Coverage of preventive measures and surveillance for neglected tropical diseases in hard-to-reach communities in Ghana.

BACKGROUND: Neglected tropical diseases (NTDs) are a major public health burden which mainly affects poor populations living in tropical environments and hard-to-reach areas. The study sought to examine coverage of preventive efforts, and case surveillance for NTDs in hard-to-reach communities in Ghana. METHODS: The study investigated treatment efforts for lymphatic filariasis (LF), and onchocerciasis and schistosomiasis/soil transmitted helminths (SCH/STH) at household level, in difficult-to-access communities in Ghana. A total of 621 households were sampled from 6 communities in the Western, Oti and Greater Accra regions. RESULTS: Over 95% of the households surveyed were covered under mass drug administration (MDA) campaigns for lymphatic filariasis (LF) and onchocerciasis. More than 80% of households had received at least two visits by community drug distributors under the MDA campaigns in the last two years preceding the study. In addition, over 90% of households in the LF and onchocerciasis endemic communities had at least one member using anthelminthic medications under the MDA campaigns in the 12 months preceding the study. However, households where no member had taken anthelminthic medications in 12 months preceding the study were over 6 times likely to have someone in the household with LF. CONCLUSIONS: This study determined that SCH/STH, LF and onchocerciasis are of serious public health concern in some communities in Ghana. There is an urgent need for holistic practical disease control plan involving both financial and community support to ensure total control of NTDs in difficult-to-access communities is achieved.

Development of an integrated, holistic care package for people with lymphoedema for use at the level of the Primary Health Care Unit in Ethiopia.

BACKGROUND: Neglected Tropical Diseases (NTDs) are a group of several communicable and non-communicable diseases prevalent in tropical and subtropical areas. The co-endemicity of these diseases, the similarity of their clinical signs, and the need to maximize limited financial and human resources suggest the importance of adoptingan integratedapproach to their prevention and treatment. AIMS: This study describes the development of a comprehensive package of physical, mental health and psychosocial care for people with lower-limb lymphoedema caused bypodoconiosis, lymphatic filariasis (LF)or leprosy as part of the EnDPoINT program in Ethiopia. METHOD: The care package was developed using a mixed-methods approach, consisting of a literature review, situational analysis, Theory of Change (ToC) workshops, qualitative research, and additional workshops to fine-tune the draft care package. The care package was developed between March 2018 and January 2020 in Addis Ababa and the implementation research site, Awi zone in the North-West of Ethiopia. RESULTS: The holistic care package includes components implemented at three levels of the health care system:health organization, facility, and community. Sections of the care package are directed at strengthening capacity building, program management, community engagement, awareness-raising, stigma-reduction, morbidity management, disability prevention, follow-up visits, referral linkage, community-based rehabilitation, and monitoring and evaluation. CONCLUSIONS: The study developed a holistic integrated care package for lower limb disorder and co-morbid mental health problems caused by podoconiosis, LF or leprosy. The approach has the potential to significantly reduce lower limb disorder-associated morbidity, disability, and psychosocial problems. It also standardizes a scalable approach appropriate for the Ethiopian setting and, most likely, other countries where these NTDs are present.

EnDPoINT: protocol for an implementation research study to integrate a holistic package of physical health, mental health and psychosocial care for podoconiosis, lymphatic filariasis and leprosy into routine health services in Ethiopia.

