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  • Indonesia firmly committed to eliminating lymphatic filariasis as a public health problem

    Indonesia firmly committed to eliminating lymphatic filariasis as a public health problem

    Indonesia recently completed the last of its annual large-scale treatment for lymphatic filariasis (also known as elephantiasis or Penyakit Kaki Gajah) in Malaka District located in its southernmost province, East Nusa Tenggara. Unprecedented
    progress by the National Lymphatic Filariasis Elimination Programme has strongly placed the country on the path to achieving the elimination of lymphatic filariasis as a public health problem.

    “We reached an estimated number of 40.7 million people living in the 118 high-risk districts during this month-long treatment campaign in October 2019” said Dr Anung Sugihantono, who recently retired as Director General of Diseases
    Prevention and Control, Ministry of Health Indonesia. “    Single doses of diethylcarbamazine citrate and albendazole facilitated by WHO were delivered to all eligible populations.”

    In 2010, an estimated 125 million Indonesians were still at risk of the disease and required treatment.

    But things changed considerably in 2015 when Indonesia mounted an annual national campaign to resolutely address transmission of the disease and to tackle the morbidity and disability associated with it. The results were apparent as early as 2017, with
    remarkable progress.

    In Indonesia, LF is considered a significant public health concern. In 2009, risk mapping identified a population of 124.5 million people needing treatment for LF. The country initiated a national level LF elimination campaign in 2015, addressing both
    disease prevention and management. 

    “In 2017 and in just two years we managed to achieve 100% geographical coverage of all people requiring treatment” said Dr Sugihantono. “It meant achieving more than 78% epidemiological coverage – much higher than the generally recommended 65% to stop transmission.”

    Transmission of lymphatic filariasis can be stopped through large-scale treatment (or mass drug administration – MDA) of entire at- risk communities with recommended medicines once a year. These medicines kill the microfilariae in an infected patient’s
    blood preventing mosquitoes to transmit1 the disease to others. Through mass treatment, the aim is to reduce the reservoir of microfilariae in the blood to a level insufficient to maintain transmission by the mosquito vector.

    This strategy to interrupt transmission is the corner-stone of the World Health Organization’s (WHO) Global Program to Eliminate Lymphatic Filariasis (GPELF). Indonesia has been using the GPELF’s strategy since 2002 using a district or city
    as its implementation unit.

    In 2005, it listed the elimination of LF as a national priority for controlling infectious diseases and the medicines it has been using in large-scale treatment programmes are diethylcarbamazine citrate (DEC) and albendazole2 which are
    largely distributed by volunteer community health workers3.

    “Community health volunteers are themselves members of the community and know how to reach people effectively to improve compliance” said Dr. Stefanus Bria Seran, the Regent of Malaka District, one of LF endemic district in Indonesia. “Besides ensuring every single person ingests the medicine given to them, these community workers help in disseminating information well before a large-scale treatment campaign and also assist in reporting activities related to each treatment campaign”. 

    Indonesia’s efforts to eliminate lymphatic filariasis began in the 1970s but faced numerous challenges including programme coordination in the many inhabited islands, conducting information, education and awareness programmes, lack of capacity and
    insufficient medicines.

    Furthermore, the situation in Indonesia is unusual than in many other countries endemic for lymphatic filariasis as the country is endemic for all three species of thread-like filarial worms – Brugia malayi, Brugia timori, and Wuchereria bancrofti –
    that cause the disease. Most of the infections in Indonesia, however, are caused by B. malayi.

    In the past, some of the factors that prevented access to the medicines (DEC and albendazole) were social stigmatization linked to the disease, the vast geography of the territory and challenges in reaching remote populations.

    With an estimated population of 242 million, Indonesia is the world’s largest island nation and consists of approximately 17,000 islands, of which 5,000–6,000 are inhabited. It is the fourth most populated nation behind China, India, and the United
    States.

    Indonesia is endemic for many other neglected tropical diseases and an estimated 110 million Indonesians are believed to suffer from at least one neglected tropical disease (NTD), including lymphatic filariasis and soil-transmitted helminth infections.
    Leptospirosis (not classified as NTD) is also widespread.

    Indonesia is the only country of WHO’s South East Asia Region with endemic schistosomiasis. Like many other countries of the Region, it also faces recurrent threats of dengue outbreaks.

    Global progress

    The world has made significant progress towards the elimination of lymphatic filariasis as a public health problem.

    Sixteen countries4 and one territory are now acknowledged by WHO to have achieved elimination of lymphatic filariasis as a public health problem.  

    Seven additional countries have successfully implemented recommended strategies, stopped large-scale treatment and are under surveillance to demonstrate that elimination has been achieved.

