Seventh meeting of the Global Alliance to Eliminate ... · elimination of lymphatic filariasis (LF) as a public-health problem. Keywords: Lymphatic filariasis, Neglected tropical

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MEETING REPORT Open Access

Seventh meeting of the Global Alliance toEliminate Lymphatic Filariasis: reaching the visionby scaling up, scaling down, and reaching outMolly Brady1* and the Global Alliance to Eliminate Lymphatic Filariasis2

Abstract

This report summarizes the 7th meeting of the Global Alliance to Eliminate Lymphatic Filariasis (GAELF), WashingtonDC, November 18–19, 2012. The theme, “A Future Free of Lymphatic Filariasis: Reaching the Vision by Scaling Up,Scaling Down and Reaching Out”, emphasized new strategies and partnerships necessary to reach the 2020 goal ofelimination of lymphatic filariasis (LF) as a public-health problem.

Keywords: Lymphatic filariasis, Neglected tropical diseases, Review

Executive summaryThe 7th Meeting of the Global Alliance to EliminateLymphatic Filariasis (GAELF) was held 18–19 November,2012 in Washington, DC. The theme of the meeting, “AFuture Free of Lymphatic Filariasis: Reaching the Visionby Scaling Up, Scaling Down and Reaching Out”, empha-sized new strategies and partnerships necessary to reachthe 2020 goal of elimination of lymphatic filariasis (LF) asa public-health problem. The meeting was held at theWorld Bank, back to back with a Uniting to CombatNeglected Tropical Diseases (NTDs) forum, in order tocapitalize on common themes, participants, and support(http://www.unitingtocombatntds.org).

Current statusThe World Health Organization’s overall goal is univer-sal health coverage with essential public health interven-tions, including access to preventive chemotherapy (PC)for NTDs. The goal of integrated PC is to eliminate LF,onchocerciasis, blinding trachoma and, in some cases,schistosomiasis as public-health problems and eliminatechildhood morbidity related to soil-transmitted helmin-thiases (STH). Given that 1.4 billion people require massdrug administration (MDA), a type of PC, for LF, the LFprogramme’s community-based MDA is often used as theplatform for integrating PC diseases. Successful scale up

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for LF MDA can also cover the majority of the 1.9 billionpeople needing PC for at least one NTD.The current status of the Global Programme to Elimin-

ate Lymphatic Filariasis (GPELF) is that 73 countries areendemic, with 1.39 million people at risk, 120 millionpeople infected, and 40 million people affected by LF-related morbidity. The goal of global elimination has twoparts: i) to stop the spread of infection and interrupt trans-mission through MDA and ii) to reduce human sufferingthrough managing morbidity and preventing disability(MMDP). The first part of the goal is realized through thesequential activities of mapping, MDA, post-MDA surveil-lance and verification. In 2011, 53 countries implementedMDA, with nearly 539 million people treated, and 12countries under post-MDA surveillance. The second partis achieved through analyzing the MMDP situation incountry, developing a plan, and providing access to aminimum package of MMDP care. In contrast to the suc-cess at scaling up MDA, only 27 countries have reportedMMDP activities.Progress towards milestones in the GPELF Strategic

Plan 2010–2020 has been impressive. Revised M&E guid-ance, including information on implementing Transmis-sion Assessment Surveys (TASs) and verifying absence oftransmission, has been published. A provisional strategyfor interrupting transmission in loiasis co-endemic areas,where MDA with ivermectin cannot be implemented dueto concerns of serious adverse reactions, will be presentedto the Strategic and Technical Advisory Group on NTDs

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for endorsement in April 2013. Revised MMDP pro-grammatic guidance, including metrics for reporting onMMDP activities to WHO, will be finalized in 2013.

Country case studiesA series of country case studies highlighted commonthemes necessary to achieve success and overcome chal-lenges. Success in scaling up was bolstered by cultivatingdedicated programme managers, maintaining governmentcommitment at all levels, and building on existing deliveryplatforms. Presentations on success in scaling down show-cased the importance of government support lastingbeyond MDA, as well as providing ongoing technical as-sistance for post-MDA surveillance and dossier develop-ment. Countries facing significant challenges were oftenthose in post-conflict situations, with poor infrastructureand weak health care systems. Overcoming these chal-lenges takes innovative thinking about delivery strategies,the creation of novel ways to motivate volunteers, and ex-ternal financial and technical support. Finally, case studieson accelerating progress showed the importance of im-proving coverage in areas with ongoing MDA before scal-ing up, and the critical need to build the capacity of LFprogramme managers to plan, budget and monitor pro-grammes, especially in large, decentralized countries.Participants learned about pioneering efforts to manage

morbidity and prevent disability, including Togo’s nationallymphoedema programme, a community-based lymphoe-dema project in a highly-endemic area of India, and theAfrican LF Morbidity Project. Providing care for LF-relateddisease was shown to increase acceptability and compli-ance with MDA. The group welcomed the results of a clin-ical trial which showed that doxycycline reversed or haltedprogression to later stages of lymphoedema more effect-ively than amoxicillin or placebo, in patients with andwithout active LF infection. The importance of linkingMMDP with other diseases, reporting on MMDP activitiesto WHO, and collecting data on surgical complicationsand recurrence was discussed.A session on linking LF programmes with other disease

programmes explored the rationale and opportunities forcoordinating with onchocerciasis, STH, trachoma, andmalaria activities. Opportunities for synergy with onchocer-ciasis and trachoma activities include integrated mapping,joint training, combined treatment registers, simultaneousMDA where feasible, and joint M&E. STH activities greatlybenefit from the LF programme; in 2010, WHO reportedthat 57% of the school-aged children treated for STH weregiven these medicines through national LF programmes.However, like MMDP activities in LF programmes, inter-ventions related to water, sanitation and hygiene often lagbehind PC interventions in STH programmes. Both pro-grammes need to bolster these supportive activities if the2020 goal to eliminate LF is to be achieved. LF and malaria

activities also complement each other: LF MDA helpslower anemia, provides community networks for bednetmonitoring, and influences adults to use bednets to avoidLF-related disease, while bednets help reduce LF transmis-sion. An animated discussion followed the presentation ofdata from ongoing entomological monitoring in Nigeriawhich found no infective mosquitoes after bednet distribu-tion in areas with LF MDA.

Moving forwardVarious speakers highlighted challenges to achieving the2020 goal, including: i) building the capacity of LFprogramme managers and NTD teams to plan, imple-ment and monitor activities; ii) scaling up to 100% geo-graphical coverage for MDA while coordinating withother PC diseases and vector control activities; iii) plan-ning for TAS, including ensuring the availability andaffordability of diagnostic tests; iv) developing effectivepost-MDA surveillance tools and methods; and v) scalingup MMDP activities to provide access to all patients.To respond to these challenges, policy, advocacy, imple-

mentation and operational research should be approachedusing a network of partners, including Ministries of Health,WHO, GAELF, GPELF, academia, and non-governmentaldevelopment organizations. Developing strategic partner-ships based on understanding the motivations of each part-ner was seen as a key to success to collaboration withother disease programmes, private business, and media or-ganizations. Presenters also stressed the need to build cap-acity of dynamic programme managers, increase supportfor MMDP, use integration as an opportunity to scaleup, and continue to galvanize government commitmentto LF programmes.The continuing importance of GAELF as one in a mix

of NTD alliances was evident, with the GAELF 7 meetingproviding an opportunity to celebrate successes, reflect onongoing challenges, and share information among circa250 representatives from country programmes, donors,and the research community. The future of GAELF as aforum for discussion and advocacy will be improved by in-creasing country participation and engagement in thedaily work of the GAELF. The group was challenged tocontinue GAELF’s evolution – already a great example ofa ‘mass uprising of compassion’ through its treatment ofmillions of at-risk people - by maintaining focus on inter-rupting LF transmission while expanding its peripheral vi-sion to include those with LF-related disease.

Opening session – are we on track for 2020?Welcome by the chair of the GAELFDr Patrick Lammie (Centers for Disease Control and Pre-vention (CDC), USA) welcomed participants to the GAELFmeeting, following on from the successful Uniting to Com-bat NTD forum (Additional file 1). He thanked Dr Don


Bundy and his team at the World Bank for hosting themeeting, the Bill & Melinda Gates Foundation (BMGF)team for arranging the meeting venue logistics, and Glax-oSmithKline (GSK) and Merck & Co., Inc. for their drugdonations and consistent support of GAELF. He also gavea special welcome to the newest GAELF partner – EisaiInc. – which will donate diethylcarbamazine (DEC) startingin 2013.He asked the group to remember two colleagues, Dr

Vely Jean Francois, the programme manager for LF andmalaria in Haiti and Dr Likezo Mubila, the WHO AfricaRegion focal point for NTDs, who were at the last GAELFmeeting in South Korea, but have since passed away. Dr.Jean Francois’ commitment to improving health was asource of inspiration. During a period of civil strife, hewas kidnapped and held for ransom, but upon his releasechose to stay in Haiti and continue his public health work.Sadly, he died before seeing the LF programme reach na-tional coverage in 2012. Dr Likezo Mubila, was ‘our con-science’, always reminding the group of the countries andcommunities left behind. Dr Lammie expressed hope thatwhen GAELF members debate ways to reach our targetsin all communities, we hear her voice reminding us of thatobligation.He closed by noting while we can celebrate successes,

we need to be mindful about finding new strategies andpartnerships to reach the ambitious 2020 objective ofelimination of LF.