INTRODUCTION: Neglected tropical diseases (NTDs) causing lower limb lymphoedema such as podoconiosis, lymphatic filariasis (LF) and leprosy are common in Ethiopia. Routine health services for morbidity management and disability prevention (MMDP) of lymphoedema caused by these conditions are still lacking, even though it imposes a huge burden on affected individuals and their communities in terms of physical and mental health, and psychosocial and economic outcomes. This calls for an integrated, holistic approach to MMDP across these three diseases. METHODS AND ANALYSIS: The 'Excellence in Disability Prevention Integrated across NTDs' (EnDPoINT) implementation research study aims to assess the integration and scale-up of a holistic package of care-including physical health, mental health and psychosocial care-into routine health services for people with lymphoedema caused by podoconiosis, LF and leprosy in selected districts in Awi zone in the North-West of Ethiopia. The study is being carried out over three phases using a wide range of mixed methodologies. Phase 1 involves the development of a comprehensive holistic care package and strategies for its integration into the routine health services across the three diseases, and to examine the factors that influence integration and the roles of key health system actors. Phase 2 involves a pilot study conducted in one subdistrict in Awi zone, to establish the care package's adoption, feasibility, acceptability, fidelity, potential effectiveness, its readiness for scale-up, costs of the interventions and the suitability of the training and training materials. Phase 3 involves scale-up of the care package in three whole districts, as well as its evaluation in regard to coverage, implementation, clinical (physical health, mental health and psychosocial) and economic outcomes. ETHICS AND DISSEMINATION: Ethics approval for the study has been obtained in the UK and Ethiopia. The results will be disseminated through publications in scientific journals, conference presentations, policy briefs and workshops.

The Epitome of Novel Techniques and Targeting Approaches in Drug Delivery for Treating Lymphatic Filariasis.

BACKGROUND: Lymphatic filariasis is a pervasive and life-threatening disease for human beings. Currently, 893 million people in 49 countries worldwide affected by lymphatic filariasis as per WHO statistics. The concealed aspects of lymphatic diseases such as delayed disease detection, inappropriate disease imaging, the geographical outbreak of infection, and lack of preventive chemotherapy have brought this epidemic to the edge of Neglected Tropical Diseases. Many medications and natural bioactive substances have seen to promote filaricidal activity against the target parasitic species. However, the majority of failures have occurred in pharmaceutical and pharmacokinetic issues. OBJECTIVE: The purpose of the study is to focus on the challenges and therapeutic issues in the treatment of filariasis. The review brings novel techniques and therapeutic approaches for combating lymphatic filariasis. It also offers significant developments and opportunities for such therapeutic interventions. CONCLUSION: Through this review, an attempt has made to critically evaluate the avenues of innovative pharmaceuticals and molecular targeting approaches to bring an integrated solution to combat lymphatic filariasis.

The roles of stakeholder experience and organizational learning in declining mass drug administration coverage for lymphatic filariasis in Port-au-Prince, Haiti: A case study.

The World Health Organization (WHO) defines an effective round of mass drug administration (MDA) for lymphatic filariasis (LF) as one that reaches at least 65% of the target population. In its first round of MDA in 2011-2012, the National Program to Eliminate LF in Haiti achieved a 79% epidemiological coverage in urban Port-au-Prince. In 2013, coverage dropped below the WHO threshold and has declined year-over-year to a low of 41% in 2017. We conducted a retrospective qualitative case study to identify key factors behind the decline in coverage in Port-au-Prince and ways to address them. Our findings suggest that the main contributors to the decline in MDA coverage appear to be the absence of effective documentation of practices, reporting, analysis, and program quality improvement-i.e., learning mechanisms-within the program's MDA design and implementation strategy. In addition to their contribution to the program's failure to meet its coverage targets, these deficits have resulted in a high cost for the MDA campaign in both lost momentum and depleted morale. Through a proposed operating logic model, we explore how the pathway from program inputs to outcomes is influenced by a wide array of mediating factors, which shape potential participants' experience of MDA and, in turn, influence their reasoning and decisions to take, or not take, the pills. Our model suggests that the decisions and behavior of individuals are a reflection of their overall experience of the program itself, mediated through a host of contextual factors, and not simply the expression of a fixed choice or preference. This holistic approach offers a novel and potentially valuable framing for the planning and evaluation of MDA strategies for LF and other diseases, and may be applicable in a variety of global health programs.