    The disease

    Lymphatic filariasis is caused by infection with parasitic worms living in the lymphatic system. The larval stages of the parasite (microfilaria) circulate in the blood and are transmitted from person to person by mosquitoes.

    Infection involves asymptomatic, acute, and chronic conditions. Most infections are asymptomatic, showing no external signs while contributing to transmission of the parasite. Although asymptomatic, these infections still cause damage to the lymphatic
    system and the kidneys and alter the body’s immune system.

    When lymphatic filariasis develops into chronic conditions it leads to lymphoedema (tissue swelling) or elephantiasis (skin/tissue thickening) of limbs and hydrocele (scrotal swelling). Involvement of breasts and genital organs are common.

    Manifestation of the disease after infection takes time and can result in an altered lymphatic system, causing abnormal enlargement of body parts, and leading to severe disability and social stigmatization of those affected.

     

    1Lymphatic filariasis is transmitted by different types of mosquitoes – e.g the Culex mosquito which widespread across urban and semi-urban areas; Anopheles, mainly found in rural areas; and, Aedes, mainly
    in endemic islands in the Pacific.

    2In 2017, WHO recommended an alternative three drug treatment to accelerate the global elimination of lymphatic filariasis. The treatment, known as IDA, involves a combination of ivermectin, diethylcarbamazine citrate and albendazole.
    It is recommended annually in settings where its use is expected to have the greatest impact.

    3Community health workers, also called ‘cadres’, are volunteers who form part of the communities they serve and work with local
    communities to educate families. Their contribution in promoting health has been significant in the country.

    4Cambodia, The Cook Islands, Egypt, Kiribati, Maldives, Marshall Islands, Niue, Palau, Sri Lanka, Thailand, Togo, Tonga, Vanuatu, Viet Nam, Wallis and Futuna, and Yemen

    Indonesia firmly committed to eliminating lymphatic filariasis as a public health problem
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    https://www.who.int/news-room/detail/29-04-2020-indonesia-firmly-committed-to-eliminating-lymphatic-filariasis-as-a-public-health-problem

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  • PRIVATE Sex Advice to Women By R. B. Armitage, M. D.

    PRIVATE Sex Advice to Women By R. B. Armitage, M. D.

    Sex Advice to Women

    In this book the writer thereof seeks to convey to women—particularly to young wives and women expecting to be married—certain important facts of knowledge, certain necessary information, which all such women should possess, but which few are given the opportunity to acquire.

    It would seem to require no argument to convince a rational individual that before a woman is capable of intelligent motherhood she should be made acquainted with the physiological processes which are involved in the sexual functions leading to the state of motherhood; but we are confronted by the fact that few young women are given such instruction.

    It is a strange thing that while even the ordinary school child is made acquainted with the physiological processes concerned with the processes of digestion, respiration, circulation, elimination, etc., and while such education is highly commended, yet at the same time not only are the young of both sexes reared as if there was no such thing as sexual functions in existence, but even full-grown adults are left to pick up their instruction on sexual subjects from chance sources—often polluted sources.

    Even those about to enter into the important offices of matrimony and parenthood are permitted to assume those duties and responsibilities without intelligent and scientific information or knowledge being given them. What would we think of expecting a woman to cook, without previous experience and without even the most elementary instruction on the subject? What would we think of expecting any person to undertake any important task or duty without experience or instruction regarding the same? And yet we seem content to allow young women to enter into the important relationship of marriage, and to undertake the important office of motherhood, often in absolute ignorance of the physiological processes involved, and the physical laws governing the same.

    All this absurd practice and custom results simply from the antiquated notion that it is “not nice” to speak or think of the subject of the sex functions. The subject has been considered “taboo” by our particular section of the human race since the Middle Ages, because the ascetic ideals of that dark period of human history brought forward a totally false and unnatural conception of sex as fundamentally impure. If the results were not so deplorable and often tragic, this condition of affairs would be a fit subject for laughter and scornful ridicule. But, alas! on the part of the thoughtful observer of this state of things there is rather great wonder and amazement accompanied by the feeling of deep sorrow.

