Where We Stand Today

Following the launch of WHO’s Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000, the MDA program to eliminate lymphatic filariasis was adopted by most endemic countries. By 2014, 44 countries were conducting MDA and 18 countries had already progressed to the surveillance phase.²

Seventeen countries have since been validated as having eliminated lymphatic filariasis as a public health problem, and an additional seven countries have stopped MDA and are in the post-MDA surveillance stage.³ Southeast Asia, which bears the highest burden of lymphatic filariasis globally, also made significant progress, with Sri Lanka, Thailand, and the Maldives successfully eliminating lymphatic filariasis.⁴ Thus, effective implementation of the strategies outlined in the GPELF, most importantly MDA, have proven to work toward eliminating lymphatic filariasis in several countries across the globe.

In 2004, India launched its National Programme for Elimination of Lymphatic Filariasis that built upon the GPELF’s two-pillar strategy of interrupting the transmission of lymphatic filariasis through MDA and morbidity management and disability prevention, thereby establishing a plan for the elimination of lymphatic filariasis across the country. This program was initially implemented in 202 endemic districts, and expanded to cover all 256 endemic districts by 2007. Since the program’s launch, emerging innovations and best practices have also been incorporated into the recommended design of the MDA program. The number of IUs that have cleared all three transmission assessment surveys continues to increase. However, despite these promising results, outcomes are varied across states, and disease prevalence rates remain high. As of 2020, 159 districts in India have not yet achieved the required thresholds to stop MDA, despite multiple MDA rounds.

Key components of India’s National Programme for Elimination of Lymphatic Filariasis

Maps of India showing the districts conducting MDA and the status of transmission assessment surveys

India has a long history of lymphatic filariasis control campaigns, starting with the National Filaria Control Programme in 1955 that attempted to control lymphatic filariasis through MDA of diethylcarbamazine, recurrent antilarval measures in urban areas, and indoor residual insecticide sprays in rural areas. The program had limited success due to community resistance and operational lapses, and in 1960, it was withdrawn at the national level. From 1960, there were several revisions in India’s national program to control and prevent lymphatic filariasis, including a pilot of diethylcarbamazine-fortified salt for disease control and transmission interruption.⁵

With the launch of India’s National Programme for Elimination of Lymphatic Filariasis in 2004, there was new momentum as elimination became central to India’s strategy to combat the disease in endemic regions.

Since the launch of the GPELF in 2000, the elimination and control of lymphatic filariasis has received increased attention, prompting more aggressive and focused elimination campaigns in several endemic nations across the globe. In this vein, India’s national program adopted the GPELF’s recommended two-pillar strategy and set an initial target of eliminating the disease by 2015.

Timeline of national strategies to reduce lymphatic filariasis in India (1955–2019)

In 2017, WHO recommended triple-drug therapy (ivermectin, diethylcarbamazine citrate, and albendazole), a more cost-efficient and effective drug regimen for lymphatic filariasis elimination. Following this, India declared the Accelerated Plan for Lymphatic Filariasis Elimination in 2018,⁶ which committed to introduce new strategies and improve implementation of MDA through close monitoring. Consequently, India started administering triple-drug therapy through MDA in 2018, starting with only one district and scaling up to 21 districts by 2020.⁷ The initial target of eliminating lymphatic filariasis by 2015 has since been updated, and India is currently targeting lymphatic filariasis elimination by 2021.⁷

Globally, while MDA for lymphatic filariasis elimination has seen an impressive expansion, numerous concerns and challenges frequently arise during its implementation and imply continued endemicity and risk of transmission.⁷ Some of these challenges include:

• Low awareness of program benefits leading to low compliance rates. Reduced risk perception from the disease and misinformation around safety of drugs in the community further exacerbate this challenge.⁸
• Operational inefficiencies, including mismatched MDA and community schedules, poor or nonexistent feedback loops, poorly planned allocation of resources, delays in drug deliveries from national stores to primary health care centers, delays in fund transfers, and gaps in coverage of hard-to-reach geographical areas.³
• Resource constraints, such as insufficient time and funds for promotional and education programs, inadequate staff and overburdened health personnel.⁹

