Filariasis
OUTLINE
I. Epidemiology
 
II. Overview of Lymphatic Filariasis
a. Etiology
b. Mode of Transmission
c. Signs and Symptoms
d. Pathogenisis
e. Diagnosis
f. Treatment 
 
III. National Objectives for Filariasis 2011-2016
IV. National Filariasis Elimination Program
a. Mission, Vision, Goal, Objective
b. Program Strategies
c. Additional Notes
(tables and figures at the last page)
Epidemiology
INTERNATIONAL
 Lymphatic filariasis is a public burden that needs
national and global attention (Oducado, 2014).
According to the World Health Organization (2012),
 it is the second most common vector-borne parasitic
infection, following malaria, and is also the second
most common cause of long-term disability and
suffering, after mental illness.
 LF puts at risk more than a billion people in 83
countries and affects more than 120 million people
globally, with over one-third becoming severely
disfigured and disabled (DOH, 1980-2010).
 Among these, 25 million men have genital diseases
and almost 15 million, mostly women, have
lymphedema of the leg.
 The WHO South-East Asian Region has the has the
highest number of people at risk for contracting
Filariasis, with approximately 66% of the total
population at risk, while the remaining are in the
African Region.
 Indonesia, South India, South China, Thailand,
Malaysia, Vietnam, Philippines and South Korea are
the countries in Asia documented to be severely
infected with Filariasis. Contrary to this, only four
countries are known to be endemic to Filariasis in
America, namely Haiti, Dominican Republic, Guyana
and Brazil.
NATIONAL
 In the Philippines, this disease remains to be one of
the public health problems that need to be given
greater concern and attention.
 The number of Filipinos who are at risk of having the
disease is approximately 3 million.
 Two types of parasite are known to cause Lymphatic
Filariasis in the Philippines:
o Wuchereria bancrofti and Brugia malayi.
Bancroftian filariasis, the periodic type, but
also sometimes varies, is prevalent in the rural
areas especially in Southern Luzon,
Mindanao, Palawan, Samar, Leyte, Sorsogon
and Bohol, where there are several abaca and
banana plantations.
o Brugian filariasis, the nocturnal sub-periodic
type, is endemic in southwestern Palawan,
Sulu, Agusan, and Samar. Both types of
filariasis can be found in Davao Oriental,
Palawan, Eastern and Northern Samar, and
Surigao del Sur.
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Forty-four (44) out of 80 provinces have been
found to be endemic for lymphatic filariasis as of
2009 (Table 1).
 9 of these have eliminated filariasis in 2012, and
an additional 11 provinces were filariasis-free in
the year 2013.
In the latest reports by the specific provincial
health offices of filarial-endemic provinces, 2
additional provinces were declared Filariasis-
free in 2015: Zamboanga del Sur and
Zamboanga Sibugay. Early this year, 2
provinces were added to the list of filariasis-free
provinces, namely Davao Oriental and
Maguindanao (Table 2).
 To date, if the provincial reports will be counted,
there are only 16 provinces left that are endemic
for filariasis. However, the Department of Health
has no latest report on the prevalence of the
disease in our country.
 Table 3 summarizes the total cases of Filariasis
per region based on the 1996 and 2011 data.
 Comparing the percent of total cases from the
1963-1996 data to 2011 data, there is a
decrease in the number of cases in each region
and all of the regions with reported cases are
considered to have low prevalence (<5%).
 In the 1963-1196 data, 12 of the 15 regions had
positive cases. Region 5 had the highest
number of cases with a moderate prevalence (5-
10%) of 5.65 %.
 In the 2011 data, only 7 of the 16 regions have
positive cases and Region 12 had the highest
number of total cases.
 Regions previously reported namely, Region 1,
3, 7, 8 11 and CAR, have no recent cases based
on the 2011 data
Global Programme to Eliminate Lymphatic Filariasis (GPELF)
 declaring endemicity of filariasis in an area are
zero-positives and any-positives considered as
non-endemic and endemic respectively.
 This is in consideration of the only the most
recent mapping survey (target 250 persons
tested) by any test in each district.
 In addition, GPELF modified criteria categorizes
endemic areas with >0% to <5% and ≥5%
positive as low endemic and high endemic,
respectively.
 Where an unknown district is bordered on all
sides by endemic districts, classify as “low
endemic” or “high endemic” based on lowest
category found in adjacent districts.
 In more recent data of the Philippines, the
affected provinces are categorized as:
o Category 1 or Endemic Areas are
provinces established as endemic areas
for Filariasis with validated recent
reports of endemicity.
o Category 2 or Probably-Endemic are
provinces identified as endemic in 1960
survey excluding provinces in category
1, without report of endemicity to date.
o Category 3 or Non-Endemic are those
provinces without validated report of
endemicity up to present.
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 In the 2014 Annual Report of the Field Health
Service Information System (FHSIS) by the
Department of Health, the clinical rate of
filariasis in the Philippines is 2.97%.
 This is a measure of the number of patients with
lymphedema over the total number of cases
examined. In addition, the prevalence rate of
Filariasis in the Philippines in the year 2014 is
0.16%, where cases were found in 3 regions:
Region 6, 9 and CARAGA (Figure 1).
 In this survey, the province of Surigao del Norte
has the highest prevalence rate of filariasis
(1.36%), followed by Aklan (1.31%).
 Looking at the history, in 2011, Aklan province
registered the highest number of cases with
microfilaria rate of 6.20%, tagging the whole
province moderately endemic of the disease
according to the WHO classification (DOH,
2010).
OVERVIEW OF LYMPHATIC FILARIASIS
ETIOLOGY
 Elephantiasis is a disease transferred by
mosquitoes from a person infected with
microfilaria parasite to another person.
 Lymphatic filariasis is a parasitic infection in the
blood.
 Enlargement (lympheodema) of the arms and
legs are common among Filipinos. Aside from
the lymphoedema of the upper or lower
extremities, enlargement of the breast of women
and enlargement of the scrotum for males are
among the manifestations of the disease.
MODE OF TRANSMISSION
 The disease spreads from person to person by
mosquito bites. Lymphatic filariasis is
transmitted by a number of species of female
mosquitoes in four principal genera, Anopheles,
Culex, Aedes and Mansonia (World Health
Organization, 2013).
 According to the periodic pattern of microfilariae
(mff) in the human host’s peripheral blood,
lymphatic fillariasis caused by Wuchereria
bancrofti may be separated into three forms:
o (1) a nocturnal periodic form, widely
found in tropical and subtropical zones
in Africa, Asia and Latin America, in
which microfilarial densities peak close
to midnight;
o (2) a non-periodic or diurnal, sub-
periodic form, prevalent in the islands of
the South Pacific, in which maximum
densities of mff occur around 16.30
hours;
o (3) a nocturnal, sub-periodic form, with
a focal distribution in western Thailand,
which is characterized by a peak in
microfilarial density at around 20.30
hours (Harinasuta et al., 1970a,b; WHO,
1992).
 Wuchereria bancrofti, which is
responsible for 90% of the cases
 Brugia malayi, which causes most of the
remainder of the cases
 Brugia timori, which also causes the
disease.
 Brugian filariasis, caused by B. malayi, also
occurs in two forms, of which the most common
is transmitted at night and the other during both
day and night.
 The first form occurs in rural populations in rice-
growing areas in Asia.
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 It is transmitted by night-biting Anopheles
species and by Mansonia species which breed
in swamps and ponds with aquatic vegetation.
 The second form is mainly a parasite of
monkeys living in swamps.
 Mansonia species breeding in swampy forests in
Indonesia and Malaysia may infect people living
nearby.
 Brugian filariasis caused by Brugia timori is
transmitted only by Anopheles barbirostris.
VECTORS:
 Anopheles spp.
o The larvae occur in a wide range of
habitats but most species prefer clean,
unpolluted water.
o Larvae of Anopheles mosquitoes have
been found in fresh- or salt-water
marshes, mangrove swamps, rice fields,
grassy ditches, the edges of streams
and rivers, and small, temporary rain
pools. Many species prefer habitats with
vegetation.
o Others prefer habitats that have none.
Some breed in open, sun-lit pools while
others are found only in shaded
breeding sites in forests.
o A few species breed in tree holes or the
leaf axils of some plants.
 Culex spp.
