A Future Free of Lymphatic Filariasis: Reaching the vision by scaling up, scaling down, and reaching out
The 7th Meeting of the Global Alliance to Eliminate Lymphatic Filariasis (GAELF) was held 18-19November, 2012 in Washington, DC. The theme of the meeting, “A Future Free of Lymphatic Filariasis:Reaching the Vision by Scaling Up, Scaling Down and Reaching Out”, emphasized new strategies andpartnerships necessary to reach the 2020 goal of elimination of lymphatic filariasis (LF) as a publichealthproblem. The meeting was held at the World Bank, back to back with a Uniting to CombatNeglected Tropical Diseases (NTDs) forum, in order to capitalize on common themes, participants, andsupport (http://www.unitingtocombatntds.org).
The World Health Organization’s overall goal is universal health coverage with essential public healthinterventions, including access to preventive chemotherapy (PCT) for NTDs. The goal of integratedPCT is to eliminate LF, onchocerciasis, blinding trachoma and, in some cases, schistosomiasis as publichealthproblems and eliminate childhood morbidity related to soil-transmitted helminthiases (STH).Given that 1.4 billion people require mass drug administration (MDA), a type of PCT, for LF, the LFprogramme’s community-based MDA is often used as the platform for integrating PCT diseases.Successful scale up for LF MDA can also cover the majority of the 1.9 billion people needing PCT for atleast one NTD. The current status of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) is that 73countries are endemic, with 1.39 million people at risk, 120 million people infected, and 40 millionpeople affected by LF-related morbidity. The goal of global elimination has two parts: i) to stop thespread of infection and interrupt transmission through MDA and ii) to reduce human suffering throughmanaging morbidity and preventing disability (MMDP). The first part of the goal is realized through thesequential activities of mapping, MDA, post-MDA surveillance and verification. In 2011, 53 countriesimplemented MDA, with nearly 539 million people treated, and 12 countries are under post-MDAsurveillance. The second part is achieved through analyzing the MMDP situation in country, developinga plan, and providing access to a minimum package of MMDP care. In contrast to the success at scalingup MDA, only 27 countries have reported MMDP activities. Progress towards milestones in the GPELF Strategic Plan 2010-2020 has been impressive. Revised M&Eguidelines, including information on implementing Transmission Assessment Surveys (TASs) andverifying absence of transmission have been published. A provisional strategy for interruptingtransmission in loiasis co-endemic areas, where MDA with ivermectin cannot be implemented due toconcerns of serious adverse reactions (SAEs), will be presented to the Strategic and Technical AdvisoryGroup on NTDs (STAG-NTDs) for endorsement in April 2013. Revised MMDP programmatic guidance,including metrics for reporting on MMDP activities to WHO, will be finalized in 2013.
Country case studies
A series of country case studies highlighted common themes necessary to achieve success andovercome challenges. Success in scaling up was bolstered by cultivating dedicated programmemanagers, maintaining government commitment at all levels, and building on existing deliveryplatforms. Presentations on success in scaling down showcased the importance of government supportlasting beyond MDA, as well as providing ongoing technical assistance for post-MDA surveillance anddossier development for verification of the absence of transmission. Countries facing significantchallenges were often those in post-conflict situations, with poor infrastructure and weak health caresystems. Overcoming these challenges requires innovative thinking about delivery strategies, thecreation of novel ways to motivate volunteers, and external financial and technical support. Finally,case studies on accelerating progress showed the importance of improving coverage in areas withongoing MDA before scaling up, and the critical need to build the capacity of LF programme managersto plan, budget and monitor programmes, especially in large, decentralized countries. Participants learned about pioneering efforts to manage morbidity and prevent disability, includingTogo’s national lymphoedema programme, a community-based lymphoedema project in a highlyendemicarea of India, and the African LF Morbidity Project. Providing care for LF-related disease wasshown to increase acceptability and compliance with MDA. The group welcomed the results of a clinicaltrial which showed that doxycycline reversed or halted progression to later stages of lymphoedemamore effectively than amoxicillin or placebo, in patients with and without active LF infection. Theimportance of linking MMDP with other diseases, reporting on MMDP activities to WHO, and collectingdata on surgical complications and recurrence was discussed. A session on linking LF programmes with other disease programmes explored the rationale andopportunities for coordinating with onchocerciasis, STH, trachoma, and malaria activities.Opportunities for synergy with onchocerciasis and trachoma activities include integrated mapping,joint training, combined treatment registers, simultaneous MDA where feasible, and joint M&E. STHactivities greatly benefit from the LF programme; in 2010, WHO reported that 57% of the school-agedchildren treated for STH were given these medicines through national LF programmes. However, likeMMDP activities in LF programmes, interventions related to water, sanitation and hygiene often lagbehind PCT interventions in STH programmes. Both programmes need to bolster these supportiveactivities if the 2020 goal to eliminate LF is to be achieved. LF and malaria activities also complementeach other: LF MDA helps to reduce anemia, provides community networks for bednet monitoring(particularly LLINs), and influences adults to use bednets to avoid LF-related disease, while LLINs helpreduce LF transmission. An animated discussion followed the presentation of data from ongoingentomological monitoring in Nigeria which found no infective mosquitoes after bednet distribution inareas with LF MDA.
Various speakers highlighted challenges to achieving the 2020 goal, including: i) building the capacityof LF programme managers and NTD teams to plan, implement and monitor activities; ii) scaling up to100% geographical coverage for MDA while coordinating with other PCT diseases and vector control activities; iii) planning for TAS, including ensuring the availability and affordability of diagnostic tests;iv) developing effective post-MDA surveillance tools and methods; and v) scaling up MMDP activities toprovide access to all patients. To respond to these challenges, policy, advocacy, implementation and operational research should beapproached using a network of partners, including Ministries of Health, WHO, GAELF, GPELF,academia, and non-governmental development organizations (NGDOs). Developing strategicpartnerships based on understanding the motivations of each partner was seen as a key to success tocollaboration with other disease programmes, private businesses, and media based organizations.Presenters also stressed the need to build capacity of programme managers, increase support forMMDP, use integration as an opportunity to scale up, and continue to galvanize governmentcommitment to LF programmes. The continuing importance of GAELF as one in a mix of NTD alliances was evident, with the GAELF 7meeting providing an opportunity to recognise successes, reflect on ongoing challenges, and shareinformation among circa 250 representatives from country programmes, donors, and the researchcommunity. The future of GAELF as a forum for discussion and advocacy will be improved byincreasing country participation and engagement in the daily work of the GAELF. The group waschallenged to continue GAELF’s evolution – already a great example of a ‘mass uprising of compassion’through its treatment of millions of at-risk people - by maintaining focus on interrupting LFtransmission while expanding its peripheral vision to include those with LF-related disease.