    It cannot be honestly denied that in our present age, and period of modern civilization, and particularly among the Anglo-Saxon branch of the race, the question of the sex functions is associated with impurity, at least so far as the popular mind is concerned. In previous civilizations the subject was accorded its proper place, and was discussed sanely and thoughtfully, without any sense of shame or impurity. The Middle Age ideals of celibacy and asceticism brought about the public conception of the human body as a thing impure—something to be modified, tortured, subdued and reviled; and a corresponding conception of sex as a vile, impure thing above which the pure in heart rose entirely and completely, and which those of a lesser spiritual ideal were permitted to indulge with a due sense of their degradation and weakness. It was considered a most worthy thing to lead an ascetic life with its accompaniment of disdain and punishment of the body. It was considered most pious and spiritual to forego the ordinary human relations of sex, marriage and parenthood. From these distorted conceptions naturally evolved the idea that sex, and all connected with it, was a subject unclean and impure in itself, and to be avoided in thought, conversation and writing. Not only the ordinary sex relations of human life were placed under this taboo, but also the phenomena of birth and parenthood. Not only did these incidents of life grow to be considered impure, but they became that which to many was still worse, that is to say, they became to be regarded as “not respectable.”

    Ignorance regarding the plain elementary facts of sexual physiology is undoubtedly the cause not only of much immorality among young people of both sexes, but also of many unhappy and inharmonious marriages. The intelligent portion of our race is now beginning to realize very keenly the fact that the first requisite of sane marital relations and intelligent parenthood is a practical and clear knowledge of the physiology of sex; education concerning the sexual organism, its laws, its functions, its normal and healthy conditions, its anatomy, its physiology and hygiene.

    The average physician of experience in general or special practice can tell tales of almost incredible ignorance on the part of young women who have recently entered into the relationship of marriage. In some cases the ignorance is more than a mere absence of knowledge—it consists too often of false-knowledge, untruthful ideas concerning matters of the most serious import. It is sad enough to think how such persons may work results harmful to themselves, but it is even sadder still to realize that these same ignorant young women must eventually gain their real knowledge through sad experience—experience paid for not only by themselves but also by their children. It is a hard saying, but a true one, that the knowledge of many young wives and mothers is to be gained by experience paid for by their (as yet) unborn children.

    The writer of the present work is one of the rapidly growing number of thinking persons who believe that the time has come to educate the race concerning the importance of sane instruction concerning the functions of sex. He, and those who think as he does, believe that the time has come to “Turn on the Light!” They believe that the importance of the subject will be realized by all intelligent persons, once that their attention is directed to the subject, and once they have considered it apart from the old prejudices and distorted customs. When public opinion on this subject is reformed, then will the taboo fall away from the body of truth; then will the subject take its place among the “respectable” topics which may be considered, discussed, and taught, without loss of caste or prestige.

    In a few decades, perhaps even much sooner, it will be regarded as quite reprehensible to permit young persons to enter into the relationship of marriage without a sane, practical knowledge of their own reproductive organism and the functions thereof, and of their physiological duties to themselves, to their companions in marriage, and to their children born or to be born. We may even see the practical application of the somewhat startling prophecy of Newell Dwight Hillis, D. D., who said: “The State that makes a man study two years before a license as druggist is given; that makes a young lawyer or doctor study three years before being permitted to practice; ought to ask the young man or young woman to pass an equally rigid examination before license is given to found an American home, and set up an American family.”

    While the information above alluded to should be given alike to the young husband and the young wife, it cannot be doubted that the latter is the one of the pair who is most in need of this kind of instruction. While both the young man and the young woman require this instruction, the need is the greater in the case of the young woman, by the very nature of the case. The sex functions and processes play a much more important part in the life of the woman than in that of the man, the protests of some of the modern feminists to the contrary notwithstanding. The careful student of the sex life of men and women frankly confesses that in both the physical and the psychical realm the sex offices make a greater demand upon the time and attention of the woman than of the man.

    The love-life of the woman is far fuller and more absorbing than is that of the man. Unhappiness concerning her love-life renders the remainder of the life of the average woman of comparatively little account; while, with a happy love-life she will put up cheerfully with the absence of many other things which are usually regarded as necessities for happiness. As a writer has said: “Essentially, a woman is made for love—not exclusively, but essentially; and a woman who has had no love in her life has been a failure.”

    The same rule operates on the physical plane. As the same writer has said: “Physically, the woman is also much more cognizant of her sex and much more hampered by the manifestation of her sex nature than man is.” The manifestation of the incidents of menstruation is a constant reminder to the woman that she is a creature of sex. The phenomenon of pregnancy is, likewise, something from which the man is free. And, finally, the menopause, or “change of life,” with its incidents greatly influencing the physical, mental, and emotional well-being of the woman, is Nature’s final word to the woman that she is the active pole of sex-life. As the above-quoted writer has said: “Altogether it cannot be denied that woman is much more a slave of her sex-nature than man is of his. Nature has handicapped woman much more heavily than she has man.”

    And so, in this book, the young woman—the young wife—is directly addressed, her companion and mate being referred to only indirectly.

    PRIVATE Sex Advice to Women By R. B. Armitage, M. D.

    For Young Wives and those who Expect to be Married.

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