Lymphatic Filariasis
Lymphatic
filariasis is present in Malaysia.
Description
Lymphatic
Filariasis, also known as Elephantiasis, is a parasitic infection caused by the Wuchereria bancrofti, Brugia
malayi, and Brugia timori nematode worms transmitted to humans through the bite of
infected Aedes,
Culex, Anopheles, and Mansonia mosquitoes. The disease targets the
body's lymphatic system. The infective microscopic larvae (microfilariae) develop
in the vector mosquitoes and are injected into humans through a blood meal. In
the human host, they reproduce and mature over a period of one year and live in
the body for approximately 4 to 6 years. The larvae hatched in humans are
ingested by feeding mosquitoes who pass the infection on to another person,
continuing the infectious cycle. Lymphatic Filariasis is a
Neglected Tropical Disease (NTD)*.
* Neglected
Tropical Diseases are chronic infections that are typically endemic in low
income countries. They prevent affected adults and children from going to
school, working, or fully participating in community life, contributing to
stigma and the cycle of poverty.
Risk
Lymphatic Filariasis is present in Africa, Central and South America, South Asia,
and the Pacific Islands. Long-term travellers, persons on work
assignments like humanitarian workers, missionaries, and military personnel
staying in endemic areas are at risk.
Symptoms
The
majority of cases are asymptomatic – persons do not exhibit symptoms – although
the worms can damage kidneys and lymph nodes over a long period of time without
signs of illness. A severe infection, which may not show up for years, causes
swelling in the genitals, breasts, arms and legs and may progress to lung
disease. Treatment includes taking the anthelmintic drugs.
Prevention
·
Use a repellent
containing 20%-30% DEET or 20% Picaridin on exposed skin. Re-apply according to
manufacturer's directions.
·
Wear neutral-coloured (beige,
light grey) clothing. If possible, wear long-sleeved, breathable garments.
·
If available, pre-soak or spray
outer layer clothing and gear with permethrin.
·
Get rid of water containers
around dwellings and ensure that door and window screens work properly.
·
Apply sunscreen first followed
by the repellent (preferably 20 minutes later).
·
More details on insect bite prevention.
There is no preventive
medication or vaccine against Lymphatic Filariasis.
Lymphatic
Filariasis nematode images, life cycle, and distribution maps
Lymphatic
filariasis in Peninsular Malaysia: a cross-sectional survey of the knowledge,
attitudes, and practices of residents
Background
Lymphatic
filariasis (LF) is a major cause of permanent disability in many tropical and
sub-tropical countries of the world. Malaysia is one of the countries in which
LF is an endemic disease. Five rounds of the mass drug administration (MDA)
program have been conducted in Malaysia as part of the Global Program to
Eliminate Lymphatic Filariasis (GPELF) by year 2020. This study investigated
the level of awareness of LF and the MDA program in a population living in an
endemic area of the country.
Discussion
This survey was conducted in the state of Terengganu which is
known to be endemic for LF. The information gathered for the purpose of this
survey was obtained from visitors to the clinics in the survey area. The
results showed that the majority of the respondents were women which may pose
potential bias. However this is not the plan of the researchers, and is not
expected to affect the findings since both the women and men have equal chances
of getting infected. Moreover, experienced medical personnel were used to
assist in data collection especially the administration of the questionnaires.
This is done because these personnel were mostly indigenes of the area, they
speak the local language of the respondents and we feel that because they
interact directly with the target population, involving them will facilitate
compliance and cooperation of the respondents to give honest information
required [10]. Furthermore, all aspects of the survey were
conducted in close supervision by the researchers.
The WHO has recommended the implementation of knowledge,
attitudes, and practices (KAP) surveys as a cornerstone for health promotion
campaigns, as the surveys help programs adjust health education messages to
increase public knowledge and awareness [12]. The KAP related to LF infection differs between
regions and is heavily influenced by socio-cultural settings. Little is known
about how individual communities incorporate knowledge of the origins and
impacts of LF into local knowledge systems [13]. To the best of our knowledge, this is the first
KAP study of LF in residents of LF endemic areas of Peninsular Malaysia.