Elimination of diurnally sub-periodic Wuchereria bancrofti in Andaman and Nicobar Islands, India, using mass DEC-fortified salt as a supplementary intervention to MDA.

Feasibility of implementing a DEC-fortified (DEC at 0.2% w/w and iodine) salt strategy to hasten elimination of diurnally sub-periodic Wuchereria bancrofti (DspWB) from the lone foci in Nancowry islands, Nicobar district, India, was assessed. This is a two-arm community-based study: one arm (12 villages, population 2936) received double fortified salt along with annual mass drug administration (MDA) of DEC plus albendazole (DEC-salt+MDA-arm), and another (14 villages; population 4840) received MDA under the National Filaria Elimination Programme. DEC salt was distributed on camp mode supplemented by door delivery. Monthly survey was carried out in fixed and random households to assess the coverage, usage of DEC salt and DEC content. The impact on prevalence of mf at community level and antigenaemia among children was assessed. A total of 21 metric tonnes of free-flow DEC salt manufactured by Tamil Nadu Salt Corporation, India, was distributed for 1 year. In the DEC-salt+MDA-arm, > 90% of the households received and used the DEC salt. DEC was within therapeutic range (0.2-0.32% w/w) in the samples collected from kitchens. Community mf prevalence reduced from 2.27 to 0.14% in the DEC-salt-arm (< 1% in all the villages) and 1.26 to 0.74% (> 1% in 4 out of 14 villages) in the MDA-arm. Ag prevalence reduced to zero from 1.0 (DEC-salt+MDA-arm) and 6.3% (MDA-arm) in 2-3 years old, 1.2 and 3.6% from 2.9 in the DEC-salt-arm and 4.5% in the MDA-arm among 6-7 years old. It was feasible to deliver DEC-fortified salt covering > 90% of the households with compliance reaching the elimination target in the islands.

Acute larvicidal toxicity of five essential oils (Pinus nigra, Hyssopus officinalis, Satureja montana, Aloysia citrodora and Pelargonium graveolens) against the filariasis vector Culex quinquefasciatus: Synergistic and antagonistic effects.

Mosquito vector control is facing a number of important and timely challenges, mainly due to the rapid development of pesticide resistance and environmental concerns. In this scenario, screening of botanical resources for their mosquitocidal activity may offer effective and eco-friendly tools against Culicidae vectors. Culex quinquefasciatus Say (Diptera: Culicidae) is a vector of lymphatic filariasis and of dangerous arboviral diseases, such as West Nile and St. Louis encephalitis. In this study, the chemical composition of five essential oils obtained from different plants, namely Pinus nigra J.F. Arnold var. italica (Pinaceae), Hyssopus officinalis L. subsp. aristatus (Lamiaceae), Satureja montana L. subsp. montana (Lamiaceae), Aloysia citriodora Palau (Verbenaceae) and Pelargonium graveolens L'Hér (Geraniaceae), was investigated by GC-MS analysis. Furthermore, it was evaluated their acute toxicity on larvae of C. quinquefasciatus. Then, the most effective oils were selected, in order to focus on the potential synergistic and antagonistic effects, testing them in binary mixtures on C. quinquefasciatus larvae. Results showed that the higher effectiveness was obtained by S. montana subsp. montana essential oil (LC50=25.6µL·L-1), followed by P. nigra var. italica (LC50=49.8µL·L-1) and A. citriodora (LC50=65.6µL·L-1), while the other essential oils showed LC50 values higher than 90µL·L-1. The larvicidal effectiveness can be enhanced by preparing simple binary mixtures of essential oils, such as S. montana+A. citriodora (ratio 1:1), which showed higher larvicidal toxicity (LC50=18.3µL·L-1). On the other hand, testing S. montana+P. nigra (1:1) an antagonistic effect was detected, leading to a LC50 (72.5µL·L-1) higher than the LC50 values calculated for the two oils tested separately. Overall, our results add useful knowledge to allow the employ of synergistic essential oil blends as effective, cheap and eco-friendly mosquito larvicides.