o Culex mosquitoes tend to have relatively
blunt-shaped posterior abdomens
compared to other mosquito genera and
are small and delicate (Marshall 2006).
o Culex pilosus adults tend to rest inside
forests or woodlands during the day, but
then fly over open land during the night
to a different habitat in which they feed,
only to return to their daytime habitat
again in the morning (Clements 1999).
o The flight patterns of adult Culex
pilosus are not influenced by wind
direction, which is unique among
mosquitoes because many species tend
to fly upwind (Clements 1999).
o
 Mansonia
o The Mansonia mosquitoes mostly breed
in marshy areas and lay their eggs in
masses, attached to the lower sides of
plants hanging or floating near a water
body.
o The breeding sites contain permanent
vegetation like swamps, ponds, and
grassy irrigation canals. They usually
bite at night, mostly outdoors (World
Health Organization, 2013).
SIGNS AND SYMPTOMS
 The clinical symptoms and signs are mainly
determined by the duration of the infection.
 The adult worms, which live in the lymphatic
vessels, can cause severe inflammation of the
lymphatic system and acute fever.
 Secondary bacterial infections are a major
factor in the progression towards lymphoedema
and elephantiasis, the characteristic swelling of
the limbs, genitalia and breasts.
 Patients affected by microfilaraemia may
present an asymptomatic infection or acute and
chronic manifestations.
 In the endemic areas, majority of affected
subjects show a clinically asymptomatic infection
and harbour microfilaria in their peripheral blood.
 It is important to know that even at this stage of
the disease abnormalities of the lymphatic
vessels such as dilatation appear to be
irreversible even after treatment.
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 Acute manifestations include Acute Adeno-
Lymphangitis (ADL) and Acute Filarial
Lymphangitis (AFL).
 ADL is the most common acute manifestation
and is characterized by attacks of fever.
 These episodes may occur both in the early and
late stages of the disease. The affected area is
painful, tender, warm, red, and swollen. The
lymph nodes in the groin and axilla are
frequently inflamed.
 These acute ADL attacks recur many times a
year in patients with filarial swelling and their
incidence increases with the degree of
lymphedema.
 Secondary infections due to bacteria such as
streptococci are responsible for these acute
episodes. In the affected limbs, lesions which
favor entry of these infecting agents may be
frequently demonstrated, either in the form of
fungal infection in the webs of the toes, minor
injuries, eczema, insect bites or infections.
 These ADL attacks are responsible for the
persistence and progression of the swelling
leading to elephantiasis not only of the limbs but
also of the external genitalia and breasts.
 AFL is caused by adult worms and are usually
rare. They generally subside without any
treatment.
 They are observed when the adult worms are
destroyed in the lymphatics either
spontaneously or by drug administration such as
diethylcarbamazine. Small tender nodules form
at the location of adult worm death either in the
scrotum or along the lymphatics.
 Lymph nodes may become tender. Inflamed
large lymphatics may stand out as long tender
cords underneath the skin, usually along the
sides of the chest or upper arm and axilla
associated with restriction in movement of the
affected limb.
 Though transient edema may sometimes occur,
these episodes are not associated with fever,
toxemia or evidence of secondary bacterial
infections. They generally subside without any
treatment.
 The chronic manifestations represent
lymphoedema and elephantiasis and genito-
urinary lesions.
 The most common chronic manifestation of
lymphatic filariasis is lymphoedema, which may
progress to elephantiasis.
PATHOGENESIS
1. During a blood meal, the infected mosquito
introduces a third-stage filarial larva onto the skin
of the human host, where they penetrate into the
bite wound.
2. They then develop in adults that commonly reside
in the lymphatics. For W. bancrofti, adults produce
microfilariae which are sheathed and have
nocturnal periodicity, except the South Pacific
microfilariae which have the absence of marked
periodicity. For B. malayi, microfilariae resemble
those of Wuchereria bancrofti but are smaller.
They are sheathed and have nocturnal periodicity.
3. The microfilariae then migrate into lymph and
blood channels moving actively through lymph and
blood.
4. A mosquito then ingests the microfilariae during a
blood meal.
5. After ingestion, the microfilariae lose their sheaths
and some of them travel through the wall of the
proventriculus and cardiac portion of the
mosquito's midgut which will reach the thoracic
muscles.
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6. There the microfilariae develop into first-stage
larvae and subsequently into third-stage infective
larvae.
7. This will then infect another human when the
mosquito takes in another blood meal
DIAGNOSIS
 The standard method for diagnosing active
infection is the identification of microfilariae in a
blood smear by microscopic examination. The
microfilariae that cause lymphatic filariasis
circulate in the blood at night (called nocturnal
periodicity). Blood collection should be done at
night to coincide with the appearance of the
microfilariae, and a thick smear should be made
and stained with Giemsa or hematoxylin and
eosin. For increased sensitivity, concentration
techniques can be used.
 Serologic techniques provide an alternative to
microscopic detection of microfilariae for the
diagnosis of lymphatic filariasis. Patients with
active filarial infection typically have elevated
levels of antifilarial IgG4 in the blood and these
can be detected using routine assays. Because
lymphedema may develop many years after
infection, lab tests are most likely to be negative
with these patients.
 The standard method for diagnosis of
lymphatic filariasis is microscopy of thick
and thin blood or buffy coat films stained
with Giemsa or other appropriate stains.
Well-trained and experienced technologists must
be available to prepare and examine these
slides and to recognize these unusual
organisms. The quantitative buffy coat system
(which requires commercial equipment and
fluorescence microscopy) may also be used to
enhance sensitivity, but it is not widely available
in clinical laboratories.
 Additional thin smears would be required to
determine identification of any microfilaria
present. Live motile microfilaria may also be
observed in fresh wet preparations of blood or
buffy coat samples. Concentration methods
using centrifugation or stained polycarbonate
filters can increase the sensitivity of light
microscopy. Wuchereria bancrofti and Brugia
malayi may have nocturnal periodicity
(depending on the geographic origin of the
infection), and blood may be best examined
from 10 pm to 2 am. Serologic testing is
available from referral laboratories (eg, Focus
Diagnostics) and can be used to detect filarial
IgG4 antibodies. Antigendetecting
immunoassays performed at the CDC are an
adjunct to assays that detect microfilaremia due
to W. bancrofti. An ICT card assay (BinaxNOW
Filariasis; Binax) and an Og43C ELISA
(Filariasis CELISA; Cellabs) are reported to be
both sensitive and specific, although neither of
these commercial assays is approved by the
FDA.
 Ultrasound detection of motile adult worms in
major lower extremity lymphatics is another
valuable diagnostic method. Living adult worms
in pelvic or lower extremity lymphatics can be
recognized by their size, appearance, and
motility, which produces a typical “filarial dance
sign”.
TREATMENT
DIETHYLCARBAMAZINE (DEC):
 This drug is effective against both microfilaria
and adult worms. DEC markedly lowers the
blood microfilaria levels even in single annual
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doses of 6 mg/kg, and this effect is sustained
even after one year. Even though DEC kills the
adult worms, this effect is only observed in 50%
of patients.
 By ultrasonography it is shown that even single
doses of DEC kill the adult worms when they are
sensitive to the drug. When they are not
sensitive even repeated doses do not show any
effect on the adult parasite.
 This drug does not act directly on the parasite
but its action is mediated through the immune
system of the host. The earlier recommended
dose of this drug was 6 mg/kg given daily for 12
days.
 The adverse effects produced by the drug are
mostly observed in patients who have
microfilaria in their blood and are due to their
rapid destruction which is characterized by
fever, headache, myalgia, sore throat or cough
lasting for 24 to 48 hours.
 They are usually mild and self-limiting requiring
only symptomatic treatment. Direct adverse
