the support of all relevant sectors, affected communities and non-governmental organisations for the elimination of the disease."

This WHO resolution to eliminate Lymphatic Filariasis has been taken seriously by Sri Lanka (a member state) and currently, the Anti-Filariasis Campaign of the Ministry of Health is a hive of activity and probably outdoing the bees in the process.

Dr. Thilaka Liyanage, Director of the Campaign and her team are fully geared to once again, successfully carry out the one-day treatment' programme on Sunday 27th July in the Western, Southern and North Western provinces in Sri Lanka in their endeavour to eliminate this disease. These three provinces with a population of 9.8 million are the areas where Lymphatic Filariasis (LF) is endemic. This means that more than half of Sri Lanka's population is at risk of developing this disease caused by the thread-like parasitic filarial worms - Wuchereria bancrofti (Wb) and Brugia malayi (Bm) that cause LF to live almost exclusively in the human body. The lymphatic system with its network of nodes and vessels is an essential component of the body's immune system as the nodes and vessels maintain the delicate fluid balance between the tissues and blood.

According to the WHO, an estimated billion people are at risk in about 80 countries. Of this number, over 120 million people are already affected and over 40 million are seriously incapacitated or disfigured by the disease. Filariasis was until recently, a neglected disease. It mainly affects the poor people in the countries where the disease is endemic and in 1995, was identified as the second leading cause of long-term and permanent disability. As such, the true extent of the illness and the resultant disability due to the infection are only now beginning to be quantified.

As is the case in any sickness or injury, in addition to the direct cost of medical treatment, the enormous indirect losses that result from incapacitation leading to loss of labour, drastically impacts on the economy. Also of concern to medical authorities are the yet unquantified effects of the newly discovered subclinical pathology of the renal and lymphatic systems that can affect all those who have the disease. Almost half of those with LF have overt clinical manifestations whilst the rest harbour the infection with hundreds of thousands of worms in their bodies causing internal damage which goes undetected and thereby untreated for a long period of time.

The fact that Wb and Bm that cause lymphatic filariasis live almost exclusively in humans cannot be treated lightly. It would be prudent for people living in the Western, Southern and North Western provinces to be alert to the signs and symptoms. Since the adult worms damage the lymphatic system, fluids collect in the arms, legs, breasts and genitals causing swelling. These are the first signs and in more acute cases, inflammation of the skin, lymph nodes and lymphatic vessels often precede or accompany lymphoedema. In the more severe cases where the normal defences have been partially lost due to underlying lymphatic damage, the result is a grotesque hardening and thickening of the skin. This condition is known as elephantiasis.

The fight against lymphatic filariasis is also a fight against poverty as those who are affected became a heavy social burden. This is because chronic complications are hidden as they are considered an embarrassment.

It may surprise the majority of people who are not affected to know that those who are grappling with the disease in its acute stage also face social stigmatisation. In fact, studies show that marriage (which is usually a source of security) is often not possible for men and women with chronic complications. This is on account of the severe handicaps and physical limitations that such people face.

LF is well established in Africa and the Indian sub-continent and is reportedly on the increase. One of the main reason cited is the rapid and unplanned development of cities that create numerous breeding sites for mosquitoes that transmit the disease. Ten years ago, in 1993 to be exact, an International Task Force for Disease Eradication, identified LF as one of six eliminable infectious diseases. Thankfully, LF has had dramatic advances in treatment methods, controlling transmission, managing the disease and remarkable improvement in technique for diagnosing filarial infections.

In Sri Lanka today, even most children are aware that LF is transmitted from person to person through mosquitoes. The mosquitoes that bite an infected person, carry the microfilariae from the blood, which then develops in the mosquito into the infective larvae stage - a process that takes 7-21 days. The larvae then 'migrate' to the mouth of the mosquito, ready to enter the bloodstream of the next person bitten by this mosquito.

The larvae thereafter 'migrate' from the site of the bite to the lymphatic system and thereby complete the life cycle in an unfortunate and unsuspecting human being. The WHO has a strategy in place, not only to eliminate LF but also to help those who are suffering from the disease. Areas identified as endemic will have community based programmes to treat the entire 'at risk' population. This treatment will effectively break the cycle of transmission between the mosquitoes and humans and will thereby also protect future generations from the disease.

This then leads to the annual 'one-day' administration of single doses of two drugs - namely Albendazole and Diethylcabamazine Citrate (DEC). This programme launched in 2002, will be carried out for five years with the aim of eliminating lymphatic filariasis in Sri Lanka. The supplementary programme coordinated by the WHO will educate individuals with clinical signs on measures they can adopt to contain the painful and debilitating progress of the disease. Further, these measures can also reverse much of the damage already sustained.

Along with the WHO, international organisations, the public and private sectors, academia and non-governmental organizations have formed a global alliance to support the Ministries of Health in countries where LF is endemic and work in synergy with other disease control or elimination programmes.

In Sri Lanka, the Anti-Filariasis Campaign of the Ministry of Health has mustered fifty thousand volunteers to cover the three provinces where filariasis is endemic and it is up to all citizens of the respective provinces to co-operate with the campaign by taking the drugs that will be given to each household. Dr. Inoka Suraweera, Medical Officer attached to the campaign, stressed the need for the drugs to be taken after a meal and when questioned on the possible side effects, said, "These drugs are absolutely safe and used all over the world. However, some may have nausea, vomiting, dizziness or gastritis". She went on to add that pregnant mothers, lactating mothers, children under two years and critically ill patients should not be given these drugs. "If the side-effects are acute, do see a doctor promptly," advised Dr. Suraweera.

The Colombo Municipal Council will also be a part of this year's programme with the Public Health Department taking on the responsibility of covering all the areas that come under its purview. Dr. Pradeep Kariyawasam, Chief MOH of the CMC and his team will be coordinating the distribution of drugs to the city's households.

The onus then is on all citizens in the Western, Southern and North Western provinces in Sri Lanka to appreciate the efforts of the volunteer who will drop by on Sunday 27th July, to hand out the drugs.

The MOH's office in the area will have these drugs for two weeks thereafter, to enable any person (or family) who was not around when the volunteer came by, to obtain the drugs. Precaution is better than cure! Let us therefore laud the untiring efforts of Dr. Thilaka Liyanage and her team at the Anti-Filariasis Campaign of the Ministry of Health, all the Medical Officers of Health in the three provinces, the officers and staff of the Public Health Department of the CMC and the volunteers - fifty thousand of them and without whom this programme might not see the light of day, by extending our whole-hearted co-operation and gratitude.

A welcome smile to greet the volunteer will be deeply appreciated when he or she visits your home on Sunday 27th July.

For each volunteer has to cover fifty to sixty houses and distribute the drugs accordingly, to ensure the overall success of the campaign. Your contribution and mine towards the success of the campaign is simple - swallow the drugs because that will protect us and prevent anyone around us too from being infected by this disease. Not difficult at all, you will agree!

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