Mathematical modelling of lymphatic filariasis elimination programmes in India: required duration of mass drug administration and post-treatment level of infection indicators.

BACKGROUND: India has made great progress towards the elimination of lymphatic filariasis. By 2015, most endemic districts had completed at least five annual rounds of mass drug administration (MDA). The next challenge is to determine when MDA can be stopped. We performed a simulation study with the individual-based model LYMFASIM to help clarify this. METHODS: We used a model-variant for Indian settings. We considered different hypotheses on detectability of antigenaemia (Ag) in relation to underlying adult worm burden, choosing the most likely hypothesis by comparing the model predicted association between community-level microfilaraemia (Mf) and antigenaemia (Ag) prevalence levels to observed data (collated from literature). Next, we estimated how long MDA must be continued in order to achieve elimination in different transmission settings and what Mf and Ag prevalence may still remain 1 year after the last required MDA round. The robustness of key-outcomes was assessed in a sensitivity analysis. RESULTS: Our model matched observed data qualitatively well when we assumed an Ag detection rate of 50 % for single worm infections, which increases with the number of adult worms (modelled by relating detection to the presence of female worms). The required duration of annual MDA increased with higher baseline endemicity and lower coverage (varying between 2 and 12 rounds), while the remaining residual infection 1 year after the last required treatment declined with transmission intensity. For low and high transmission settings, the median residual infection levels were 1.0 % and 0.4 % (Mf prevalence in the 5+ population), and 3.5 % and 2.0 % (Ag prevalence in 6-7 year-old children). CONCLUSION: To achieve elimination in high transmission settings, MDA must be continued longer and infection levels must be reduced to lower levels than in low-endemic communities. Although our simulations were for Indian settings, qualitatively similar patterns are also expected in other areas. This should be taken into account in decision algorithms to define whether MDA can be interrupted. Transmission assessment surveys should ideally be targeted to communities with the highest pre-control transmission levels, to minimize the risk of programme failure.

Neglected tropical diseases in Africa: a new paradigm.

Programmes to control onchocerciasis have been ongoing for over 40 years. What was once a devastating blinding and disabling disease, particularly in West Africa, has largely been eliminated at least as a public health problem. Efforts continue to eliminate the transmission of the disease. However, as the elimination agenda has developed so have efforts to control/eliminate other neglected tropical diseases (NTDs). The African Programme for Onchocerciasis Control will close at the end of 2015. There has been considerable discussion as to what should replace it and the World Health Organization Africa Region has been consulting widely during the first part of 2015 and has established a new project framework that will be presented to a wider group of stakeholders to mobilise support with the aim of the coordination of NTD activities in the region. This will be called the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN). This will put the countries in the driving seat but offer technical advice, capacity building and financial support, where needed, to enable countries to implement their NTD Master Plans, and also to implement recommendations of the Regional Programme Review Group. An NTD forum will be held periodically to consult with stakeholders.

Accuracy of Coverage Survey Recall following an Integrated Mass Drug Administration for Lymphatic Filariasis, Schistosomiasis, and Soil-Transmitted Helminthiasis.