effects related to the drug are very rare. Recent
trials have clearly shown that DEC has no action
either in the treatment or prevention of the acute
ADL attacks occurring in lymphoedema. DEC is
the drug of choice in the treatment of Tropical
Eosinophilia syndrome in which it should be
given for longer periods of 3 to 4 weeks.
IVERMECTIN:
 This drug acts directly on the microfilaria and in
single doses of 200 to 400 ugm/ kg keeps the
blood microfilaria counts at very low levels even
after one year, such as DEC. The adverse
effects noticed in microfilaraemic patients are
similar to those produced by DEC but are milder
due to the slower clearance of the parasitaemia.
 Ivermectin has no proven action against the
adult parasite or in tropical eosinophilia .
Ivermectin is the drug of choice for the treatment
of onchocerciasis because of its safety and
efficacy, when compared to DEC.
 It is also the drug of choice for the prevention of
filariasis in African countries endemic for
Onchocerca and Loa loa, where DEC cannot be
used due to possible severe adverse reactions.
 Ivermectin is also effective against human
ectoparasites such as head and body lice,
scabies var hominis and many intestinal
helminths. This drug is not licensed for human
use in India.
ALBENDAZOLE:
 This antihelmintic drug is shown to destroy the
adult filarial worms when given in doses of 400
mg twice a day for two weeks. The death of the
adult worm induces severe scrotal reactions in
bancroftian filariasis since this is the common
site where they are lodged.
 Albendazole has no direct action against the
microfilaria and does not immediately lower the
microfilaria counts. When given in single dose of
400 mg in association with DEC or ivermectin,
the destruction of microfilaria by these drugs
becomes more pronounced.
 Albendazole combined with DEC or invermectin
is recommended in the global filariasis
elimination programme. The strategy that
appears most suitable for the elimination of
filariasis in India is the administration of a single
annual dose of albendazole 400 mg along with
DEC 6 mg/kg of body weight.
 This not only prevents transmission of filariasis
in the community by reducing the microfilaria
levels, but also has the added benefit of clearing
the intestinal helminths.
National Objectives for Filariasis 2011-2016
The overall goal of the Department of Health for
Filariasis is “Elimination of filariasis as a public
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health problem through a comprehensive approach
and universal access to quality health services.”
Figures 2 and 3 show the strategic objectives and
strategies set for Filariasis for 2011-2016
Figure 2. National objectives for 2011-2016 (National
Objectives for Health, DOH, 2011-2016)
Figure 3. Strategies to eliminate Filariasis (National
Objectives for Health, DOH, 2011-2016)
National Filariasis Elimination Program
 The program is composed of the Elimination
Plan by means of the Mass Annual Treatment
using the combination drug, Diethylcarbamazine
Citrate and Albendazole.
 The program targets individuals, families and
communities living in endemic municipalities in
44 provinces in 12 regions (30 million targeted
for mass treatment or 1/3 of the total population
in the country).
 The Philippine Plan was approved by WHO
which gave the government free supply of the
drugs for filariasis elimination. Administrative
Order No. 25-a, s. 1998 was issued by the
Department of Health (DOH) spearheading the
elimination of filariasis by formally shifting
control to elimination strategies
 An Executive Order N. 369 s. 2004 declaring
November as Filariasis Mass Treatment Month
was signed by the Secretary of Health last July
2004 as support to the program and was
disseminated to all endemic regions.
 In addition, administrative Order No. 2010-0009
has set guidelines in the prevention of
disabilities due to lymphatic filariasis
 If the area reached a consecutive 85% above
performance of elimination for the 5 years
period, they will be monitored, screened and
tested for LF Free status and if their
microfilaremia rate will fall to 0.1%, WHO will
declare the area as LF Free but if the rate is
higher than the 0.1% rate, it will be extended for
another year. DOH will give a grant to those
provinces declared as LF Free to sustain and
retain their LF Free Status.
VISION
Healthy and productive individuals and families for
Filariasis-free Philippines
MISSION
Elimination of Filariasis as a public health problem thru a
comprehensive approach and universal access to quality
health services
GOAL
To eliminate Lymphatic Filariasis as a public health
problem in the Philippines by year 2017
GENERAL OBJECTIVE
To decrease Prevalence Rate of filariasis in endemic
municipalities to less than 1/1000 population
SPECIFIC OBJECTIVES
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The National Filariasis Elimination Program specifically
aims to:
 Reduce the Prevalence Rate to elimination level of
<1%;
 Perform Mass treatment in all established endemic
areas;
 Develop a Filariasis disability prevention program in
established endemic areas;
 Continue surveillance of established endemic
areas 5 years after mass treatment.
STRATERGIES
STRATEGY 1: ENDEMIC MAPPIING
 Endemic mapping is used to assess the disease
situation in the country, and identify areas where
mass drug administration (MDA) should be
done.
 This may be done through reviewing existing
information on the distribution of the disease of
the disease, and updating this knowledge by
collecting new information through
questionnaires.
 Through this, quick and easy estimate of the
prevalence in high-risk areas can be made and
used in classification of implementation units
(IU).
 Implementation units are classified into three:
o (1) confirmed filarial-endemic units,
o (2) confirmed non-endemic units, and
o (3) units contiguous to confirmed
endemic units and units with
inadequate information.
Doubtful areas are also surveyed in order to establish
boundaries between implementation units.
Endemic mapping involves the following:
1. Community diagnosis. This is done through
subset sampling taken in one barangay per
municipality, examining a total of 200 persons
per baranggay. The data collected will be taken
to be true for the whole municipality.
2. Immunochromatographic test (ICT). This is a
rapid assessment antigen test that is useful in
detecting filarial infection even at daytime. The
sensitivity and specificity of ICT were 51.2% and
98.4%, respectively (Nguyen et al., 1999)
(Nguyen, Plichart, & Esterre, 1999).
3. Deformity survey. This survey is done to
determine the presence of clinical cases of the
disease through interviews, community surveys,
and hospital records review.
STRATEGY 2: CAPABILITY BUILDING
Guided by the needs and goals of the
organization, restructuring the program improves its
effectiveness. New structure, roles and processes must
ensure that the activities in the program contribute to the
achievement of the organization’s goal. Therefore,
effective performance of the individuals involved in the
program is necessary.
This strategy is aimed at providing knowledge,
skills, and access to information to individuals in order to
enable them to perform tasks effectively. Such include
management structures, processes and procedures that
must be known for managing relationships between
different groups. Also, the ability to initiate, plan,
manage, undertake, organize, budget, monitor or
supervise, and evaluate specific activities are
empowered. Training and education of members,
especially for the new organization and process, are
essential.
Capability building has the following components:
1. Advocacy. This involves motivating and
soliciting the support and participation of the
local government units (LGU).
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2. Training of health workers. The primary training
of health workers in the Philippines is through
attending medical or nursing schools and covering
topics on the diagnosis and management of
lymphatic filariasis..
3. Development of family competencies. Families
are educated on and involved in the prevention,
control and elimination of Filariasis in the study
areas.
4. Community organizing. Core groups, such as
the Municipal Filariasis Elimination committee and
Family Clusters, are involved in the program, and
empowered for action.
5. Vector control. This serves as an adjunct that
focuses on personal protection measures.
6. Morbidity control. Referral and support groups
are established for chronic patients.
STRATEGY 3: MASS TREATMENT
Mass drug administration (MDA) for filariasis is a
strategy conducted for the interruption of transmission of
the parasite. It is integrated with other existing anti-
parasitic programs of the Department of Health including
Soil-Transmitted Helminthiasis Control Program, and