These challenges have undermined the program in India. While coverage of MDA has consistently increased since the launch of India’s National Programme for Elimination of Lymphatic Filariasis, several districts remain endemic. There have been cases of not passing transmission assessment surveys (44 districts in India failed the first transmission assessment survey) despite having conducted the recommended rounds of MDA for more than five or six years. The national program has acknowledged that the program needs to be strengthened and its overall performance and quality improved, with a focus on well-planned quality MDA, community participation, increased compliance, and intensive surveillance.³

India missed its initial target to eliminate lymphatic filariasis by 2015. In 2018 it launched the Accelerated Plan for Lymphatic Filariasis Elimination and in 2019 it extended the deadline for elimination to 2021. The plan focuses on well-planned MDA, community participation, increased compliance, and commitment to incorporating latest innovations in treatments, to support the goal of lymphatic filariasis elimination in India.³ While India will not achieve the goal in 2021, this new aggressive strategy reinforced the government’s commitment toward elimination of lymphatic filariasis across the country, and has spurred recent advancements in the implementation of the NPELF.

Implementation of Triple-Drug Therapy

In 2018, as part of the aggressive strategy to eliminate lymphatic filariasis (outlined in the Accelerated Plan for Lymphatic Filariasis Elimination), India introduced triple-drug therapy (ivermectin, diethylcarbamazine, and albendazole) across endemic districts. Studies in India, as well as in other countries, indicate that the introduction and implementation of triple-drug therapy through MDA safely clears almost all lymphatic filariasis parasites from infected individuals and is more effective than the previously applied two-drug regimen treatment (diethylcarbamazine and albendazole).^10,11  Rolling out triple-drug therapy through MDA therefore implies that communities would need to be treated with fewer MDA rounds to reach elimination targets. In 2019 triple-drug therapy was used in 16 districts, and in 2020 it continued to scale up and covered 21 districts across six states.¹²

Triple drug therapy coverage in 2019

Source: National Vector Borne Disease Control Programme (NVBDCP), Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India https://nvbdcp.gov.in/index4.php?lang=1&level=0&linkid=461&lid=3739

Focus on Effective Implementation

The Accelerated Plan for Lymphatic Filariasis Elimination also outlines specific objectives that focus on assessing, mapping, and targeting resources for the most vulnerable populations to ensure no one is left behind. Objectives include:

• Institutionalized oversight and coordination at the state and district levels in the form of task forces and steering committees.
• Creation of a national advisory group that generates insights on leveraging local resources for social mobilization to increase awareness and community ownership of the program.
• Strengthening local capacity for timely care of lymphoedema and hydrocele cases using morbidity management and disability prevention and hydrocelectomy.
• Preparation of a lymphatic filariasis elimination validation dossier for monitoring and evaluation purposes.³
  Lymphatic filariasis: reporting continued progress towards elimination as a public health problem. World Health Organization website. Published October 30, 2020. Accessed May 14, 2021. https://www.who.int/neglected_diseases/news/LF-reporting-continued-progress-towards-elimination-as-php/en/

   
• Provision of a minimum package of care to all people affected with chronic lymphatic filariasis to alleviate suffering.³
  Lymphatic filariasis: reporting continued progress towards elimination as a public health problem. World Health Organization website. Published October 30, 2020. Accessed May 14, 2021. https://www.who.int/neglected_diseases/news/LF-reporting-continued-progress-towards-elimination-as-php/en/

   
• Supplementary interventions like diethylcarbamazine-medicated salt in districts that continue to have above-threshold infection prevalence even after repeated MDAs.³
  Lymphatic filariasis: reporting continued progress towards elimination as a public health problem. World Health Organization website. Published October 30, 2020. Accessed May 14, 2021. https://www.who.int/neglected_diseases/news/LF-reporting-continued-progress-towards-elimination-as-php/en/