This survey of indigenous adults who have lived in the area for at
least 5 years was the first to be performed in this LF endemic area of
Malaysia. The survey was limited to only those who attended the clinics for any
reason; however, all pregnant women were excluded from the study. The majority
of the survey respondents were female respondents, likely due to the fact that
women in the area make more hospital visits or that women in the area are more
cooperative and willing to volunteer for surveys. After receiving training from
the researchers, medical doctors and nurses administered the questionnaires to
ensure unbiased reporting and responses from the subjects.
Our study revealed that although the study area is categorized as
an LF endemic area, the majority of the respondents were not aware of that
status, revealing that information about the disease was not effectively
conveyed to the general public. Thus, there were people who had poor or no
knowledge of LF. This finding is in agreement with several previous studies
performed on the population of endemic areas in Thailand [14], Ghana [15], Tanzania [16], and India [17,18].
In the control or elimination of a disease, the population
involved must have prior knowledge of the disease for the control measure to be
successfully implemented. Our survey, as well as others [19,20],
indicated that the major sources of information were schools, health centers,
and the mass media. In order to achieve greater awareness in the community,
additional informational campaigns should be considered, including
house-to-house visits.
In our survey, the majority of the respondents indicated knowing that
LF is transmitted by mosquitoes. This is in agreement with the findings of
previous studies [20,21], however, several other studies [18,22,23] have reported that the majority of respondents
did not know that mosquitoes are the vectors that transmit LF. The implication
of this deficit of knowledge is that families may not take appropriate measures
to protect their family members, which could counteract efforts to control the
disease.
In our study, the majority of the respondents recognized that the
common symptoms of LF include swelling of the legs, as well as other symptoms
including fever. This is consistent with previous studies [12,20,21,24,25]. In contrast, it has also been, reported that the
majority of respondents in 1 study did not know the symptoms of LF [17].
Our findings with respect to the attitudes of the respondents
towards LF showed that the majority of respondents view LF to be a problematic
disease. Furthermore, the respondents had differing views in terms of the
significance of LF as a problem, with respondents viewing LF as a medical, a
social, or an economic problem. This finding is in agreement with the findings
from a recent Indonesian survey [26]. The fact that only two-thirds of the respondents
indicated that they view LF to be a problem shows that awareness and knowledge
of the disease in general is lacking among the residents of this endemic
community. Thus, there is a need to increase efforts to improve education of
the residents to ensure effective control of LF.
Our survey revealed that the majority of respondents preferred
hospital treatment during illness, indicating that there is awareness of the
usefulness of hospitals. However, approximately 40% of the respondents still
consider traditional methods when treating illnesses. Similarly, in Nigeria,
the majority of respondents were reported to prefer hospital treatment, while a
small portion preferred traditional treatment methods [20].
Although, most of the respondents preferred hospital treatment, their knowledge
of the drug used in the treatment of LF was poor, similar to what has been
observed previously in India [18].
Despite the fact that the study area is known to be endemic for LF
and an MDA program was previously conducted in the area, our survey showed that
only a small proportion of respondents had obtained treatment for LF. This
result could suggest that the respondents are either ignorant of or are taking
for granted the treatment of LF and the MDA program. It could also be possible
that the drug deliverers do not strictly observe the people taking their drugs
directly. As approximately two-thirds of the respondents were not aware of the
MDA program that took place in the area and approximately one-fifth had not
heard of LF before the survey, it is likely that a large proportion of people
did not participate in the MDA program. Similarly, the poor awareness of the
people regarding the MDA program results in poor participation. Thus, the
success of an MDA program depends upon the target population’s knowledge of the
benefits. Knowledge is therefore a vital component in the success or failure of
any MDA program [11]. Poor knowledge leads to poor participation, and
poor participation leads to low coverage and persistence in transmission of the
disease. Moreover, we observed that the MDA program in Malaysia concentrated
mainly on distributing the drugs to people, with less emphasis on ensuring that
they actually swallowed the drugs or that they are educated on preventive
measures such as the use of bed nets and care of enlarged limbs. Hence,
suspected patients kept on going to the hospitals with one complain or the
other. However, in this survey we did not encounter any admitted case of LF in
any clinic.