Schistosomiasis Control Program. It involves the
administration of drugs to the entire population at risk
ages 2 years and above in all established endemic areas
once a year. However, the following groups should be
excluded from treatment: sick individuals, children less
than 2 years of age and pregnant women.
This large-scale treatment involves a single
dose of two medicines given annually to the population
at risk: diethylcarbamazine citrate (DEC) (6 mg/kg) and
albendazole (400 mg). This strategy, also known as
preventive chemotherapy, when conducted annually for
4–6 years, can interrupt the filarial transmission cycle.
Studies have shown that a single dose of DEC has been
effective in clearing microfilaremia with effects sustained
for at least one year. Albendazole is added due to the
enhancing effect it has on microfilarial clearance.
Moreover, the use of albendazole has a second major
beneficial effect for individuals infected with
gastrointestinal parasitic helminths. DEC and
albendazole are both safe and well-tolerated drugs.
However, adverse reactions to these drugs may occur
especially amongst infected individuals wherein the
death of the parasite after treatment causes reactions in
the body. Fever, headache, dizziness, anorexia,
malaise, urticarial and vomiting may occur. These
reactions are usually self-limited, although treatment with
analgesics or antipyretics may alleviate symptoms.
Different approaches on drug delivery are
utilized, from house-to-house administration, booth
distribution, administering drugs in special population
groups and in areas of community aggregation. Greater
political and government support was accomplished in
2006, with an executive order declaring November as
Filariasis Mass Treatment Month.
Aside from mass treatment, other forms of
management that can be employed. Selective treatment
can be undergone by individuals who are found to be
positive for microfilariae in nocturnal blood examination,
wherein they will be given DEC in 3 divided doses for 12
consecutive days (usually given after meals). Morbidity
management and disability prevention should also be
emphasized and fully integrated into the health system
to ensure sustainability. Clinical severity and progression
of the filariasis can be reduced and prevented with
simple measures of hygiene, skin care, exercise, and
elevation of affected limbs. Patients with lymphedema
must have continuous access to health care throughout
their lives, both to manage the disease and to prevent
progression to more advanced stages. Patient education
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is the key to the success of this approach. Support
groups can be an important tool to maintain motivation.
Mosquito control is another auxiliary strategy
supported by WHO that can reduce the transmission of
lymphatic filariasis and other mosquito-borne infections.
Observing measures such as insecticide-treated nets or
indoor residual spraying may help protect people from
acquiring infection.
The components of Mass Treatment for filariasis
are the following:
a. Drug Regimen
The drugs given is a combination of
Diethylcarbamazine Citrate (DEC) and Albendazole.
DEC will be given at a dose of 6mg/KBW and
albendazole will be given at a dose of 400 mg/ single
standardized dose.
b. Coverage
Individuals from 2 years old and above living in
endemic areas will be covered.
c. Exclusion Criteria & Special Precautions
Treatment is deferred in pregnant women until
delivery. Special precautions must be observed in
treating individuals with cardiac and kidney diseases.
d. Outlet
In all barangays of endemic municipalities, drugs
will be delivered through a “Filaria Health Fair”
conducted annually for four years with activities that
include:
 General Health Check-up
 Community/ Family Contests
 Exhibits
 Dispensing of mass Treatment Dose per Family
(Families not covered in “Filaria Health Fair” will be
covered in Family Clusters one week later.)
e. Management of Side Effects
Adverse side-effects like fever, headache and nausea
should be recorded and provided symptomatic
treatment.
STRATEGY 4: SUPPORT CONTROL
This strategy secures, mobilizes, and distributes
(Department of Health) (Department of Health
Epidemiology Bureau, 2014) (Organization, 2013)
resources for sustaining mass drug administration
(MDA) in specific localities. This involves the following
(1) treating the human host, and (2) decreasing human-
vector contact through: reduction in vector density, use
of polystyrene beads, use of insecticide-impregnated
bed nets and curtains, and indoor spraying of
insecticides.
Support control involves the participation of the following
agencies:
1. Department of Interior and Local Government
(DILG). They issue the memorandum circulars to
all local leaders, assemble field offices, and help
in the supervision of mass treatment.
2. Department of Education (DepEd). They
oversee mass treatment programs in all public
and private schools.
3. Department of Social Welfare and
Development. They see to it that all patients in
identified endemic areas are administered with
mass treatment drugs. They are also responsible
in spreading information about filariasis, and
coordinating with the LGUs in supporting the
campaign.
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1.1
4. Department of National Defense (DND) through
the National Disaster Coordinating Council
(NDCC). They are responsible in issuing and
disseminating memorandum circulars to the
regional and provincial offices governing the
endemic communities.
5. Department of Environment and Natural
Resources. The provide assistance in the
training, advocacy, and social mobilization in
endemic communities to ensure high coverage of
mass treatment.
6. Local Government Units (LGU) and
organizations. They are the leaders in the local
implementation of mass treatment campaign.
They also provide the necessary supportive drugs
to their constituents who are identified positive
with filariasis.
7. Philippine Information Agency (PIA). They
provide assistance in spreading filariasis
awareness nationwide.
STRATEGY 5: MONITORING AND SURVEILLANCE
MONITORING (WHO, 2013)
As the objective of the programme is to interrupt
transmission of Filariasis, routine data collection and
reporting which determine progress made in
implementation of the programme is involved in the
monitoring system that covers the entire country, and not
merely endemic areas. Progress is monitored in terms of
the use of inputs and the expected outcomes and
impacts.
Indicators identified for measuring progress in
this program include both process and outcome
indicators. Outcome indicators relate to recovery,
restoration of functionality and survival of patients or,
simply, the programme’s efficiency usually measured by
the ratio of activity to input. Examples include the impact
of mass drug administration (MDA) on prevalence of
microfilaremia by night blood surveys undertaken in the
sentinel sites, disease prevalence rate, lymphedema
rate, hydrocoele rate, antigenemia in the 6 to 10 years
age-group to detect interruption of transmission once the
microfilaraemia rates have fallen below 1%; assessment
of community awareness and behavior through
knowledge, attitudes, and practice (KAP) surveys; and
surveys for vector infections for transmission
assessment. Outcomes, however, are not always direct
measures of the safety and quality of health care
provision in the same way as process measures are. For
this reason, outcome measures are sometimes reported
with an associated process measure.
Process indicators aim to measure the extent of
the application of ‘good’ health care or the status of the
various components of the program. They are usually
defined by reference to best practice guidelines or
standards for specific health interventions. Examples
include the number of people who have ingested the
drugs; supplies; staff resources; village/implementing
unit (IU) reporting system; adverse events; morbidity
(disability); control/reduction; information, education, and
communication (IEC) campaigns; and practices in the
program area such as ongoing vector control activities,
antilarval, insecticidal bed-net program, deworming
campaigns, and improved sanitation. Process indicators
are usually more sensitive to differences in quality than
are outcome measures and they can be easier to
interpret.
Proper supervision of each activity and close
monitoring and evaluation should be built into all
aspects, activities and all stages of the programme. This
would include assessing results of mapping, Mf
prevalence before and after MDA, reported and actual
coverage, mid-term assessment/evaluation and impact
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assessment, including impact of social mobilization, case finding