Welcome by the Minister of Health, TanzaniaDr Hussein Mwinyi (Honorable Minister of Health,Tanzania) remarked that it was good to be back amongold friends, having been involved in the early days ofGAELF. Dr Mwinyi was first struck by the suffering ofelephantiasis patients when he was a member of parlia-ment from a highly-endemic district. That experiencemotivated him to start the Tanzanian LF programme asa way to signal hope for the neglected populations inendemic communities.He expressed delight at the progress GAELF has made

in a relatively short time, including the number ofpeople treated and the number of countries with activeprogrammes. The clear goal of elimination – with thecountries at the centre – has resulted in tremendousachievements, although it is essential to upscale faster,especially in parts of sub-Saharan Africa and Indonesia,and monitor progress closely.He noted many of the outstanding needs of the

GAELF, such as improved tools for ongoing post-MDAsurveillance, stronger morbidity programmes, strategiesfor MDA in urban areas, and operational research guidedby programme needs. He highlighted how the TanzanianPresident established a fund to support LF patients, butthere is still a major backlog of hydrocele surgeries

needed. He challenged the group to report on progress ofmorbidity burden assessment and activities at the nextGAELF meeting.Dr Mwinyi emphasized that partnership and coordin-

ation are key components of the effectiveness of GAELF,encouraging the group to re-examine what the GAELFcan learn and share with other NTD alliances and to useGAELF’s momentum to meet NTD goals.

Preventive chemotherapy and WHO’s strategicplan for NTDsDr Dirk Engels (WHO Department of Control of NTDs,Geneva) discussed how WHO is focusing on universalhealth coverage with essential public health interven-tions, including access to preventive chemotherapy (PC)for NTDs. The medicines used in PC for LF, onchocer-ciasis, soil-transmitted helminthiases (STH), schistosom-iasis and trachoma are all safe, single dose medicinesthat can be used without prior individual diagnosis. Therationale for expanding integrated PC is that the sameindividuals in poor environments are affected by multiplediseases and programmes have an ethical responsibility totreat all diseases. Integrating and coordinating PC inter-ventions can result in increased cost-effectiveness, feasibil-ity, visibility, acceptability, and can reduce the risk of drugresistance. Given that 1.4 billion people require PC for LFand that LF drug distribution is community based, LF isoften used as the platform for integrating PC diseases.Other strategic components overlap among the diseaseprogrammes, such as morbidity management (LF, schisto-somiasis, trachoma), vector control (LF, onchocerciasis,schistosomiasis) and water and sanitation (schistosomia-sis, STH, trachoma).He noted that the goal of integrated PC is to eliminate

LF, onchocerciasis, blinding trachoma and in some casesschistosomiasis as public health problems and eliminatechildhood morbidity related to soil-transmitted helmin-thiases by 2020. This will be achieved by scaling up PCfor all diseases to full national scale as quickly as possible,and enhancing these interventions through integratedplanning, implementation and management. Steps for roll-ing out integrated PC include: i) institutionalizing a NTDtask force, ii) developing a national plan of action throughsituational analysis, action planning and mapping, andidentifying funding gaps, and iii) holding a stakeholdersmeeting to mobilize resources and coordinate partners.Currently, 1.9 billion people in 124 countries require

PC for at least one of the diseases, with 710 milliontreated in 2010. The WHO South-East Asia Region has53% of the burden and the African Region has 31%. Spe-cifically for LF, 1.4 billion people in 73 countries requireMDA, with 539 million treated in 2010–2011. The South-East Asia Region has 63% of the global burden of LF, whilethe Africa Region has 31%. Thus successful scale up for


LF MDA can also cover the majority of the global burdenof PC (Figure 1).However, Dr Engels cautioned that there is still a need to

sustain the impact of LF MDA through non-LF PC oncethe LF programme scales down, particularly for STH andonchocerciasis. While there often will be a shift to school-based PC after LF MDA ends in some areas, some pro-grammes will still need community-based interventions.

LF strategic planDr Kazuyo Ichimori (WHO Department of Control ofNTDs, Geneva) presented the current status of theGlobal Programme to Eliminate Lymphatic Filariasis(GPELF) as 73 countriesa endemic for LF, 1.39 billionpeople at risk, 120 million infected, and 40 millionpeople affected by morbidity. The goal of global elimin-ation has two parts: i) to stop the spread of infectionand interrupt transmission through MDA and ii) to re-duce human suffering through managing morbidity andpreventing disability (MMDP). In 2011, 53 countries im-plemented MDA, with 538.6 million people treated in2010–2011, and 12 countries under post-MDA surveil-lance. However, only 27 countries reported MMDP ac-tivities to WHO. Baseline sentinel site data from 37countries showed an average microfilaraemia prevalenceof 12.6%, which dropped to 2.7% according to mid-termsentinel site data from 36 countries.Dr Ichimori then summarized the GPELF Strategic

Plan 2010–2020 [1], which was developed largely as aresult of conversations at the last GAELF meeting inKorea [2]. The vision of the strategic plan is a worldwithout the risk of LF through global elimination of LF asa public-health problem. The objective for the MDA

A

Figure 1 Overlap between population requiring PC for all diseases anPC 1.9 billion. B: Population requiring MDA for LF 1.39 billion. AFR: Africa REurope Region, SEAR: South East Asia Region; WPR: Western Pacific Region.

component is to reduce infection prevalence below targetthresholds in all endemic areas, with targeted prevalencelevels defined for various species/vector complexes. Thisis achieved through stepwise activities of mapping, MDA,post-MDA surveillance, and verification (Figure 2).In order to achieve the MDA goal, the strategic plan

included four milestones for 2011–2013: i) revised moni-toring and evaluation (M&E) guidance, ii) criteria forverifying absence of transmission, iii) provisional strategyfor interrupting transmission in loiasis-endemic areas,and iv) final strategy for interrupting transmission inloiasis-endemic areas. The M&E manual, which includesguidance on verifying absence of transmission, has beenpublished [3]. The provisional strategy for loiasis-endemicareas has been recommended to the Strategic and Tech-nical Advisory Group for NTDs for endorsement in April2013 [4]. The MDA target is that by 2020 70% of countrieswill be verified free of LF and the other 30% will beunder post-MDA surveillance. As of 2011, 19 countrieshad not started MDA, 41 were implementing MDA, 12were under post-MDA surveillance, and nine had beenverified free of LF.The target for the MMDP component is no new clinical

cases, measured by i) reduction in the number of acuteattacks, ii) the number of hydrocele patients cured, andiii) the MMDP geographical coverage in LF-endemiccountries. This is achieved through analyzing the MMDPsituation in country, developing a plan, and providing aminimum package of MMDP care (Figure 3).In order to achieve the MMDP goal, the strategic plan

included two milestones for 2011–2013: i) revised guide-lines and training modules for MMDP, and ii) metricsdeveloped for annual reporting on MMDP activities to

B

d population requiring MDA for LF. Legend: A: Population requiringegion, AMR: Americas Region, EMR: Eastern Mediterranean Region; EUR:

MappingVerification

Post-MDAsurveillance

MDA

Figure 2 Programmatic steps: MDA component.


WHO. A position statement has been published [5] andthe MMDP manual for programme managers, which in-cludes indicators and forms for reporting to WHO, iscurrently in draft. The MMDP target is that by 2020100% of endemic countries will have achieved full geo-graphical coverage and access to basic MMDP care.Critical challenges include: increasing LF MDA cover-

age to 100% while coordinating with other PC diseasesand vector control; planning for TAS; ensuring availabil-ity and affordability of diagnostic tests; developing effect-ive post-MDA surveillance tools; defining the role of theregional programme review groups and the Strategic andTechnical Advisory Group for NTDs in the verificationprocess; scaling up MMDP activities; and collecting evi-dence on best practices of linking MMDP activities withhealth services. These challenges can be best met byusing a network of partners and integrated approaches(Figure 4) to work on policy, advocacy, implementation,and operational research.

Regional progressDr Ricardo Thompson (National Institute of Health,Mozambique) presented the status of the Programme toEliminate LF in each of the WHO Regions: African Region,Americas Region, Eastern Mediterranean Region, South-East Asia Region, and the Western Pacific Region. Despite

MDAPlan Min

oSituationanalysis

M

Figure 3 Programmatic steps: MMDP component.

success in scaling up MDA, regions face challenges as theyreach the peak of delivering required treatments, whilesimultaneously needing to build capacity to implementTAS to evaluate success. He presented regional statisticson the number of countries and people requiring MDA,the number treated, and country status (Table 1 andFigure 5).

African RegionThe African Region has achieved remarkable progress inscaling up effective MDA since 2000, with 76% coverageof total population in areas with MDA in 2011. However,by 2015 both the number of countries conducting MDAand the number treated must be doubled. In particular,the countries which have not finished mapping orstarted MDA, mostly in Central Africa, must start, espe-cially now that guidelines for MDA in loiasis-endemicareas are available. The region faces logistical and polit-ical challenges which have delayed completion of map-ping and initiation of MDA. Heavy burden countriessuch as the Democratic Republic of Congo, Nigeria andEthiopia need specific plans to aid in scaling up, includ-ing consideration of alternatives to annual MDA to ac-celerate the progress of interruption of transmission.The regional partnership is being strengthened to sup-port country implementation.

