Title

Title: “AN EVALUATION STUDY: EMPOWERMENT OF LOCAL GOVERNMENT UNITS TO SUSTAIN THE FIRST FILARIASIS-FREE REGION IN THE PHILIPPINES (EASTERN VISAYAS)”

CHAPTER I. INTRODUCTION

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BACKGROUND OF THE STUDY

The Eastern Visayas region in the Philippines composed of six provinces was once considered as endemic for Filariasis and Malaria several years ago. The parameters such as baseline survey, clinical and diagnostics, mid- sentinel surveillance, active case detection, Mass Drug Administration (MDA), post- MDA survey and dossier was conducted and implemented to attain the very high target of filariasis and malaria program which is the elimination of the disease. There are two pillars in the National Filariasis Elimination Program of the Department of Health, one is the Mass Drug Administration (MDA) which is to cut the transmission of the disease and two is to halt the progression of the disease through Morbidity Management and Disability Control (MMDP).
Southern Leyte, Biliran, and Eastern Samar Province attained the target of MDA coverages above the benchmark of 85% from the time of its MDA implementation until its declaration as Filariasis-free. The remaining provinces such as Western Samar, Leyte, and Northern Samar, hit the target in its late years of MDA’s implementation. In the epidemiological assessment through mid-sentinel and spot check evaluations, cluster survey and final evaluation of the six provinces, it established favorable results which led to the official declaration of the first Filariasis- Free region in the Philippines. Southern Leyte province, the first province declared in the country in 2008, followed by Biliran Province in 2010, as the third, Eastern Samar province, rank eleventh of the Filariasis- Free province in 2011, Western Samar and Leyte, rank 13th and 14th, respectively in 2013 and in 2014 Northern Samar province rank 20th filariasis- free provinces of the country. The strategies brought by the national government such as technical assistance on leadership management, networking, collaboration, advocacy, integration, capability building, monitoring and partnership and collaboration with non-governmental organization yield to an explicit and creditably good Mid- sentinel survey, final evaluation, border operation surveillance, post- MDA result and report in the six (6) previously declared filariasis endemic provinces in Eastern Visayas Region.
Filariasis, according to the World Health Organization (WHO) is a disease of the poor. The disease is usually seen in areas with low visibility and low political voice which is common in remote and rural areas. It primarily affects the poor communities in developing countries. The shame and stigma are common in Filariasis and is most often “covered-up,” wherein the principal clinical manifestations of enlargement of the extremities are imminent eventually results to avoidance in coming to seek help in the health facility. This gives a picture of the scope and the impact of the disease, which mainly affects the economic and social burden in the endemic areas. Since the disease is not fatal, it ranks low on the health priority agenda, and the disability it causes is greatly underestimated
The global data shows that filariasis affects more than a billion of people in 83 countries who are living in areas endemic for lymphatic filariasis, which makes them at risk. Eight hundred seventy-three (873) millions of it resides in the South-East Asia Region, which the Philippines is part of it.

Based on WHO, filariasis is otherwise known as Elephantiasis, because of its recognizable sign of swelling of either one or both legs which looks like an elephant’s leg. It is one of the oldest and most neglected tropical diseases in the world, second from Leprosy, a mosquito-borne parasitic disease, which in the very late stage is painful and very disfiguring.

Figure 1 Distribution and status of MDA for lymphatic filariasis worldwide, 2011

Source: WHO. (2013). A handbook for National Elimination Programmes. WHO Lymphatic Filariasis. p4

According to the LF manual of the WHO, filariasis resembles a thread-like filarial worm under the microscope. There are three filarial parasite that affects human which are : Wuchereria bancrofti, Brugia malayi and B. timori: Wuchereria bancrofti or Bancroftian Filariasis, is most common parasite in the tropics and sub- tropical areas, Brugia malayi parasite is usually present in the Southeast and Eastern Asia, while Brugia timori is common Indonesia and Timor- Leste. Figure 1, gives a picture of the worldwide data of filariasis in terms of endemicity and MDA.
” According to the WHO, worldwide data shows an estimated 120 million cases of lymphatic filariasis, wherein there are about 40 million people disfigured and incapacitated by the disease.
When the male and female filarial worms together form “nests” in the human lymphatic system, the human lymphatic system which is responsible for the network of nodes and vessels that maintain the delicate fluid balance between blood and body tissues is affected.”
The CDC describes the life cycle of filariasis starts firstly with a bite by a mosquito of an infected human. While in the mosquito, the parasite goes through different stages while developing, of which only the third stage is infective. When an infected mosquito bites a human, the parasites are deposited on the person’s skin, the entry point to the body. From this, the parasites will migrate to the lymphatic vessels and eventually developed into an adult worm over a period of 6-12 months causing damage and enlargement of the lymphatic vessels. The adult filariae live for several years in the human host. During this time, they produce millions of immature microfilariae that circulate in the blood. The larvae further develop inside the mosquito before becoming infectious to man When a mosquito bites an infected person the microfilaria are then ingested. Thus, a cycle of transmission is established.