disability alleviation and other activities. either
through
Table 4. Monitoring Outline of DOH Adopted from mandatory
Administrative Order no.25-A ser. 1998. screening of
INDICATOR SCHEDULE AREA blood
Process Indicator (% Annual Per donors,
Target Population barangay military
Covered) recruits, or
Percentage of Annual Per school
Population given mass barangay children.
treatment experiencing
adverse reactions 𝐀𝐧𝐭𝐢𝐠𝐞𝐧 𝐑𝐚𝐭𝐞 = Number of persons positive in ICT
Outcome Indicators Biennial Per Sentinel Number of people examined 𝑥 100
 MF Rate Site
 MF Density
Outcome Indicators Random Spot Any STRATEGY 6: EVALUATION
 MF Rate Check Sentinel The recommendation given states that the first
MF Density Site independent evaluation must be carried out after three
Resistance Monitoring To be To be years of program implementation (i.e. after
Vector Surveillance scheduled identified administration of two rounds of mass drug
administration). The subsequent evaluation should be
done at intervals of two or three years. Programs such
Surveillance (WHO, n.d.) as the MDA must be evaluated periodically by
Surveillance is essential to identify previously independent experts, both national and international.
undetected foci of infection and to monitor the reduction This method is necessary to determine if a program was
of microfilariae resulting from elimination efforts. Note able to achieve its objective of reducing microfilariae
that it is expected that the elimination level will be levels in endemic populations to an extent where
achieved in each IU after 5-6 rounds of MDA, provided transmission is unlikely to be sustainable. It also
the annual coverage has been >65% of the total provides an assessment of the MDA and whether it has
population and >80% of the eligible population. It can succeeded in lowering the prevalence of infection to a
also demonstrate the number of morbidity and disability level where recrudescence will not occur (WHO, 2011).
due to Filariasis; hence, aid in achieving the objective of
disability prevention and control by implementing The evaluations should address aspects of both
additional plans to prevent follow-on issues after MDA. program implementation and impact on infection and
disease. The findings are then utilized in further
Just like in monitoring, filariasis surveillance strengthening, possibly through revising, the program
should be within an integrated disease surveillance strategy.
system of the country. Surveillance implementation can
be implemented through longitudinal surveillance of The following shows the post-intervention outline
populations in sentinel sites; cross-sectional spot checks of DOH as printed in the Administrative Order no. 25-A
in other sites; and background checks. ser. 1998.