Post-MDASurveillanceimum package

f MMDP care

Do

ssie

r d

evel

op

men

t

Ver

ific

atio

n

MMDP and rehabilitation

integrated into health services

&E

A

GPELF

WHOPolicy and guidelines

GAELFAdvocacy and

fundraising

MOHsCoordination & implementation

NDGOsAssistance to

MOHs

AcademiaOperational

research and evidence

B

Figure 4 Working together to meet the GPELF goal. Legend: A: Integration: MMDP, vector control and MDA. B: Partnership: Collaboration tosupport one GPELF. MDA: mass drug administration; SCH: schistosomiasis; STH: soil-transmitted helminthiases; TRA: trachoma; ONCHO: onchocerciasis;VC: vector control; IVM: integrated vector management; GPELF: Global Programme to Eliminate Lymphatic Filariasis; MMDP: morbidity managementand disability prevention; GAELF: Global Alliance to Eliminate Lymphatic Filariasis; NGDO: non-governmental development organization; MOH: ministryof health.

Table 1 Number of countries and people requiring MDAand number treated, by WHO Region

Region No. ofcountriesrequiringLF MDA

Totalpopulation(m) requiringMDA

No. people(m) treatedin 2011

Africa 34 443 113

Americas 4 12 9

Eastern Mediterranean 4 22 0.5

South-East Asia 9 879 414

Western Pacific 22 37 21

TOTAL 73 1,393 557.5


Americas RegionThe high burden of LF in Haiti, which constitutes 80% ofthe Americas burden, presents a special situation, espe-cially after the earthquake in 2010 which destroyed muchof the government’s infrastructure. However, LF MDA in2012 achieved full national coverage for the first timehelped, in part, by the strong regional partnership that in-cludes Ministries of Health and Education, IMA WorldHealth, University of Notre Dame, US Centers for DiseaseControl and Prevention (CDC), United States Agency forInternational Development (USAID), Inter-American De-velopment Bank, and the Global Network for NTDs. Inaddition, a bi-national project to eliminate malaria in Haitiand the Dominican Republic will also have positive effectsfor the LF programme.

Eastern Mediterranean RegionThe Eastern Mediterranean Region showed a peak intreatments in 2004, with numbers of people treated dras-tically falling off from 2005 onwards, since two of the LF-endemic countries are moving towards elimination andscaling down treatments, while the fragile infrastructurein Sudan and South Sudan has made it difficult to upscaleMDA. Yemen and Egypt now need to procure immuno-chromatographic tests (ICTs) to carry out TAS since allimplementation units (IUs) have implemented at leasteight rounds of MDA and achieved <1% microfilaraemiarates in sentinel and spot-check sites. In addition, the re-gion needs to strengthen morbidity management.

South-East Asia RegionAll the LF-endemic countries in the South-East AsiaRegion are implementing MDA, except Sri Lanka and

Maldives which are under post-MDA surveillance. Whilethe high-burden countries of Bangladesh and India havemade significant progress in implementing MDA, they arefacing difficulties procuring ICTs for implementing TAS.Political instability in Timor Leste led to the interruptionof MDA, which has not restarted. The region also muststrengthen the commitment of implementation partnersin the region and scale up MMDP activities.

Western Pacific RegionIn the Western Pacific Region, three countries have notstarted MDA, nine have ongoing MDA and ten are underpost-MDA surveillance. Challenges include availability andaffordability of ICTs, reaching prevalence goals in areaswith Aedes vectors where repeated MDA rounds have notlowered levels adequately, and strengthening MMDP activ-ities. Scaling up MDA in Papua New Guinea (PNG)continues to be a major task. Finally, there is a lack ofcountry-level capacity to prepare dossiers for verification,

Figure 5 Status of MDA by country.


which will become a challenge in other regions as coun-tries progress.

DiscussionIn order to truly analyze regional progress, participantssuggested that presenters provide details of the epi-demiological situations and implementation progress atan IU level. In addition, the most appropriate way to pro-vide support to countries – given the multiple demands onWHO and regional programme review group members -was debated, with a suggestion to allow decisions by acountry-level review group under the auspices of the re-gional programme review groups for larger countries.Given the need to build country and regional capacity toanalyze country situations and review programme pro-gress, participants were asked to give specific ideas onshort- and medium-term capacity building needs to Profes-sor David Molyneux, who is chair of the WHO NTDworking group on capacity building. Finally, an update onthe new ICT platform was provided: it is currentlyundergoing field evaluation, and the effect of the newtest format on TAS guidance will be reviewed after theresults are compiled. A small group of partners is in dis-cussion with Alere, the company that produces the ICTswho have requested accurate demand forecasts fromcountry programmes in order to ensure supplies are ad-equate and timely.

Highlighting successHighlighting success in scaling upModerator: Mr Andy Wright (GlaxoSmithKline, UK).

Haiti: triumph over adversity Dr Abdel Direny (IMAWorld Health, Haiti) described the LF situation in Haiti,where 88% of communes have Bancroftian filariasis,transmitted by Culex mosquitoes. MDA began in 2000

in the Leogane commune and scaled up to 24 communesby 2005, when it was stopped due to lack of funding. Since2008, with help from GSK, IMA World Health/USAID,University of Notre Dame, CDC, and Partners in Health,the programme has gradually scaled up, reaching fullcoverage of 140 communes in 2012. Coverage in the2011–2012 round of MDA averaged 90% of total popula-tion, with a range between 80-116% (using populationnumbers based on 2003 census data without accountingfor migration). Drugs are administered at distributionposts and schools, with three community drug distributorsper post. Social mobilization is accomplished throughradio spots, announcements from trucks, and communityleader announcements. The community drug distributionnetworks are also used to distribute shoes, water filters,and essential medicines.Dr Direny recounted the many challenges of the Haiti

programme, including the 2010 earthquake, cholera out-breaks, and political instability. The programme needsto scale up morbidity management, latrine construction,hygiene activities, and determine how to continue withSTH MDA after LF MDA is stopped. He emphasizedthat these challenges can only be addressed through col-laboration; integration of LF and STH programmes; andparticipation of community leaders, health promoters andcommunity drug distributors in population sensitizationto ensure sustained interest in participating in MDA. Thetriumph of the programme over unavoidable adverse situ-ations was feasible due to the commitment of governmentand partners, the ability to immediately assess and plannext steps after the earthquake, the contributions fromvolunteers, and the consistent use of monitoring andevaluation to measure impact.

Malawi: an inspirational personal story Mr SquareMkwanda (LF Programme in the Ministry of Health,


Malawi) discussed the history of the LF programme inMalawi, where 26 of 28 districts are endemic, with 14.1million people at risk. While the country was mapped in2003, MDA did not start until 2008, after the Ministerof Health was influenced by hearing about other countries’progress at the 2008 GAELF meeting in Tanzania. Eventhough there was no LF-specific budget, Mr Mkwandawas tasked with rolling out LF MDA in eight districts,which he achieved through integration with other healthactivities, such as distribution of bednets. In order to showpolitical will and convince the public the drugs were safe,drugs were distributed in parliament and the state house.After achieving 80% coverage, the programme scaled upin 2009 to total geographical coverage, and was able touse the results of 2008 and 2009 MDA to secure supportfrom the Centre for Neglected Tropical Diseases (CNTD)for 2010 onwards. He noted that challenges to eliminateremain, including cross-border issues, morbidity manage-ment, and competing government priorities. Althoughmorbidity management is ongoing, with 3,201 hydroce-lectomies and 2,008 lymphoedema patients treated overthe past four years, there are gaps in supervising self-care groups and building capacity of health workers incase management.

India: impact of government commitment Dr VKumaraswami (Consultant, India) presented the statusof LF in India, which accounts for 40% of the global bur-den with 600 million people at risk and 509 million tar-geted for MDA in 20 endemic states. MDA for LF waspiloted in the 1950s, with a 2002 national health policycalling for elimination by 2015. Single-dose DEC MDAcovered all endemic areas by 2004 and DEC + albenda-zole MDA covered all areas by 2006; however, issues ofsocial mobilization and compliance still exist. Sentinelsites show a positive impact of MDA – with an average1.2% mf rate in 2004, compared to an average of 0.35%in 2011.In 2011, the programme was supported by US$10 mil-

lion for MDA and morbidity activities from the centralgovernment, state budget contributions, and a donationof 300 million albendazole tablets by GSK. Other part-ners include medical colleges to implement independentcoverage assessments, the Indian Council of Medical Re-search to assess MDA coverage and implement oper-ational research, the National Centre for Disease Controlto train, and non-governmental development organiza-tions to implement and evaluate morbidity activities.He noted some of the complexities of the Indian

programme, including drug needs (1 billion DEC tabletsand 500 million albendazole tablets a year), quality-assured drug procurement, storage and distribution ofdrugs, training of 2.5 million peripheral health workers,and treatment of 250 people per day per worker during

MDA. Current critical issues include scaling up morbid-ity training, hydrocele surgery, and home-based lym-phoedema care, as well as strategies and funding forscaling down, as 170 IUs are ready for TAS, necessitat-ing procurement of 150,000 ICTs in 2013 when TAS ac-tivities are conducted.