BACKGROUND: Achieving target coverage levels for mass drug administration (MDA) is essential to elimination and control efforts for several neglected tropical diseases (NTD). To ensure program goals are met, coverage reported by drug distributors may be validated through household coverage surveys that rely on respondent recall. This is the first study to assess accuracy in such surveys. METHODOLOGY/PRINCIPAL FINDINGS: Recall accuracy was tested in a series of coverage surveys conducted at 1, 6, and 12 months after an integrated MDA in Togo during which three drugs (albendazole, ivermectin, and praziquantel) were distributed. Drug distribution was observed during the MDA to ensure accurate recording of persons treated during the MDA. Information was obtained for 506, 1131, and 947 persons surveyed at 1, 6, and 12 months, respectively. Coverage (defined as the percentage of persons taking at least one of the MDA medications) within these groups was respectively 88.3%, 87.4%, and 80.0%, according to the treatment registers; it was 87.9%, 91.4% and 89.4%, according to survey responses. Concordance between respondents and registers on swallowing at least one pill was >95% at 1 month and >86% at 12 months; the lower concordance at 12 months was more likely due to difficulty matching survey respondents with the year-old treatment register rather than inaccurate responses. Respondents generally distinguished between pills similar in appearance; concordance for recall of which pills were taken was over 80% in each survey. SIGNIFICANCE: In this population, coverage surveys provided remarkably consistent coverage estimates for up to one year following an integrated MDA. It is not clear if similar consistency will be seen in other settings, however, these data suggest that in some settings coverage surveys might be conducted as much as one year following an MDA without compromising results. This might enable integration of post-MDA coverage measurement into large, multipurpose, periodic surveys, thereby conserving resources.

Towards elimination of lymphatic filariasis: social mobilization issues and challenges in mass drug administration with anti-filarial drugs in Tamil Nadu, South India.

India is a signatory to World Health Assembly resolution for elimination of lymphatic filariasis (LF) and National Health Policy has set the goal of LF elimination by 2015. Annual mass drug administration (MDA) is ongoing in endemic districts since 1996-97. Compliance rate is a crucial factor in achieving elimination and was assessed in three districts of Tamil Nadu for 10th and 11th treatment rounds (TRs). An in-depth study assessed the impact of social mobilization by drug distributors (DDs) in two areas from each of the three districts. Overall coverage and compliance for assessed TRs were 76.3 and 67.7% which is below the optimum level to achieve LF elimination. Modifiable determinants continue to be the reason for non-consumption even in the 11th TR and 20.8% were systematic non-compliers. In 76.4% of the cases, DDs failed to adhere to three mandatory visits as per the guidelines. Number of visits by DDs in relation to low and high MDA coverage areas showed a significant relationship (P ≤ 0.000). MDA is limited to drug distribution alone and efforts by DDs in preparing the community were inadequate. Probable means to meet the challenges in preparation of the community is discussed.

Laboratory observations on the larvicidal efficacy of three plant species against mosquito vectors of malaria, dengue/dengue hemorrhagic fever (DF/DHF) and lymphatic filariasis in the semi-arid desert.

Comparative larvicidal efficacy of aqueous and organic solvent extracts from seeds, leaves and flowers of three desert plants viz. Calotropis procera (Aiton), Tephrosia purpurea (L.) Pers. and Prosopis juliflora (Sw.) DC. was evaluated against Anopheles stephensi (Liston), Aedes aegypti (Linnaeus) and Culex quinquefasciatus (Say). For this purpose larvae of all the three mosquito species were reared in the laboratory and studies carried out on late 3rd or early 4th instars using standard WHO technique. Based on concentration mortality data 24 and 48 hr LC50and LC90 values along with their 95% fiducial limits, regression equation, chi-square (chi2)/ heterogeneity of the response were determined by log probit regression analysis. Experiments were carried out with different solvent extracts of seeds of C. procera which revealed that methanol (24 hr LC50: 127.2, 194.8, 361.0) and acetone (229.9, 368.1,193.0 mg l(-1)) extracts were more effective with the three mosquito species, respectively. Petroleum ether extract was effective only on An. stephensi while aqueous extracts were not effective at all with any of the mosquito species (mortality < 10-30%). Tests carried out with methanol extracts of fresh leaves (24 hr LC50: 89.2, 171.2, 369.7) and flowers (24 hr LC50: 94.7,617.3, 1384.0 mg l-(-1)) of Calotropis showed that preparations from fresh parts were 2-3 times more effective as compared to the stored plant parts. Efficacy was less than 10-30% with both An. aegypti and Cx. quinquefasciatus while An. stephensi was still susceptible to extracts from both leaves and flowers even after two years of storage. The 24 hr LC50 values as observed for methanol extracts of seeds of T. purpurea and leaves of P. juliflora were 74.9, 63.2 and 47.0 and 96.2,128.1 and 118.8 mg l(-1) for the above three mosquito species, respectively. Experiments carried out up to 500 mg l-(1) with leaves (T. purpurea) and seeds (P. juliflora) extracts show only up to 10-30% mortality indicating that active larvicidal principle may be present only in the seeds of Tephrosia and leaves of Prosopis. In general, anophelines were found more susceptible than the culicines to the plant derived derivatives. More studies are being carried outon some other desert plants found in this arid region. The study would be of great importance while formulating vector control strategy based on alternative plant based insecticides in this semi-arid region.