For background surveillance, a routine annual
reporting for five years of aggregated data on probable
and confirmed cases should be sent from health
institutions to the district, from district to the state or the
national headquarters. Examination for lymphedema or
hydrocoele in population surveys for other diseases or
purposes such as leprosy, family planning, or school
health can also be included under background
surveillance. On a similar note, screening for Filariasis
should be done during medical examinations of recruits
in the uniformed services such as the military, and the
police as well as random testing for filarial antigenemia
by immunochromatographic test (ICT) cards among
blood donors in non-endemic areas.
Since cluster sampling techniques are
ineffective and monitoring the entire population of the
programme is not feasible due to the focal nature of
filarial distribution, monitoring of populations in sentinel
sites is, therefore, recommended in monitoring progress
in endemic areas and collecting baseline data, Sentinel
and spot-check sites may help ascertain the baseline
parasitological and clinical indicators and also help
monitor the trend and impact of MDA rounds on the
indicators.
Table 5. Surveillance outline of DOH adopted from
Administrative Order no.25-A ser. 1998.
INDICATOR/S SCHEDUL AREA
E “outcome” based for better program monitoring. Impact
 MF Rate Every year Sentinel Sites of 1
 MF for five barangay per
Density years after province
 Antigen the Backgroun
Rate completion d
of mass Surveillanc
treatment e – passive
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1. Site- sentinel site of 1 barangay per province
2. Indicators- DOH shall use the following
parameters:
a. MF Rate
b. MF Density
c. Antigen Rate
3. Schedule of Measurement- baseline blood
survey and post-treatment blood survey must be
conducted
To establish the vectors of the disease in the endemic
areas, the following parameters are assessed.
1. Local vector species identification
2. Man Biting Rate- defined as the average number
of mosquitoes biting man per hour or the
number of captured mosquitoes per man per
hour
3. House Resting Density- refers to the number of
mosquitoes collected in the house per man-hour
4. Both the Larval Index and the Annual
Transmission Potential are not really
necessary
Monitoring and evaluation studies showing the effect
of vector control on lymphatic filariasis have been
described. The strategies command setting of realistic
targets and baseline measures for indicators. In addition,
theses indicators must be “process”, “input” and
indicators are a measure of the programme success and
are divided into impacts on the disease and on the
vector. Methods for measuring these indicators have
also been discussed above.
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STRATEGY 7: NATIONAL CERTIFICATION
National certification requires the fulfilment of the
following standard criteria:
1. Ensure international credibility for the expected
future claim that filariasis had been eliminated
from an area;
2. Have an established and consistent mechanism
for judging success of National Filariasis
Elimination Programs, and
3. Have a standard, effective procedure to identify
and eliminate any previously known foci of
transmission.
WHO also recommends that five years after
cessation of community treatment, 3000 school children
5 years of age from endemic areas should be screened
with appropriate methodology (i.e. thick blood smear and
antigen testing). Children who yield positive results will
be subject to further testing for determination of their true
status.
Moreover, the confirmation of the absence of
transmission in a country will be judged on the basis of
an assessment of:
1. The thoroughness and adequacy of the original
ascertainment of the local areas of endemic
filariasis within the country
2. The surveys and survey findings done in all local
areas with endemic filariasis (in order to
substantiate elimination of filariasis
transmission)
STRATEGY 8: INTERNATIONAL CERTIFICATION
According to the framework for control,
elimination and eradication of neglected tropical
diseases of the World Health Organization (2016), the
elimination of filariasis as a public health problem at a
global level is targeted by 2020. Elimination as a public
health problem is a term associated to both infection and
disease. It is defined by achievement of measurable
global targets set by WHO in relation to a specific
disease. When measures are attained, continued actions
are necessary to maintain the targets and/or to advance
the interruption of transmission.
The formal process of certification of filariasis
elimination will involve an International Commission for
Certification of Lymphatic Filariasis Elimination
(ICCLFE), which will be established by the World Health
Organization, to recommend countries that fulfill the
requirements for certification, as well as provide advices
on criteria, procedures and progress made towards
elimination of filariasis to WHO. Validation of elimination
as a public health problem or verification of elimination of
transmission should be assessed based on the given
objective criteria in a country, area or region, and the
attainment should be recorded formally. WHO, including
the Regional offices, will facilitate national preparations
for certification by carrying out regular visits by WHO
staff, members of the designated International
Certification Teams, or consultants to the country or the
region concerned.
Certification of elimination may be granted as
long as the adequate documentation shows that there
are no residual foci of infection that exist. The
requirements for such certification include the following:
 A detailed description of the extent of any former
endemic areas;
 A possible need to present findings of active
case searches conducted within the last 5 years
in areas which may formerly have been
endemic. Results must ascertain that residual
foci of infection does not exist; and
 Countries with areas that are determined to
have current filariasis transmission will
subsequently need to be certified.
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International certification of elimination of filariasis in
the Philippines will be certified by the World Health
Organization upon fulfillment of the following conditions:
 Cumulative incidence rate of less than 1/1000
over 5 years measured yearly after completion
of the mass treatment scheme in each endemic
municipality in the country
 Provision of the necessary documentation and
satisfaction of the needed international
requirements
If certification of elimination is granted, the country
will then be listed on a WHO official register of areas
now verified as free of filariasis transmission.
OTHER POLICIES AND PROGRAMS IN LINE WITH THE NATIONAL
FILARIASIS ELIMINATION PROGRAM
ADMINISTRATIVE ORDER NO. 157 S. 2004
“Declaring the month of November of every year as
the mass treatment month
for Filariasis in established endemic areas in the
Philippines.”
To better facilitate program monitoring, drug
distribution, drug re-application and program
management, the Global Elimination Group
recommended that the month of November of every year
be designated as “Mass Treatment Month for Filariasis.”
This will not only address the previously stated activities
but will also ensure concentrated efforts especially in
those areas identified to be endemic for filariasis.
In the Philippines, the DOH also recognized the
need to improve the implementation of Mass Drug
Administration by centrally coordinating the timing of all
MDAs. This coordinated schedule will increase public
awareness of the health problem, create advocates for
program implementation, and increase the efficiency of
the said lead agency in carrying out the needed support
activities to the implementing LGUs.
The following are the offices involved in
implementing the needed mechanisms for this
declaration. Their responsibilities are also presented.
A. NATIONAL CENTER FOR DISEASE PREVENTION
AND CONTROL (NCDPC)
1. Provide technical assistance to CHDs, LGUs and
other agencies involved in the elimination filariasis
2. Provide program information materials to CHDs,
LGUs and other partner agencies
3. Ensure the timely availability of appropriate drugs
in adequate numbers for MDA in identified
endemic areas
4. Provide other forms of support, whenever
possible, to CHDs and LGUs implementing MDA
B. CENTERS FOR HEALTH DEVELOPMENT (CHD) –
OF PROVINCES ENDEMIC FOR FILARIASIS
1. Initiate advocacy activities in the implementation of
“Filariasis Awareness Month”
2. Provide technical assistance in the implementation
of the program at the provincial and municipal
levels
3. Provide technical assistance in the conduct of
Mass Treatment in established endemic areas
4. Mobilize health partners and other stakeholders to
participate in the campaign
5. Monitor the annual implementation of the MDA
program
6. Conduct other activities to support filariasis
elimination program
7. Furnish the DOH through NCDPC with the
standard recommended reports pertaining to
Filariasis elimination
C. LOCAL GOVERNMENT UNITS (LGUS)
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1. Disseminate to the other constituents information

