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
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In a new position paper, published in the Weekly