Evaluation of toxicity of plant extracts against vector of lymphatic filariasis, Culex quinquefasciatus.

BACKGROUND & OBJECTIVES: Conventional insecticides are generally used as larvicides to control Culex quinquefasciatus, vector of lymphatic filariasis. This study was undertaken to evaluate the larvicidal activity of some potential larvicidal plants leaf extracts against Cx. quinquefasciatus larvae. METHODS: The toxic effects of petroleum ether leaf extracts of plants viz., Argemone mexicana (Mexican prickly poppy), Clausena dentata (Dentate), Cipadessa baccifera (Rana bili), Dodonaea angustifolia (Hop bush) and Melia dubia (Pride of India) were evaluated under laboratory conditions in individual and in combination against 3 rd - 4 th instar larvae of Cx. quinquefasciatus. RESULTS: The results indicated that among the selected plants, A. mexicana showed maximum larvicidal activity with an LC 50 value of 48.89 ppm. Its toxicity was enhanced when the extract was mixed (1:1) with that of C. dentata as the LC 50 value became 28.60 ppm indicating synergistic action of A. mexicana. INTERPRETATION & CONCLUSIONS: Our results showed high larvicidal potential in A. mexicana leaf extract, and it also showed additive effect when mixed with C. dentata extract.

Withania somnifera chemotypes NMITLI 101R, NMITLI 118R, NMITLI 128R and withaferin A protect Mastomys coucha from Brugia malayi infection.

Withania somnifera is an ayurvedic Indian medicinal plant whose immunomodulatory activities have been widely used as a home remedy for several ailments. We recently observed immunostimulatory properties in the root extracts of chemotypes NMITLI-101, NMITLI-118, NMITLI-128 and pure withanolide, withaferin A. In the present study, we evaluated the potential immunoprophylactic efficacies of these extracts against an infective pathogen. Our results show that administration of aqueous ethanol extracts (10 mg/kg) and withaferin A (0·3 mg/kg), 7 days before and after challenge with human filarial parasite Brugia malayi, offers differential protection in Mastomys coucha with chemotype 101R offering best protection (53·57%) as compared to other chemotypes. Our findings also demonstrate that establishment of B. malayi larvae was adversely affected by pretreatment with withaferin A as evidenced by 63·6% reduction in adult worm establishment. Moreover, a large percentage of the established female worms (66·2%) also showed defective embryogenesis. While the filaria-specific immunological response induced by withaferin A and NMITLI-101 showed a mixed Th1/Th2 phenotype, 118R stimulated production of IFN-γ and 128R increased levels of IL-4. Taken together, our findings reveal potential immunoprophylactic properties of W. somnifera, and further studies are needed to ascertain the benefits of this plant against other pathogens as well.

Preventive chemotherapy in human helminthiasis: theoretical and operational aspects.