on the disease and the annual mass treatment
programs
2. Pass the necessary local resolutions or laws
for the annual mass treatment program
3. Organize health officials and mobilize health
facilities and the community for the
elimination program
4. Provide support drugs such as antipyretics and
antihistamines for mass treatment
5. Monitor health situation and disease occurrence
in its area of jurisdiction
6. Submit pertinent and standardized reports on the
mass treatment and filarial elimination programs
to their respective CHD
ADMINISTRATIVE ORDER NO. 2010-0009
“Guidelines in the Prevention of Disabilities due to
Lymphatic Filariasis”
The most number of people with Filariasis-
related disabilities was documented in Bicol Region,
Davao Region, and Zamboanga Peninsula.
These guidelines were created to help achieve
the two-fold goal of the WHO in the reduction of the
burden of Lymphatic Filariasis, namely: (1) the
interruption of transmission by drastically reducing
microfilaria prevalence and (2) the implementation of
disability prevention activities for those individuals
already suffering from LF-related disabilities.
The ultimate objective of this order, however, is
to enable every Lymphatic filariasis patient to enjoy
quality and more productive life, both socially and
economically.
This increased interest and support starting after
the WHA’s call led to the formation of the Global Alliance
to Eliminate Lymphatic Filariasis (GAELF) also in 2000.
This public–private partnership assists GPELF promote
its advocacy, coordinate partners and mobilize
resources.
Strategy 1: Interrupting Transmission :
Important
Four sequential programmatic steps have been
recommended by the WHO to interrupt transmission as
is shown in the figure below.
1. Areas suspected of being endemic are mapped to
determine the geographical distribution of the
disease and identify areas in need of MDA.
2. MDA is implemented and continued for a period of
five years or more to reduce the number of
parasites in the blood to levels that will prevent
mosquito vectors from transmitting infection.
3. Surveillance is implemented after MDA is
discontinued to identify areas of ongoing
transmission or recrudescence.
4. If criteria are met, the elimination of transmission
is verified.
Strategy 2: Alleviate Suffering and Disability
The GPELF aims to control morbidity and
prevent disability primarily by providing basic
lymphedema management and, in areas where there is
bancroftian filariasis, urogenital surgery for affected
males.

