Maharashtra’s other health crisis

While struggling with the pressure of saving its people from the COVID-19 pandemic, Maharashtra is silently fighting a disabling, disfiguring disease that has gripped its 18 districts

The Indian government is racing against time. And we are not talking about the Coronavirus pandemic. India bears 45 per cent of the global burden of filariasis. Currently, 67 crore people in the country are at risk of contracting the disease, with special danger in 272 districts in 16 states and five Union Territories. “Of the 36 districts in Maharashtra, 18 are endemic for filariasis. These districts are Akola, Amravati, Bhandara, Chandrapur, Gadchiroli, Gondia, Jalgaon, Latur, Nagpur, Nanded, Nandurbar, Osmanabad, Sindhudurg, Solapur, Thane, Palghar, Wardha and Yavatmal,” says a report by the National Vector Borne Disease Control Programme (NVBDCP), Ministry of Health and Family Welfare, Government of India.

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An endemic is a disease regularly found in a particular place or among a particular group of people and is difficult to get rid of. Lymphatic Filariasis (LF or Filariasis) is a disabling disease that is transmitted by mosquitoes. Usually acquired in childhood, filariasis damages the lymphatic system and if left untreated, causes abnormal enlargement of body parts such as hydrocele (abnormal swelling of the scrotum) and lymphedema (swelling in the limbs). A few people also develop chronic cough called Tropical Pulmonary Eosinophilia and can have symptoms like passing of milky white urine (chyluria). Filariasis is one of the leading causes of disability worldwide. Patients suffering from lymphedema and hydrocele often experience difficulty in carrying out day-to-day activities in their lives, thus affecting their earning capacity and livelihood opportunities. Worse, patients face stigma and discrimination due to the disfiguration.

Lymphatic Filariasis (LF or Filariasis) is a disabling disease that is transmitted by mosquitoes. Usually acquired in childhood, filariasis damages the lymphatic system and if left untreated, causes abnormal enlargement of body parts such as hydrocele (swelling of the scrotum) and lymphedema (swelling in the limbs)

According to a study published in Parasitology Today, it is estimated that patients and families affected by Lymphatic Filariasis in India lose over USD 842 million (Rs 5,900 crore) every year in treatment cost and reduced work time.

In 1997, the World Health Organization (WHO) and its Member States made a commitment to eliminate filariasis as public health problem by 2020 through the World Health Assembly Resolution. The National Health Policy, set up in 2002, had earmarked the goal of eliminating the disease in India by 2015. “In pursuit of this, the Government of India launched nationwide Mass Drug Administration (MDA) in 2004 in endemic areas. That same year, only 202 districts could be covered with a coverage rate of 72.6 per cent. The Accelerated Plan, which includes Triple Drug Therapy, was launched in the Global Alliance Elimination of Lymphatic Filariasis (GAELF) meeting held in June 2018. The population coverage during MDA improved from 73 per cent in 2004 to 87.33 per cent in 2019,” adds the NVBDCP report.

IDA (triple drug therapy) undertaken in a prison in the Chandrapur corporation area

When the deadline could not be met until 2019, the then health minister of India Harsh Vardhan signed a call to action to eliminate the disease by 2021. Now, while there is steady progress under the national programme to reduce the infection levels in the community, the challenge continues to persist in some districts that sustain active transmission. Uttar Pradesh, Bihar, West Bengal and Orissa are worst-affected states, but Maharashtra has fared better so far.

And yet, in its accelerated effort to eliminate the disease, the Maharashtra government flagged off the MDA rounds earlier this month on July 1. Dr Sanjeev Jadhav, additional director of health services, says, “From 2005 till date, the Maharashtra government has been successful in eliminating several districts from the endemic category. Amid the suspicion of a third COVID-19 wave, we wanted to use the window period to start MDA in six districts of Maharashtra. Between July 1 and 15, we undertook the MDA campaign in Gadchiroli, Chandrapur, Bhandara, Gondia, Nanded and Yavatmal. Of these, the worst-affected, Gadchiroli, Chandrapur and Bhandara, undertook the crucial triple drug therapy.”

Dr Sanjeev Jadhav

Filariasis is the second-most disabling disease after mental health globally, according to the World Health Organisation. It is, however, preventable with the administration of anti-filarial drugs, which have been distributed during the annual MDA campaigns. Dr Jadhav continues, “During MDA, a combination of two drugs i.e. diethylcarbamazine (DEC) and albendazole or three drugs—Ivermectin, DEC, and Albendazole [also known as IDA or triple drug therapy]—are administered to the eligible population in affected areas to interrupt transmission. We exclude children below two years for the two drug therapy, and below five years, pregnant women and the seriously ill for the triple drug therapy. IDA, a new drug combination approved by the WHO, has been proven to be more efficacious for LF elimination and can help reduce the number of annual MDA rounds in affected regions.”
 
As of 2020-21, close to 31,258 lymphoedema and 11,929 hydrocele cases were reported from the endemic districts of Maharashtra. Speaking about the state’s efforts, Dr Archana Patil, Director of Health Services, says, “COVID-19 has taught us, that now more than ever, it is crucial we integrate public health programmes at the systemic and ground level.”

ASHA workers administer anti-filarial drugs in Lodhitola village in Gondia district during the Maharashtra MDA rounds held last week

Filaria tends to afflict the poorer, marginalised sections of society, especially those in remote areas and traditionally forgotten in the larger health narrative. Dr Patil adds, “Given that this drive was originally meant to be held in March 2021, there has been a delay already. What if these patients were to be pushed back further into poverty and illness because of more delay? Although Maharashtra was badly affected by both COVID-19 waves, it has been praised for its efforts and foresightedness. In anticipation of the third wave, the state has started a paediatrics training programme for medical staff and students to ensure basic treatment for patients on admission. The state was also keen to make use of this window between now and the third wave to ensure that the eligible population was administered these drugs.”

But is it safe for a person who does not have symptoms of filariasis to consume these anti-filarial drugs? The NVBDCP explains, “Everyone living in endemic areas is at risk of contracting filarial infection; even those who appear healthy may be infected. Filariasis shows no visible symptoms initially, but slowly and irreversibly damages the lymphatic system, kidneys and the body’s immune system. About two-third of people who are infected may not show any visible symptoms. In areas where a large population fails to consume the medicine, a potential source of parasite/filaria infection remains in the community and results in continued transmission of the infection in the community. Therefore, it is essential for all eligible beneficiaries in endemic areas to consume the anti-filarial drugs.”

Chimur police officers take anti-filarial drugs in the presence of health workers in Chandrapur district

Unfortunately, the MDA campaign is only a preventive effort and not a cure for lymphoedema and hydrocele patients. “Lymphoedema is usually not reversible by consuming anti-filarial drugs, except in very early states. However, the drugs can prevent further disease progression. Hydrocele can be treated by conducting hydrocele operations known as hydrocelectomy,” the report adds.

While the government conducted MDA rounds by following strict COVID-19 safety protocols such as respiratory and hand hygiene and maintenance of physical distancing, the healthcare workers did expect some hesitancy from the population. “Since its inception, these drives are conducted door to door, so nobody needs to step out of their homes in the pandemic. And public awareness about the disease is also quite high. Both of these helped people come forward during the lockdown. Some people, who were recently vaccinated against COVID-19, were given a buffer of 10 days before they were administered anti-filarial drugs,” says Dr Nupur Roy, Additional Director, NVBDCP.

With this drive, Maharashtra has become the first state in the country to resume MDA rounds post the second wave of COVID-19.

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