Its acute local inflammation, involves the skin, lymph nodes, and lymphatic vessels and often accompanied by chronic lymphoedema, the swelling of the lymph nodes. The painful swelling of the limbs is caused by fluid retention. The genital disease which is the collection of fluid and swelling of the scrotum and penis is sometimes accompanied by high fever.

Most of the population infected with filariasis are asymptomatic and do not have obvious symptoms in its early infection, although virtually all of them have subclinical lymphatic damage. And these infected people have 40% kidney damage, with proteinuria and haematuria (protein and blood in the urine, which is not normally found in healthy people).

After the death of the adult worms which usually takes place for about 10-15 year, is the start of the overreaction of the disease which is the enlargement of the upper and lower extremities, and some affect also the human organs such us scrotum and vagina, the breast will be visible. The most common disabilities of filariasis are lymphoedema, particularly of extremities (hands and feet) and hydrocele (scrotal swelling).

Figure 2Filariasis life cycle: Wuchereria bancrofti
Source: WHO. (2013). A handbook for National Elimination Programmes. WHO Lymphatic Filariasis. p17

Based on the history, LF is among the most neglected tropical disease in the world One the obstacles is the lack of diagnostic and investigative tools and is largely underestimated by the government and the implementers. The following paragraphs will describe the reasons why LF is part of NTD.

In Figure 2, it describes the life cycle of filaria in the vector and in the human host. It shows that after copulation, the adult worms release their young or microfilaria (MF) into the blood. Not all infected individuals are infested with MF, many have active infection with living adult parasites but with no MF circulating in the blood, some MF only circulate in the blood during the few hours on either side of midnight, thus making the diagnosis difficult. It, therefore, needs a lot of time and involves manpower and support. Among the reasons why Filariasis is part of NTD is due to its nocturnal character periodicity which contributes enormous practical barrier for diagnosing lymphatic filariasis and understanding its distribution. The blood collection and examination should be at night because of its nocturnal periodicity. A blood collection is made wherein thick blood smear should be made and stained with Giemsa or hematoxylin and eosin. In endemic regions like the Philippines, blood smear method is the most practical and affordable method of examination. Other serological test and technique such as concentration are tedious, difficult, expensive and requires technical expertise, therefore it is not recommended for field implementation.

Moreover based on a study it is notable that the laboratory test for patients in its very late stage is more likely result in negative in the blood test. Hence, patients with enlarging extremities are oftentimes negative in laboratory examination

The technical aspect of LF program like understanding its cycle is important for its diagnosis. Without knowing the periodicity of the parasite will likely give a false result in laboratory examination.

The difficulty in diagnosis of LF as discussed in the previous paragraph leads to mass drug administration (MDA) as the main intervention for the filarial program. The use of this strategy results in the reduction of the transmission of filarial infection resulting to decrease of transmission that it is not any more sustainable

The drugs of choice for filariasis in the Philippines are Diethylcarbamazine Citrate (DEC) and Albendazole. Albendazole has a synergistic effect in combination with and is effective at reducing microfilaraemia for up to 12 months. It is significantly more effective than any drug alone.
MDA is implemented and treated on an outpatient basis, whether through a house to house technique or conducted in an affixed site by the health workers in the community. Overseeing and supervision by the local health implementers in the conduct of MDA is recommended for community member’s compliance with therapy and for the management of febrile reactions in heavily infected patients.

The first pillar of LF which is MDA is explained and elaborated in the preceding chapter, which purpose is to progressively reduce and interrupt transmission.

The following paragraphs will discuss on the second pillar of the program which is disability management or MMDS of patients with overt reaction to halt the progress of the disease and to alleviate the suffering in which is conducted by educating the patient through home disability management to effectively manage lymphedema and avoid secondary infection.

Figure 3 Overall framework of GPELF and sequential programme steps recommended by WHO
Source: WHO. (2013). A handbook for National Elimination Programmes. WHO Lymphatic Filariasis. p3

In the process of eliminating the disease in areas endemic for filariasis, as shown in Figure 3 the initial activity of the health department in every region is to conduct a mapping through blood examination in the entire area to evaluate the endemicity. Once the smallest administrative unit which is known as the “barangay” has >1MFR, the entire municipality/city and eventually the entire province is declared endemic for LF. In this case, the recommendation of the WHO is to conduct MDA in declared endemic areas for at least 5 years targeting an 85% MDA coverage or until the MFR is

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