The following are the key activities included in Studies have shown that simple measures such
the said guidelines: as improving hygiene and care of the skin on the
1. Conduct a deformity survey to masterlist and affected foot and leg, can reduce the frequency of acute,
establish contact with lymphedema and/or painful inflammatory episodes of adenolymphangitis, and
hydrocele patients. help arrest the progression of lymphedema.
2. Provide sustainable care to all patients by
establishing a functional referral system and
follow-up mechanism.
3. Intensify and sustain health promotion campaigns.
4. Empower patients to play an active role in the
management of their lymphedema through self-
care.
5. Improve access to safe and affordable
hydrocelectomy.
6. Provide counselling to lymphadema and/or
hydrocele patients.
7. Establish linkages to improve socioeconomic
status of lymphedema and/or post hydrocelectomy
patients.

WHO GLOBAL PROGRAMME TO ELIMINATE

LYMPHATIC FILARIASIS
In 1997, the World Health Assembly called upon
all its Member States to develop national plans to
eliminate LF. This resolution was positively received as
national governments, donors, and aid agencies heeded
the call.

In January 1998, GlaxoSmithKline announced

that it would donate albendazole for as long as needed
to eliminate the disease while Merck & Co., Inc., pledged
to provide ivermectin in countries where LF and
onchocerciasis are co-endemic.

In 2000, the World Health Organization (WHO)

established the Global Programme to Eliminate
Lymphatic Filariasis (GPELF). It has the goal of
eliminating LF as a public health problem by the year
2020. To achieve this, the program adopted a two-fold
strategy – (1) interrupt transmission using combinations
of two medicines delivered to entire populations at risk
and (2) alleviate suffering and disability by introducing
basic measures. Tables
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Table 1. Regions and provinces endemic to Lympat

ic Filariasis (DOH, 2009)
REGION PROVINCES
Region IV-A Quezon
Region IV-B Marinduque, Oriental Mindoro, Occidental Mindoro, Romblon, Palawan
Region V Sorsogon, Albay, Camarines Norte, Camarines Sur, Masbate
Region VI Iloilo, Capiz, Aklan, Antique
Region VII Negros Oriental
Northern Leyte, Southern Leyte, Biliran, Northern Samar, Eastern Samar, Western
Region VIII
Samar
Region IX Zamboanga del Norte, Zamboanga del Sur, Zamboanga Sibugay
Region X Misamis Oriental, Misamis Occidental, Bukidnon
Region XI Davao del Norte, Davao del Sur, Davao Oriental, Compostella Valley
Region XII Northern Cotabato, Southern Cotabato, Saranggani, Sultan Kudarat
CARAGA Agusan del Norte, Agusan del Sur, Surigao del Norte, Surigao del Sur, Dinagat
ARMM Sulu, Maguindanao, Basilan

Table 2. Filariasis-free provinces as of July 2016

2012 2013 2015 2016
Oriental Mindoro
Marinduque Palawan
Romblon Camarines Sur
Albay Western Samar
Sorsogon Northern Leyte
Zamboanga del Sur Maguindanao
Southern Leyte Misamis Occidental
Zamboanga Sibugay Davao Oriental
Eastern Samar Northern Cotabato
Biliran Southern Cotabato
Bukidnon Agusan del Sur
Compostella Valley Surigao del Sur
Dinagat

Table 3. Total Cases of Filariasis Per Region Based on the 1996 and 2011 Data
Region Population 1963-1996 Percent Population 2011 Percent (%)
(1996) Total (%) (2011) Total
Cases Cases
NCR 9, 406, 184 0 0 11, 819, 300 0 0
CAR 1, 357, 428 180 0.01 1, 662, 900 0 0
1 4, 219, 604 196 0.005 4, 828, 100 0 0
2 2, 779, 154 0 0 3, 361, 900 0 0
3 7, 361, 569 1, 756 0.02 10, 457, 100 0 0
4A 9, 810, 184 51, 705 0.53 13, 636, 000 2 0.000015
4B 2, 910, 600 0 0
5 4, 664, 975 262, 484 5.65 5, 555, 100 4 0.000072
6 6, 541, 150 0 0 7, 159, 800 0 0
7 5, 450, 656 4, 331 0.08 7, 021, 000 0 0
8 3, 765, 778 57, 340 1.52 4, 283, 000 0 0
9 2, 919, 524 12, 512 0.43 3, 485, 400 7 0.0002
10 2, 608, 276 49, 694 1.91 4, 342, 100 35 0.00081
11 5, 120, 482 74, 656 1.46 4, 627, 600 0 0
12 2, 155, 259 20, 232 0.94 4, 338, 200 79 0.0018
ARMM 2, 441, 248 56, 575 2.32 3, 734, 000 2 0.000054
CARAGA 2, 611, 700 25 0.00096
Total 72, 676, 547 654, 232 0.89 95, 793, 800 154 0.02

Table 6. Parameters used as Indicators for Evaluation

To establish infection

Antigen Rate

To characterize infection

Microfilaria Rate

Microfilaria  16.7 (using uL of blood)

Density  Number of persons MF (if only 20 uL is used, the factor is 50)

Clinical Rate

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Table 7. Categories and Conditions for National Certification

Category Condition General Activities
Mapping for endemic areas using ICT
and deformity survey
Completion of Mass Treatment for 4
Capability building
1 years and with Post-treatment
Mass treatment
Prevalence Rate of <1/1000
Evaluation
Post treatment surveillance
 Previously endemic municipalities
still found to be endemic after survey: Mapping for endemic areas using ICT
Completion of Mass Treatment for 4 and deformity survey
years and with Post-treatment Capability building
Prevalence Rate of <1/1000 Mass treatment
2
 Previously endemic municipalities Evaluation
found to be non-endemic after Post treatment surveillance
survey: 5-year Cumulative
Prevalence Rate of <1/1000 by
background surveillance
Previously non-endemic municipalities
before and after mapping and with 5-year Mapping for endemic areas using ICT
3
Cumulative Prevalence rate of <1/1000 and deformity survey
by background surveillance Background surveillance

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