Liberia: capitalizing on existing platforms Dr KarsorKollie (LF Programme, Ministry of Health, Liberia) de-scribed Liberia’s LF programme, which covers the 13 en-demic counties and an at-risk population of 3.4 million,in a country that is post-conflict, with a weak health sys-tem. The LF programme built on the success of the on-chocerciasis programme, which uses community drugdistributors (CDDs) for MDA and has a mechanism inplace to monitor the impact of MDA. The programmetargeted 1.6 million people in the 13 endemic countiesin 2012, with an aim of 100% coverage in the next twoyears. The largest challenges have been the turnover ofCDDs due to poor motivation and logistical issues, such asthe need for motorbikes to reach isolated areas. Integrationwith the malaria programme has been helpful to determinethe impact of vector control on MDA and determine theexistence of urban LF transmission. Lessons learned in-cluded: integration can enhance coordination and out-comes, use of existing structures increases ability to scaleup, and collaboration with malaria programmes on inte-grated vector management might speed up LF elimination.Support for the programme is provided by CNTD,

Sightsavers, WHO and the African Programme for On-chocerciasis Control (APOC). In addition, LF is now in-cluded in the 10-year national health policy and essentialpackage of health services, so government funding willhopefully increase. Continued government advocacy willbe important, especially as the President of Liberia is nowco-chairman of the United Nations committee shapingthe post-Millennium Development Goals priorities.

Highlighting success in scaling downModerator: Dr Adrian Hopkins (Mectizan DonationProgram, USA).

Togo: a first in Africa Dr Monique Dorkenoo (LFProgramme, Ministry of Health, Togo) discussed howTogo – the only country in Africa that has been able tostop MDA – was able to scale down. Togo has 1.3million people at risk of LF in seven districts. MDAstarted in one district in 2000, with full geographic scaleachieved in 2003 and continued for at least six years inall districts until 2009. Every district had a sentinel sitewith regular evaluation of microfilaremia levels. In 2008,all districts were assessed for stopping MDA using the2005 WHO guidelines. MDA was stopped in five ofseven districts after the 2008 MDA and in two districts


after the 2009 MDA. She noted that the critical chal-lenge is how to monitor for, and avoid, resurgence. Afirst round of post-MDA surveillance using TAS was im-plemented in Kozah district in December 2009 as part ofthe BMGF-supported global operational research projectand a second round will be implemented in 2012. Theprogramme aims to maintain advocacy to ensure fundingfor post-MDA ongoing surveillance, currently focused inborder areas. It also is working to increase bednet cover-age and usage to ensure interruption of transmission.

Ghana: gradually scaling up and down Dr Nana-Kwadwo Biritwum (NTD Programme, Ministry of Health,Ghana) described how LF activities in Ghana are adminis-tered in the context of the NTD programme, as every dis-trict in Ghana is endemic for at least three NTDs. Thepopulation at risk of LF in Ghana is 12 million, in 74 of170 districts. From 2001–2006, Ghana scaled up MDAfrom five districts to all 74 endemic districts. Coveragesurveys were completed in three to ten districts each year.As of 2010, four districts have stopped MDA. He notedthat the three greatest challenges were i) urban MDA andcommunity fatigue in rural areas, ii) tools for post-MDAand non-endemic district surveillance, and iii) limited hu-man and financial resources. In order to overcome thesechallenges, the programme is working to develop alterna-tive social mobilization and distribution strategies forurban MDAs, implementing operational research withCDC on surveillance, and building technical capacity.

Vietnam: planning for dossier development Dr DoTrung Dung (LF Programme, Ministry of Health, Vietnam)described LF in Vietnam, where both Bancroftian andBrugian filariasis are present. One and a half million peopleare at risk in 12 districts, which were combined into sixIUs for MDA implementation. From 2003–2008, all sixIUs underwent five rounds of MDA. In 2009, all districtswere assessed for stopping MDA using the 2005 WHOguidelines. Post-MDA TAS surveys will be implemented in2013 and in 2015, grouping districts into four evaluationunits. He noted that a major challenge is to conduct TASin schools in rural, minority areas due to difficulties obtain-ing consent for blood collection. The programme aims toinvolve teachers and parents with survey teams when col-lecting blood in these areas. In addition, the programmewill need external financial and technical support, as it haslimited government funding and limited ability to collectdata and technically write the verification dossier.

Philippines: ensuring government support at all levelsDr Leda Hernandez (Ministry of Health, Philippines) ex-plained that 28–30 million people are at risk of LF inthe Philippines in 44 endemic provinces. MDA has beenongoing since 2001 in selected areas, with a peak of 37

IUs conducting MDA in 2007 and 2009. As of 2011, 12provinces stopped MDA, with TAS scheduled for eightmore in 2012. Three IUs have finished post-MDA sur-veillance, and six others have ongoing surveillance. Shenoted that the key drivers of this success have been govern-ment budget (e.g. for DEC), partnerships to fill gaps andaddress morbidity, presence of committed health workers,and external technical assistance. The programme is ad-dressing the challenge of ownership and commitment oflocal government units by offering performance-based in-centives for IUs which achieve elimination goals. It also isholding regular stakeholder meetings to increase coordin-ation of, and feedback to, partners, especially those fromother sectors; training health workers on new guidelines;and conducting rapid assessment surveys, operational re-search, and post-MDA surveillance in order to strengthenM&E. Finally, the programme is lobbying for the sustain-ability of the annual LF budget until the elimination goal isreached –not just until MDA is stopped.

DiscussionFour main issues were discussed following these presenta-tions. First, the importance of collecting data on baselineprevalence was stressed, as it is a factor in determininghow many rounds of MDA are necessary. Second, thechallenges of cross-border collaboration and synchroniz-ing MDA cycles were brought up, with a suggestion tointensify surveillance in cross-border areas. Third, the sug-gestion of twice-yearly treatment was put forward to speedinterruption of transmission, especially in places withtwice-yearly onchocerciasis treatment. Finally, it was sug-gested that it would be helpful if countries found a way toacknowledge donors and partners to encourage sustaineddonations in a tough financial climate.

Meeting programme challengesReaching the unreachedModerator: Professor Moses Bockarie (Center forNeglected Tropical Diseases, UK).

Sierra Leone: how did Sierra Leone do it? Mr MustaphaSonnie (Helen Keller International, Sierra Leone) de-scribed the LF situation in Sierra Leone, where LF is co-endemic with onchocerciasis and transmitted by theAnopheles vector. Despite prior conflict, a poor healthsystem, and low technical capacity, the programme is ontrack to eliminate LF transmission by 2015. Building onthe well-established community-based onchocerciasisMDA system, the LF MDA was scaled up to nationalcoverage in the three years from 2007 to 2010. Trainingand advocacy follow a cascade from national supervisorsto district health management teams to primary healthunit staff to community drug distributors, with targetedmessages for each. Social mobilization activities include


community meetings, interactive programmes in urbanareas, and radio programmes.Mr Sonnie noted that the programme faces challenges

of competing health priorities such as cholera, highinfant and maternal mortality and malaria; poor road in-frastructure; and motivation of community volunteers.Community leaders are asked to find ways to motivatevolunteers, such as exemption from communal work,helping CDDs with farming activities during the harvestseason, and recognition by the community. The nationalNTD programme and partners have over the years pro-vided motivation to volunteers such as free t-shirts andcertificates. In addition, traditional beliefs that equateelephantiasis with witchcraft mean that the programmehas to reach out to traditional healers to ensure theirbuy-in to the MDA. Partners include USAID, DFID,Helen Keller International, Sightsavers, and CNTD.

Liberia: why is Liberia so optimistic? Ms Marnijina G.Moore (Marjin) (LF Programme, Ministry of Health,Liberia) described Liberia’s plan to scale up to 100% geo-graphic coverage of LF MDA in the next two years. Theprogramme’s strategy relies on an integrated programmewith onchocerciasis, STH, schistosomiasis, Guinea wormand Buruli ulcer, led by a single director and a motivatedyoung team. MDA for LF and STH are being added tothe onchocerciasis community-directed treatment inter-vention platform, which covers the entire country. Suc-cess is helped by the relatively small size of the countryof 3.4 million people, and a decentralized health systemthat enables counties to plan and implement their ownNTD interventions. Commitment from the governmentof Liberia and donors such as APOC, DFID, CNTD andSightsavers allowed the programme to add more trainedhealth workers and CDDs after LF was added to the on-chocerciasis platform. She remarked that even thoughpeople might not understand the details of the NTD strat-egy, there is a demand for ivermectin from communitieswhich made it easy to add albendazole to the MDA. Chal-lenges of infrastructure, motivation of volunteers, verticalprogrammes, a limited government budget, poor inter-sectoral collaboration, and lack of a mechanism for mor-bidity management were noted.