One of the most important preventative measures in the eradication
of mosquito-borne diseases, such as filariasis, is the prevention of mosquito
bites. Our study indicated that the majority of respondents use protective
clothes or sleep under bed nets to protect against mosquito bites; however,
approximately one-sixth of the respondents did not mention using any form of
protection. The fact that a proportion of respondents did not mention any
protective measures probably indicates that the respondents did not see the
need for protection or that they are not comfortable taking preventative measures.
There could be some other barriers too such as cost, availability or ease of
use of the materials. Either way, the lack of knowledge with respect to the
transmission of LF is apparent. Interestingly, our survey revealed that most of
the respondents were aware of several ways used to control mosquito breeding,
demonstrating some understanding of vector control strategies, although this
knowledge was not necessarily translated to be part of an effective eradication
program. While our results are in agreement with a previous study [20,27], a number of previous studies demonstrated that
the majority of their subjects did not know the importance of minimizing
mosquito contact in preventing infection [13,16,23,26].
As evidenced from the findings of a previous survey, the knowledge
gap regarding LF, as well as general attitudes towards and perceptions of the
eradication program, was the basis of the major causes of lower compliance [28], this could have likely resulted in the continued
endemicity of LF in the endemic areas of Malaysia. This has been shown to occur
in Kenya [29,30], Papua New Guinea [31], and in India [25,32], where it was reported that there was low
compliance for an MDA program due to poor knowledge of LF by the target
population. On one hand there is sometimes the problem of poor drug delivery.
This was observed to be among the hindrance encountered in Malaysia after the
completion of TAS −1 when MDA was continued [8].
Furthermore, as observed by some other researchers, no single
formula can ensure success of MDA in all settings as compliance may be
negatively affected by other factors such as the perceptions of the potential
benefits of participation, the possible risk of adverse events as well as the
fear of the unknown by the target population [10].
The success of the MDA program to treat LF is dependent on the
knowledge of the target population. It cannot be assumed that the distribution
of information from schools, health centers, and mass media is sufficient at
conveying the information effectively. Recent studies have shown that the
distribution of information leaflets and posters [25] are effective. The use of appropriate means of
communication based on prevailing conditions is important in ensuring that
messages reach the target audience.
There was no significant association found between LF knowledge
and gender, occupation, age, educational status, or income of the respondents;
however, our results did indicate that females, older respondents, employed
respondents, and respondents with higher income had greater knowledge of LF.
This finding is in contrast to the results of a study performed in the
Philippines [13] that found significant associations between
gender, age, and educational status of respondents with LF knowledge.
Despite
the fact that LF is an increasing burden from the perspective of both public
health and economics, there seems to be little research on LF in comparison to
other neglected tropical diseases. Public health authorities therefore have a
great role to play in educating the people living in endemic areas for LF on
the dangers posed by the disease in terms of loss of DALYs, causing permanent
incapacitation to patients and huge economic loss on treatment etc., which
leads to a general low productivity. The effect of LF is also very serious on
the part of the governments, as considerable funds are needed for both MDA
administration and case management in endemic areas. There is thus, an urgent
need for continued research on methods of elimination of LF infection among
endemic and vulnerable communities. This could be achieved by an effective
education program that focuses on LF transmission and prevention, via public
media awareness, or by strategic advocacy on vector control. Other innovative
methods of educating residents of endemic and vulnerable communities include
incorporating public health professionals, audio-visual campaigns, and the
running of workshops and seminars. In addition, participation in activities or
exhibits that promote the adoption of policies regarding prevention and control
of the disease would increase public awareness. Nevertheless, it is important
that the information is presented in a concise, informative, and easy to
understand form. Finally, it is recommended that an awareness campaign
regarding the importance of MDA be stressed in all endemic areas of Malaysia
before embarking on subsequent MDA rounds for successful implementation and
control.
conclusion
The findings from this survey showed that there
was some awareness regarding LF among people in Kemaman district of Malaysia,
although knowledge of the MDA program was poor. Pre-MDA campaigns would help in
improving residents’ knowledge of LF and of the purpose of MDA programs and
would increase the likelihood of participation in the MDA program, thereby
improving the general wellbeing of the people in the area.
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