Preventive chemotherapy (PC), the large-scale distribution of anthelminthic drugs to population groups at risk, is the core intervention recommended by the WHO for reducing morbidity and transmission of the four main helminth infections, namely lymphatic filariasis, onchocerciasis, schistosomiasis and soil-transmitted helminthiasis. The strategy is widely implemented worldwide but its general theoretical foundations have not been described so far in a comprehensive and cohesive manner. Starting from the information available on the biological and epidemiological characteristics of helminth infections, as well as from the experience generated by disease control and elimination interventions across the world, we extrapolate the fundamentals and synthesise the principles that regulate PC and justify its implementation as a sound and essential public health intervention. The outline of the theoretical aspects of PC contributes to a thorough understanding of the different facets of this strategy and helps comprehend opportunities and limits of control and elimination interventions directed against helminth infections.

Rapid community identification, pain and distress associated with lymphoedema and adenolymphangitis due to lymphatic filariasis in resource-limited communities of North-eastern Nigeria.

Identification of communities with people that could benefit from adenolymphangitis (ADL) and lymphoedema morbidity management within Lymphatic Filariasis Elimination Programmes (NLFEP) in many African countries is a major challenge to programme managers. Another challenge is advocating for proportionate allocation of funds to alleviating the suffering that afflicted people bear. In this study we developed a rapid qualitative technique of identifying communities where morbidity management programme could be situated and documenting the pain and distress that afflicted persons endure. Estimates given by health personnel and by community resource persons were compared with systematic household surveys for the number of persons with lymphoedema of the lower limb. Communities in Northeastern Nigeria, with the largest number of lymphoedema cases were selected and a study of local knowledge, physical, psychosocial burden and intervention-seeking activities associated with the disease documented using an array of techniques (including household surveys, key informant interviews, group discussions and informal conversations). Health personnel gave a more accurate estimate of the number of lymphoedema patients in their communities than either the community leader or the community directed ivermectin distributor (CDD). Community members with lymphoedema preferred to confide in health personnel from other communities. The people had a well developed local vocabulary for lymphoedema and are well aware of the indigenous transmission theories. Although the people associated the episodic ADL attacks with the rains which were more frequent at that period they did not associate the episodes with gross lymphoedema. There were diverse theories about lymphoedema causation with heredity, accidental stepping on charmed objects and organisms, breaking taboos. The most popular belief about causation, however, is witchcraft (60.9%). The episodic attacks are dreaded by the afflicted, since they are accompanied by severe pain (18%). The emotional trauma included rejection (27.5%) by family, friends and other community members to the extent that divorce and isolation are common. Holistic approach to lymphoedema morbidity management should necessarily be an integral component of the ongoing transmission elimination programme. Any transmission prevention effort that ignores the physical and psychological pain and distress that those already afflicted suffer is unethical and should not be promoted.

The sharp end - experiences from the Tanzanian programme for the elimination of lymphatic filariasis: notes from the end of the road.

The Tanzania Lymphatic Filariasis Programme, which was launched in 2000, is, in terms of geographical coverage, among the largest disease-control programmes in Tanzania's history, currently reaching 9.4 million people in 34 districts. The issues associated with this programme's implementation are reviewed here, in the context of the various players/stakeholders involved. This article provides an insight of how the programme began and discusses key areas in the programme's design. Mainly, however, it gives some impressions of how the programme is perceived by, and how it affects, village healthworkers, patients and politicians - the people who contribute to the implementation of the programme at various levels.

Editorial: Global elimination of lymphatic filariasis: fact or fantasy?

In 1997, the World Health Assembly resolved to eliminate lymphatic filariasis as a public health problem by the year 2020. By the end of 2004, almost half of the 83 endemic countries had initiated national programmes, providing mass drug administration to an at risk population of approximately 435 million. This remarkable achievement is the result of an enormous amount of technical, financial and political support from public and private sectors at the community, national, regional and global level. As the global programme to eliminate lymphatic filariasis enters its second quarter of operations, there are substantial opportunities to be taken and critical challenges to be addressed. These are the focus of this editorial.