Papua New Guinea: why is PNG struggling? Dr LeoMakita (Malaria and Vector Borne Diseases, Ministry ofHealth, PNG) discussed the LF situation in PNG, whereLF is endemic in most districts and transmitted by theAnopheles vector. Seventy-five percent of the populationlives in rural areas. He noted that PNG’s challenge tofind enough resources to deliver health services to allareas remains unmet. While the LF programme achievedsuccess at scaling up MDA in 2004 by integrating withmalaria programme bednet distribution, in the following

years there were not enough resources to implement LFMDA alone.Using the health system to reach those at risk has pro-

duced limited results, due to areas that have no accessto any health services (where health posts might be closeddue to tribal fights), a decentralized system where civilservants in each district have to be convinced to imple-ment MDA, the high cost of MDA, the length needed tocomplete an MDA using health staff, and unsatisfactoryreporting. In addition, finding health staff to supervise vol-unteer distributors, drug logistics, and developing socialmobilization strategies for many unique communities hasproven difficult. Other health programmes, such as mal-aria, have found success using private partners to imple-ment health activities, such as Rotary’s attainment of 95%national coverage of bednets in a short time frame.Dr Makita summarized PNG’s plan to move forward

by grouping villages into manageable populations forMDA, appointing and training more volunteers, havingMDA on an appointed day in a district, recruiting extranational staff, and ensuring availability of drugs and ad-equate information. The new PNG Minister of Health hasrenewed the government commitment after attending aNTD meeting in Australia, and partners such as WHO,James Cook University, the Institute of Medical Research,and the private sector are becoming more involved.

DiscussionParticipants offered suggestions for the PNG programme,including a cost comparison of using community volun-teers versus hiring a third party to implement, piggybackingon the Expanded Programme on Immunization activities,looking at cross-border solutions with Indonesia, and ex-ploring private sector infrastructure networks such as thosedistributing cell phones, liquor, etc.

How can we accelerate the process?Moderator: Dr Frank Richards (The Carter Center, USA).

Indonesia: moving from partial to full coverageDr Rita Kusriastuti (Vector Borne Disease Control, Min-istry of Health, Indonesia) summarized the LF situation,where 368 of 497 districts are endemic, with 125 millionpeople at risk of Bancroftian and/or Brugian filariasis.The programme defines the district as the IU, but manydistricts are only able to support MDA in some sub-districts each year. In 2011, 98 districts conducted MDA,with 61 covering the entire district and 37 covering onlysome sub-districts. In addition, some districts have con-ducted more than five MDA rounds, but are still endemic.These issues have led to problems in fully implementingthe elimination strategy, which called for MDA implemen-tation in 80 districts per year from 2012–2018. To acceler-ate progress the programme needs to improve programme


management by strengthening case finding, reporting andrecording; involve the community in the population regis-tration; increase monitoring of ingestion of the drugs; andimprove the referral system for serious adverse reactions.In addition, human resource capabilities need to be im-proved through training in planning and surveillance,managerial skills, communication skills, and monitoringand evaluation.Dr Kusriastuti noted that expansion of the national LF

committee to cover NTDs, advocacy to both high-levelleaders and local government leaders to support oper-ational costs, integration with the school health programmefor STH, partnerships with other sectors, involvement oflocal non-governmental development organizations, andassistance from international partners such as WHO,USAID, AusAID, RTI International, Rotary, World Vision,and the Global Network for NTDs is all critical to achievethe elimination goal. Although $12 million is already com-mitted by donors and the government, the Indonesiaprogramme has a funding gap of $10 million in 2013.

Nigeria: improving integration to assure fundingMr Chukwu Okoronkwo (NTD Programme, Ministry ofHealth, Nigeria) explained that over 106 million peopleare at risk of LF in 541 local government units (LGAs)of the 705 that have been mapped. Only 175 LGAs(32%) implemented MDA in 2011, covering an at-riskpopulation of 33 million, but with less than half of theLGAs achieving the coverage goal of 80% of eligiblepopulation treated. The programme started scaling upMDA in 2009 in areas co-endemic with onchocerciasis,with 4.7 million treated in 2009, 10 million treated in2010 and 22 million treated in 2011. He noted that theprogramme intends to complete mapping by March2013 with USAID and DFID support, conduct baselinesurveys in sentinel sites, provide adequate managementand technical training to improve planning and coordin-ation skills of State Coordinators, and conduct compre-hensive census updates. However, plans to accelerateprogress have been hampered by ineffective coverage ofMDA in urban areas, which has brought overall cover-age rates down. Financial issues of inadequate funding,late release of approved funds by partners, and depend-ency on assisting non-governmental development orga-nizations can be solved by advocacy and sensitization atthe highest levels, improving the integrated NTD platformimplementation to share resources, and mobilizing add-itional partners. The programme also needs to address theissue of incentives for CDDs and health workers, asfunds are insufficient. Policymakers’ desire to extendMDA to areas that are not yet mapped or are non-endemic have been problematic, so the programme aimsto target more sensitization and advocacy activities topolicymakers at all levels.

Tanzania: phasing in integrated MDADr Upendo Mwingira (National NTD Programme, Min-istry of Health, Tanzania) discussed the integrated NTDprogramme on mainland Tanzania, which includes fivePC NTDs and ten case-management NTDs, targeting 44million people. The programme follows a NTD masterstrategic plan, implemented by NTD coordination unitsat national, regional and district levels. It uses the LFMDA as the platform, training health workers, schoolteachers and CDDs, and is scaling up MDA through aphased approach of adding one region each year. In2011, 11.3 million people were treated for NTDs in 76implementation units (50% geographic coverage), withthe goal to reach full geographic coverage by 2014. Shenoted that the programme needs a NTD database sys-tem that can send data collected at health center leveldirectly to national level and can be integrated into thehealth management information system in order to over-come challenges of delays in data collection and reporting.The programme will encourage increased programmemonitoring, using partner support to maintain at least onesentinel sites in every region and will increase advocacyand support for morbidity management at all levels. Othertechnical issues include the need for clear tools for allNTDs, more training, and support for a drug logistician. Interms of administrative issues, Dr Mwingira remarked thatan integrated country strategic plan and joint planningmeetings are necessary when dealing with multiple part-ners and donors, including CNTD, the SchistosomiasisControl Initiative, RTI International, IMA World Health,Sightsavers, and Helen Keller International. Local advocacyis necessary to ensure local government contribution andengage partners from other sectors. The programme seesopportunities in a strong health system, existing part-nerships, links to interventions such as Water, sanita-tion and hygiene (WASH), indoor residual spraying formalaria, and the global momentum resulting from theLondon Declaration.

DiscussionParticipants remarked on the tension between scaling upand ensuring appropriate treatment coverage in currentMDA areas, advising that it is important to meet treat-ment coverage in current areas first before expandinggeographic coverage. Suggestions on improving advocacyand funding included the use of ministers of parliamentand involving African and Asian Development Banks.Decentralized systems that have power at district levelcan help accelerate progress as services are deliverednearer the community, freeing the central level to focuson advocacy and coordination. The issue of finding hotspots, e.g., clusters of residual transmission, in large dis-tricts was also raised.


Strategies for achieving disability prevention andmorbidity managementModerator: Ms Ann Varghese (IMA World Health, US).

Togo national programme for lymphoedema managementDr Dorkenoo summarized the three elements of the na-tional lymphoedema management programme: detectionand referral of cases, treatment and management of cases,and follow up and evaluation. In every village, villagechiefs and community leaders are asked to inform thecommunities that anyone with a large swollen leg shouldgo to a clinic and this is enforced through TV and radioannouncements, posters and public criers. A nationaltraining-of-trainers model trains nurses from throughoutthe country and community health workers in seven en-demic districts. The national programme does periodicsupervision of nurses and patient visits.She described how the programme started in June

2007 in the seven endemic districts and was scaled upwithin two years to the entire country. Even though LFMDA ended in 2009, the number of patients continuesto increase, with over 1,200 patients currently undertreatment, and 32% of patients living in non-endemicdistricts where LF MDA was not needed. Operational re-search funds to determine the feasibility of a countrywidemorbidity control programme included start-up fundingfor training, IEC material, washing kits and supervision.The well-functioning and decentralized health system is agood platform for the programme, with the aim to con-tinue providing services even after the LF elimination tar-get of 2015. The Ministry of Health continues to maintainthe LF programme coordination staff posts, even thoughMDA has stopped, and provides support for supervisionactivities. However, Dr Dorkenoo noted challenges with ahigh turnover of trained staff and long-term complianceof patients, necessitating refresher training and continuingbehavior change communication activities.

Community-based support for lymphoedema patientsMr Jonathan Rout (Churches Auxiliary for Social Action,India) described their project to provide community-based support for lymphoedema patients in the highly-endemic state of Orissa, where 3.5 to 6.3 million peopleare estimated to be infected with LF. The multi-facetedapproach includes health education to entire communi-ties, patient registration, extensive training, patient fol-low up, and impact assessment. In a census of 215,515households, 27,671 people with hand swelling, breastswelling, hydrocele or lymphoedema were found. Atleast one LF task force volunteer per village was trainedand certified in lymphoedema management and basicfirst aid and, in turn, distributed posters and leafletsdoor-to-door. They continue to follow closely 20 pa-tients each. The project also supports wall paintings and

street plays to raise awareness of MDA and footcare man-agement, and implements classroom and field training inlymphoedema management for school children, familymembers, village volunteers, and paramedics. Patients areprovided with soap, anti-fungal cream, towels, shoes, anda 365-day booklet to track exercises and routine hygiene.An impact study found that quality of life improved sig-nificantly among patients, with daily washing associatedwith lower disability scores. The frequency of acute at-tacks was the strongest predictor of disability. In addition,a CDC study found that MDA coverage in districts withthe lymphoedema management programme (90.2%) wasbetter than in districts with MDA only (52-59%) or acommunity-based pre-MDA education programme only(75%) [6].

New therapeutic options for lymphoedemaDr Achim Hoerauf (University of Bonn, Germany) pre-sented the results of recent research that aimed to deter-mine whether doxycycline improves filarial lymphoedemain filarial antigen-positive patients (e.g., those with on-going infection) as well as antigen-negative patients [7]. Inaddition, it compared the effect of doxycycline, an anti-biotic which targets Wolbachia as well as exogenous bac-teria, to amoxicillin, an antibiotic which targets exogenousbacteria only. The study had three treatment arms: i)doxycycline 200 mg/day for 6 weeks and hygiene manage-ment, ii) amoxicillin 1000 mg/day for 6 weeks and hygienemanagement, and iii) placebo drug and hygiene manage-ment. Approximately 40 patients were in each arm, themajority of whom were in stages 1–3. Dr Hoerauf pre-sented results that doxycycline was beneficial in revert-ing or halting progression of early stage lymphoedema,regardless of whether patients had active infection. Theresults suggest that doxycycline might have an anti-inflammatory effect that makes it superior to other anti-biotics. Of those patients treated with doxycycline, 37%showed improvement in stage, compared to 3.2% ofthose treated with amoxicillin and 5.6% of those treatedwith placebo. A lack of progress to more severe stageswas shown in 95% of those treated with doxycycline,71% with amoxicillin, and 44% with placebo. There is aneed to extend this research to patients with stages 4and higher, as well as to replicate it in other settings.The study recommended that a 6-week course of doxy-cycline be given to lymphoedema patients once everytwo years as part of morbidity management.

African LF morbidity projectDr Sunny Mante (African LF Morbidity Project, Ghana)explained its goal to build capacity for filarial hydrocelesurgery, reconstructive plastic surgery for genital lym-phoedema, and hygiene therapy for lymphoedema. A2006 evaluation of the BMGF-supported pilot project to


train hydrocele surgeons reached 399 of the 1,771 pa-tients who had received hydrocelectomies and foundthat 92% were very satisfied with the surgery. Many pa-tients were lost to follow up because they had gone backto work or were away for seasonal agriculture.The project was scaled up in 10 West African coun-

tries plus Tanzania, and Malawi through funding fromHealth and Development International and InternationalVolunteers in Urology, training 469 people in 12 coun-tries in hydrocele surgery and operating on 3,975 pa-tients during training. A 2007 revised surgical manualdetails the technique used, which includes total removalof the sac and no drains [8]. Since 2011, training on her-nia surgery has been explicitly included in these train-ings, as it is difficult to differentiate between hydroceleand hernia patients pre-operatively and many hernia pa-tients present for surgery when free hydrocele surgery isoffered.Dr Mante noted that currently four workshops are

planned (two each in Ghana and Sierra Leone) throughsupport from International Volunteers in Urology andJohnson & Johnson, although the project would like toextend to East Africa and Asia. Because 25-40% of adultmales have hydrocele in highly LF-endemic areas, thereis a need to scale up provision of surgeries, provide sup-port to hernia patients, report and evaluate surgeriesongoing in all countries, and ensure hydrocele surgerytechniques are included in routine medicine training inendemic countries. Capacity building of plastic surgeonson reconstructive surgery for genital lymphoedema isalso needed. Finally, while two articles on hydrocele sur-gery were recently published [9,10], there is a need formore advocacy and publishing of results.

DiscussionIntegration of these activities with other diseases was themajor topic of discussion. The African LF Morbidity Pro-ject is in discussion to have joint workshops for hydrocele,genital lymphoedema, and urogenital fistula, although itwas noted that it might be difficult to combine trainings ofdistrict surgeons responsible for hydrocele with gynecolo-gists who are responsible for urogenital fistula. Treatingpodoconiasis patients in conjunction with lymphoedemapatients was seen as useful, given that management issimilar. In addition, the importance of having countries re-port on these activities to WHO and collecting data fromthe hospital system on number of operations, complica-tion rate, and recurrence was raised.

Linking the programmesNew partnerships with onchocerciasisDr Hopkins presented a rationale for partnering withonchocerciasis: the diseases affect overlapping popula-tions, have almost identical disease agents, recommend

similar treatment, employ similar M&E methods, andface common challenges. While countries where LF andonchocerciasis are endemic completely overlap, co-endemicity only occurs in some districts (Figure 6).The LF and the onchocerciasis parasites can be difficult

to distinguish, a difference which does not matter fortreatment, but does when monitoring progress towardelimination. During preventive chemotherapy, both dis-eases use ivermectin, while the LF programme adds alben-dazole. For M&E, both disease programmes need betterdiagnostics, as skin snips for onchocerciasis and nightblood films for LF are not popular and existing serologicaltests require additional validation. There is a related needto build human and laboratory capacity to carry out ento-mological and parasitological surveys in both programmes.In addition, existing M&E methods are costly and wouldneed to include parasitological, entomological and sero-logical surveys for onchocerciasis elimination.In terms of challenges common to both programmes,

there are mapping gaps for both LF and onchocerciasis, aswell as cross border issues in conflict areas, such as SouthSudan and neighbouring countries. Both programmes arelagging behind goals for scaling up. Particularly if oncho-cerciasis moves towards an elimination strategy, there are18 million people (not including the Central African Re-public, Sudan, and the Democratic Republic of Congo)who live in areas with a nodule prevalence between 5-15%that are not currently being treated. Eighty percent of thepeople not yet covered by LF treatment live in nine coun-tries, many of which are either treating for onchocerciasis,such as Nigeria, or have found new areas of onchocerciasisendemicity that also need treatment, such as in Ethiopia.Finally, loiasis presents a major obstacle for both pro-grammes in co-endemic areas in central Africa, such asCameroon, the Democratic Republic of Congo, Congo,Gabon, and Equatorial Guinea, with 30 million peopleat-risk for loiasis (based on those living in areas withgreater than 20% on the RAPLOA scale). In areas whereonchocerciasis is meso- or hyper-endemic and co-endemic with loaisis, treatment can still occur. However,given that only 1-2% of people might be infected inareas where LF treatment is prescribed, it is too risky totreat with ivermectin in areas with loiasis, given thechance of serious adverse events due to high levels ofLoa microfilaremia. The LF programme is now movingforward with a strategy of using twice annual albenda-zole and bednets in these areas.Dr Hopkins concluded that there are many opportun-

ities for synergy including integrated mapping, joint train-ing, combined treatment registers, simultaneous MDA,joint M&E, and joint epidemiological evaluations. Hechallenged the group to not just see the benefit in exploit-ing synergies for the two programmes, but to see the LFand onchocerciasis activities as one programme in Africa.

Figure 6 Overlap between LF and onchocerciasis in Africa. Legend: A: Lymphatic Filariasis current status (Source: AFRO NTD programme).B: Onchocerciasis treatment areas (Source: APOC).


Extending the benefitsDr David Addiss (Children Without Worms, USA) pre-sented a summary of ancillary benefits from the LF MDAprogramme. The LF programme has given the STH com-munity a bold vision of elimination, with a platform for in-tegrated NTD activities related to MDA and M&E. From2001 to 2011, LF MDA included two billion treatmentswith albendazole that also treated STH. For example, in2010, WHO reported that 57% of the school-aged childrentreated for STH were given these medicines through na-tional LF programmes. In areas with LF programmes, en-tire communities are treated for LF, which likely gives agreater impact than those areas that only implementschool-based STH treatment. In terms of M&E, the LFTAS platform could be used to collect information onSTH as well.However, Dr Addiss cautioned that often the benefits

of LF programme have not been fully extended to thosewith LF-related disease. The rationale for the two pillarsof the LF programme stems from the wording of theWorld Health Assembly resolution – elimination as apublic-health problem – which includes those with clin-ical disease, and not just infection. Providing care forLF-related disease has also been shown to increase ac-ceptability and compliance with MDA. Furthermore,providing care for those with LF-related disease was

considered the right and compassionate thing to do. Butas of 2010, only 27 (33%) of endemic countries had ac-tive morbidity management programmes.The four basic components of NTD control include

preventive chemotherapy (which is usually the largestcomponent and often has a direct clinical benefit); vectorcontrol; water, sanitation and hygiene; and clinical care. Inthe LF programme, morbidity management and disabilityprevention (MMDP) lags behind PC, while in the STHprogramme, the water, sanitation and hygiene activitieslikewise take a back seat to PC. The trachoma programme,however, has a more balanced approach with the fourcomponents of the SAFE strategy – surgery, antibiotics,facial cleanliness, and environmental improvement. Forthe LF programme to truly achieve elimination, it needs tobe both internally integrated in terms of MDA, vectorcontrol and MMDP activities, as well as externally inte-grated with other health programmes. A model for howMMDP can be integrated externally has been described inthe Legs to Stand On framework, which identifies thecommon elements of treatment across diseases such asLF, diabetes, leprosy, and Buruli ulcer.Dr Addiss related another benefit of the GPELF in

context of a quote from Bill Foege about ‘seeing thefaces’ behind everything we do - i.e., having a compas-sionate response to suffering. The GPELF represents a


compassionate response to LF-related suffering, and hasincluded the three main elements of compassion, whichinclude: i) awareness of suffering, ii) empathy, and iii)action. Publications focusing on the awareness of suffer-ing include studies of psychological distress and disabil-ity caused by LF-related diseases. In terms of emotionalattunement with patients, he related the power of thepersonal story - of 'seeing the faces' for those who workin LF elimination. Finally, compassion must lead to action.The magnitude of action in the global LF programme is,by any standard, impressive. Although the GPELF is agreat example of a ‘mass uprising of compassion’, theexpression of that compassion faces several importantchallenges. It is difficult to keep seeing the faces whenworking with populations in the millions and billions, andacross great geographical distances. In addition, a globalprogramme requires acting through complex systems ofinstitutions, each with its own agenda, and with compet-ing motivations. Dr Addiss challenged the group to try tomaintain focus on interrupting LF transmission whileexpanding its peripheral vision to include those with LFdisease; to unite the LF programme activities across differ-ent sectors in the health system; to see faces and numbersat the same time; and to combine compassion for individ-uals with action at the population level.

Two programmes: a shared goal – LF and trachomaDr Teshome Gebre (International Trachoma Initiative(ITI), Ethiopia) discussed the shared goals and common-alities between LF and trachoma. Both diseases are ac-quired in childhood, with terribly painful and severelyincapacitating complications that appear later in life. InAfrica, there are mapping gaps in nine countries for LFand 19 for trachoma; coordinated mapping could occurin areas of potential overlap to leverage resources. Bothprogramme strategies include MDA and morbidity man-agement, while trachoma also includes the preventiveactivities of face washing and environmental improve-ment. In order to achieve trachoma goals by 2020, thereis a backlog of 4.6 million trichiasis patients that needsurgery, which means scaling up from 160,000 surgeriesto 500,000 surgeries a year. While more than 200 milliontrachoma treatments have been delivered since 1998,380 million more are needed before 2020. Dr Gebre dis-cussed various ideas for linking the programme inter-ventions including: i) empowering CDDs to handle allMDA through joint planning, training, and implementa-tion; ii) co-administration of drugs where feasible, depend-ing on results of clinical trials underway for ivermectin,albendazole and azithromycin; iii) joint M&E, and iv) initi-ation of regional, sub-regional, and national NTD coord-ination mechanisms or annual reviews which are smallerand more technical, using the sub-regional forums toaddress cross-border issues. Beyond just LF and other

NTDs, he proposed links with HIV/AIDS, tuberculosis,and malaria, such as a ‘MalTra’ week approach to reachseveral million people with MDA and bednets in Ethiopia.He then discussed the unresolved issues that are ham-

pering achievement of goals, such as gaps in behaviorchange, hygiene and sanitation, and effective communitymobilization strategies. There are concerns with resultsof MDA coverage surveys; for example, Ethiopia foundless than 49% coverage in surveys when health facilitiesreported over 85% coverage. This has translated into im-pact assessments that have shown that very few districtsshowed infection levels of TF less than 10% after threeor five rounds and so must continue MDA. Finally, theNTD community needs to find the most effective levelof integration and coordination among partners and do-nors at all levels. He cautioned that if the LF and trach-oma programmes do not start doing things differentlythe 2020 elimination goal will not be achieved.

A partnership with malaria programmesDr Richards discussed the Nigerian experience in linkingLF with the malaria programme, where Anopheles gam-biae is the primary vector of both diseases. A 2011WHO position statement on integrated vector manage-ment (IVM) made the case that the policy of using IVMto control malaria and LF makes epidemiologic sense[10]. In Plateau and Nasarawa States in Central Nigeria,the Carter Center has been implementing LF activitiesintegrated with onchocerciasis, schistosomiasis and mal-aria since 1998. During that period the programme hasdissected over 80,000 mosquitoes as part of LF entomo-logical monitoring, using the percentages of any larvalstage (L1, L2, and L3 but not including mf stages) andonly infective stage larvae (L3) as the critical indicators.The programme saw mosquito rates of infection withany stage larvae decrease during MDA, for an averagereduction of 85% from 3.1% to 0.3% in 2010, after atleast 7 years of MDA (Figure 7). L3 also were sporadic-ally found in dissections.In 2010, several million long-lasting insecticidal nets

(LLINs) – two nets for every household - were distrib-uted in Plateau and Nasarawa States as part of a massivecampaign throughout Nigeria to distribute over 65 mil-lion LLIN. A year after LLIN distribution, entomologicalmonitoring in LF sentinel villages recorded 0% mosqui-toes infected with L3 larvae, as well as 0% mosquitoesinfected with any larval stage. Preliminary results from2012 are also showing no infected mosquitoes. Thus,there is synergy between LLIN and MDA.In southeastern Nigeria, where MDA cannot be pro-

vided due to concerns about adverse reactions from co-endemic loiasis infection, the Carter Center has studiedthe entomological impact of LLIN alone (without MDA)in reducing LF transmission. The use of LLIN alone

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

Baseline 2004 2005 2006 2007 2008 2009 2010 2011

3.1%

1.1%

0.5%0.4%

0.4%0.8%

0.4% 0.3%0.0%

Mass drug administration

Figure 7 Average mosquito LF infection rates in nine sentinelvillages. Legend: Based on >46,000 dissections. blue rectangle =Infected.


showed an 84% reduction in all larval mosquito infectionrates, compared to areas with LLINs and MDA, where100% reduction was shown. In 2011 in both these areas,no L3 stage larvae were found. This indicates that trans-mission of LF has stopped – although in LLIN areas itmight not be interrupted since halting LLIN use couldresult in a rapid return of transmission.Over 90% of Nigeria has been mapped for LF, with

over 106 million people found to be at risk in 541 localgovernment areas (LGAs). However, only 19% of LGAsare currently implementing MDA for LF. In contrast, al-most all states completed the distribution of LLINs in2012, and will complete the job in early 2013. If the re-sults from the entomological impact studies hold trueelsewhere in areas with good LLIN coverage in Africa, LFprogrammes can celebrate a major impact on LF trans-mission now, despite the fact that MDA scale-up is lag-ging. GAELF partners should encourage, and indeed help,the malaria programme reach its LLIN coverage and usagegoals, as it is to the LF programme’s advantage!Building on advocacy efforts using political figures

such as former head of state General Dr Yakuku Gowon,the Carter Center sponsored a national combined LFand malaria programme meeting in March 2012. Themeeting presented the entomological monitoring find-ings, planned scale up of both LF and malaria activities,and created awareness about the benefits of integration,such as the fact that infection with intestinal worms canworsen malaria outcomes. Another benefit is that LFMDA, which intensively targets hookworm through distri-bution of albendazole to entire communities, results inlower anemia prevalence. Severe anemia accounts for halfof all malarial deaths in African children and women,co-infection with malaria and intestinal worms has beenshown to result in greater anemia. In addition, LFcommunity-based networks can be used by the malariaprogramme to mop up LLIN distribution, and implement

annual monitoring of LLIN ownership, usage and condi-tion. Finally, behaviour change communication can bestrengthened by showing the protection offered by LLINsfrom both malaria and LF, as focus groups showed thatadults are more motivated to sleep under nets to protectthemselves from lymphoedema and hydrocele than frommalaria fever, which is seen as an infection of youngchildren.

DiscussionDr Adiele Onyeze (WHO Africa Regional Office) askedhow the global LF community could scale up these ap-proaches at national or regional levels. He related theWHO African Region strategy of the ‘4 1’s approach’ thatincludes common partnership, planning, delivery andM&E, with a goal of making life better for fellow humanbeings at risk or already infected. The African Region’spriority is to have NTD national plans and fora by 2013,with new regional programme review group mechanismsat a regional level. The most difficult component of theNTD work in Africa goes beyond the availability of drugsand tools to figuring out how to bring various targets, or-ganizations and personalities together.Participants agreed that there is a moral imperative to

look at synergies in collaboration and coordination. It isimportant to clearly state the LF community’s needsfrom other programmes, e.g. what exactly do we wantfrom the malaria, water, morbidity and health systemstrengthening programmes and organizations? We needto articulate how the LF programme can help other pro-grammes achieve their goals. The LF programme needsstrong advocates and quality data to persuade other pro-grammes that “we are not just there for the money”. Thechallenges of translating the good examples of collabor-ation in these presentations into other country settingswas discussed, including the difficulties of replication indifferent settings, and the need for new programmes tohave access to this information.

GAELF: the next chapterModerator: Dr Mwele Malecela.Dr Malecela (National Institute for Medical Research,

Tanzania) opened the final session by sharing a Swahilisaying: ‘in order to see how far you have come, lookback and see where you were’. She reflected that GPELFhas made great progress since 2000 – with stronger na-tional programmes, great country leadership, a focus oncountries and the patients, and an acknowledgement ofthe importance of good data and research.

Strategic partnershipsDr Neeraj Mistry (Global Network for NTDs, USA) dis-cussed the key elements to strategic partnerships at a coun-try level, including trust, clear objectives, and specific roles


and responsibilities. Contributions to a LF programmeshould focus on partner competencies, such as involvingbusiness people who have better training in logistics anddistribution than medical doctors. Programmes need tounderstand the motivation that each partner has to be in-volved, whether it is the use of their logo, a free t-shirt, orraising their public profile. For programmes (and partner-ships) to work, charismatic leadership is necessary to con-vince governments and partners to support NTD work.The GAELF should cultivate national programme leaderswho have the ability and trust to negotiate partnerships atcountry level.He then offered some examples of potential partner-

ships, such as car dealerships lending vehicles duringMDA, mobile phone companies donating costs of text-ing MDA reports, cinema groups showing awarenessraising short movies in mobile cinemas in rural areas,local artists or celebrities advocating for NTDs, or com-panies donating t-shirts. Dr Mistry recommended thatnational programme reviews include outsiders from busi-ness or media in order to get a different perspective onprogramme success and challenges. He mentioned that afull assessment of the links between HIV/AIDS, tubercu-losis, and malaria and NTDs has been sent to the GlobalFund for AIDS, Tuberculosis and Malaria (GFATM) to en-courage them to approve proposals which include NTDactivities. Finally, he implored the group to use its anger atinjustice to advocate on behalf of NTDs as we are the onlyvoice of many of these communities.

Future of GAELF in post-London declaration environmentProfessor David Molyneux (Liverpool School of TropicalMedicine Centre for Neglected Tropical Diseases, UK)discussed the role of GAELF in the greater context of achanging global health, economic and political environ-ment. He highlighted steps in the evolution of the fightagainst LF, including: pharmaceutical company support;BMGF seed funding; delineation of the role of theGAELF in coordination, resource mobilization and advo-cacy; emergence of the concept of NTDs; and USAIDsupport.Since 2000, with support from endemic countries,

BMGF, DFID, USAID and others, there have been 2 billioncumulative treatments for LF, one of the most rapidlyupscaling public health programmes. GAELF has beenused as an umbrella to capture a diversity of partners, learnfrom country experience, and focus on a particular goal,while recognizing the complexity of problem. GAELF’sstrengths are in its loose structure, ability to speak inde-pendently, and as a forum for communication betweencountry programmes, researchers and donors. However,more funds are needed to expand morbidity activities,meet elimination goals, and implement critical operationalresearch. The Representative Contact Group is not yet fully

representative of the broader constituency. Innovativefunding mechanisms, whether centralized funding atthe World Bank, from APOC, the GFATM or othermodels, need to be explored.Professor Molyneux expressed his vision of keeping

GAELF focused on LF and the elimination goal, but adapt-ing to upscale PC for all NTDs given that if LF reaches itstarget for MDA, a high proportion of PC objectives will bemet as well. Instead of one NTD alliance, GAELF wouldbe one in a mix of alliances that would link to the othersat different levels, through articulating specific operationalresearch priorities, global advocacy, and capacity buildingfor data management, logistics and clinical issues.

DiscussionThe possibility of having a resident technical advisor inplace for key countries (following the example of theguinea worm eradication programme), who sits with thenational programme but has the freedom to talk withother ministries, private sector and stakeholders was dis-cussed. Other methods of providing support included i)continuing forums like GAELF to ensure opportunitiesfor discussion among many stakeholders, ii) twinning suc-cessful countries with those needing assistance or juststarting, and iii) broadening GAELF’s reach to includemore African and Indian research centres and universities.While participants agreed with keeping the GAELF as anLF-specific alliance, the idea was put forward of a three-in-one concept of combining parts of LF, STH and oncho-cerciasis meetings or holding them back-to-back.

Next stepsDr Lammie introduced the newly elected ExecutiveGroup members: Patrick Lammie, Moses Bockarie,Frank Richards, Adrian Hopkins, Charles Mackenzie,and Njeri Wamae. He then thanked all the speakers forpreparing thought-provoking, quality presentations andlisted five key recommendations that had emerged fromthe meeting:

1. Inspirational stories from countries showed clearexamples of the quality of country leadership in theGAELF, with leaders who are problem solvers andhave the ability to motivate governments andpartners to contribute. Since good programmemanagers make good programmes, support needs tocontinue to these programme managers. The idea ofa mentorship programme, perhaps through theWHO capacity building working group, in whichnew programme managers could shadow moreexperienced managers through an MDA cycle,should be explored. In addition, the idea of residentadvisors should be taken forward, especially incountries with a single NTD programme manager.


2. The concept of integration has changed from apotential threat to the GPELF to an opportunity toscale up LF, as well as other NTD activities.Countries provided examples from building LFMDA onto onchocerciasis CDD in Sierra Leone andLiberia to child health days in the Philippines tolowering LF prevalence through use of bednets inNigeria to the use of LF MDA as the single largestmechanism for STH delivery. However, evaluation ofthe impact of integration is missing, with prioritiesto strengthen evaluation capacity and operationalresearch in mapping, elimination criteria andpost-MDA surveillance needed.

3. The willingness to see the faces in the data is a clearchallenge. Thus far, in many countries, theprogrammes have been highlighting people withdisability to leverage community compliance withMDA without providing care for them. This needsto change by the time of the next GAELF meeting.

4. The single greatest determinant of success atcountry level has been government commitment.The idea of GAELF representatives visiting keycountries with WHO and other donors to galvanizesupport at country level should be taken forward.

5. There is a challenge to be innovative in the wayGAELF is organized, both in terms of themechanism of engaging the Representative ContactGroup and in how it coordinates with otherdisease-specific and NTD meetings. Anyone withsuggestions on how best to ensure greater countryparticipation and engagement, as well as moreeffective use of meeting time, was encouraged tosend an email through the GAELF website.

Dr Lammie expressed gratitude to Don Bundy and theWorld Bank, Julie Jacobson, and the Global Health Strat-egies team and the CNTD team for organizing the meet-ings and to the outgoing Executive Group members forputting together the series of panel discussions. Finally,he gave thanks to the 65 countries represented, and theenormous commitment by donors including Merck &Co. Inc. and GSK, as well as the many partners that havesupported NTD programmes at country level and sup-ported partners to attend the meeting.Don Bundy closed the meeting by sharing his impres-

sions of the NTD and GAELF meetings. In the 1980s,LF control was based on vector control, with the onlymedical input at the clinical and immunological levels.The community is now too focused on preventivechemotherapy, a change facilitated by the drug dona-tions targeting LF. Since incentives are the key tochange, he challenged GAELF to continue exploring thereasons for working together and what informationneeds to be shared.

EndnoteaWhen South Sudan became independent in 2011, the

number of endemic countries rose from 72 to 73.

Additional file

Additional file 1: Lists of participants.

AbbreviationsAPOC: African Programme for Onchocerciasis Control; BMGF: Bill & MelindaGates Foundation; CDC: (United States) Centers for Disease Control andPrevention; CDD: Community drug distributor; CNTD: Centre for NeglectedTropical Diseases (Liverpool); DEC: Diethylcarbamazine citrate;DFID: Department for international development, UK; GAELF: Global Allianceto Eliminate Lymphatic Filariasis; GPELF: Global Programme to EliminateLymphatic Filariasis; GSK: GlaxoSmithKline; ICT: Immunochromatographic test;IU: Implementation unit; LF: Lymphatic filariasis; LLIN: Long-lastinginsecticide-treated net; MDA: Mass drug administration; MMDP: Morbiditymanagement and disability prevention; M&E: Monitoring and evaluation;NTD: Neglected tropical diseases; PC: Preventive chemotherapy; PNG: PapuaNew Guinea; STH: Soil-transmitted helminthiases; TAS: Transmissionassessment survey; USAID: United States Agency for InternationalDevelopment; WHO: World Health Organization.

Competing interestsThe authors declare that they have no competing interests.

AcknowledgementsThe author would like to express her gratitude to the speakers andparticipants at the GAELF7 meeting for their permission to summarize theirremarks and for their review of the manuscript. In particular, thanks are dueto Professor David Molyneux, Mrs Joan Fahy and Miss Alison Blacklock at theLiverpool School of Tropical Medicine and to Dr Patrick Lammie and theentire GAELF executive committee for their editorial guidance in preparingthe report. All the GAELF7 participants thank Professor Donald Bundy and hiscolleagues at the World Bank for their generosity in hosting the meeting.

Author details1RTI International, 701 13 St NW, Suite 750, Washington DC 20005, USA.2Centre for Neglected Tropical Diseases, Liverpool School of TropicalMedicine, Pembroke Place, Liverpool L3 5QA, UK.

Received: 3 January 2014 Accepted: 8 January 2014Published: 23 January 2014

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doi:10.1186/1756-3305-7-46Cite this article as: Brady: Seventh meeting of the Global Alliance toEliminate Lymphatic Filariasis: reaching the vision by scaling up, scalingdown, and reaching out. Parasites & Vectors 2014 7:46.

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Seventh meeting of the Global Alliance to Eliminate ... · elimination of lymphatic filariasis (LF) as a public-health problem. Keywords: Lymphatic filariasis, Neglected tropical