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1.
PLoS Negl Trop Dis ; 14(1): e0007862, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31978060

RESUMO

BACKGROUND: Lymphatic filariasis (LF) is targeted for elimination by the year 2020. As of 2017, 67 of the 72 endemic countries have implemented annual Mass Drug Administration (MDA) for interrupting LF transmission. Transmission Assessment Survey (TAS) is the recommended protocol to evaluate the impact of MDA and to decide when to stop MDA in an Evaluation Unit (EU, population ≤2 million). As the human infection levels go down with repeated MDA rounds, it becomes a challenge to select the appropriate survey methods to assess transmission interruption. This study validates a standard protocol for molecular xenomonitoring of infection in vectors (MX) at an EU as a complementary tool for TAS to stop MDA and its utility for post-MDA or post-validation surveillance. METHODOLOGY: The study was conducted in Cuddalore district, Tamil Nadu, India, which was found eligible for TAS after 15 annual rounds of MDA (4 with DEC alone and 11 with DEC plus albendazole). The district was divided into two EUs as per the TAS protocol and one EU was randomly selected for the study. A two-stage cluster design vector sampling, developed and validated at a sub-district level, was implemented in 30 randomly selected clusters in the EU. Female Culex quinquefasciatus were collected placing gravid traps overnight (1800-0600 hrs) inside the premises of systematically selected households. Pools of 20-25 blood-fed, semi-gravid and gravid Cx. quinquefasciatus were subjected to real-time quantitative PCR (polymerase chain reaction) assay for detecting Wuchereria bancrofti DNA. Pool infection rate (% of pools positive for W. bancrofti DNA), and the estimated prevalence of W. bancrofti DNA in mosquitoes and its 95% confidence interval were calculated. Additionally, in these 30 clusters, microfilaria (Mf) survey among individuals >5 years old was carried out. School-based TAS was conducted using Immunochromatographic Card Test (ICT) in the EU. Prepared itemized cost-menu for different cost components of MX survey and TAS were estimated and compared. RESULTS: MX survey showed that only 11 (3.1%) of the 358 pools (8850 Cx.quinquefasciatus females), collected from 30 clusters, were found positive for W. bancrofti DNA. The estimated vector infection rate was 0.13% (95% CI: 0.07-0.22%), below the provisional threshold (0.25%) for transmission interruption. Of 1578 children tested in the TAS, only four (0.25%) were positive for filarial antigenemia, and it is well below the critical cut-off (18 positives) for stopping MDA. Among 9804 persons tested in the 30 clusters, only four were found positive for Mf (0.04%; 95% CI: 0.01-0.1%). The Mf-prevalence was <1% threshold for transmission interruption in humans. The estimated costs for TAS and MX per EU were $14,104 USD and $14,259 USD respectively. CONCLUSIONS: The result of MX protocol was in good agreement with that of TAS, providing evidence to recommend MX as a complementary tool to TAS to decide on stopping MDA. MX can also be a potential surveillance tool for post-MDA and post-validation phases as it could detect sites with residual infection and risk of resurgence of transmission. MX is economically feasible as its cost is slightly higher than that of TAS.


Assuntos
Culex/parasitologia , DNA de Helmintos/análise , Filariose Linfática/prevenção & controle , Administração Massiva de Medicamentos , Wuchereria bancrofti/isolamento & purificação , Animais , Criança , Filariose Linfática/epidemiologia , Feminino , Humanos , Índia/epidemiologia , Mosquitos Vetores/parasitologia , Prevalência , Reação em Cadeia da Polimerase em Tempo Real , Wuchereria bancrofti/genética
2.
PLoS One ; 14(12): e0224422, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31856176

RESUMO

BACKGROUND: Preventive chemotherapy was administered to 3.2 million Sierra Leoneans in 13 health districts for lymphatic filariasis, onchocerciasis, and soil transmitted helminthes from October 2008 to February 2009. This paper aims to report the findings of a coverage survey conducted in 2009, compare the coverage survey findings with two reported rates for lymphatic filariasis coverage obtained using pre-mass drug administration (MDA) registration and national census projections, and use the comparison to understand the best source of population estimates in calculating coverage for NTD programming in Sierra Leone. METHODOLOGY/PRINCIPAL FINDINGS: Community drug distributors (CDDs) conducted a pre- MDA registration of the population. Two coverage rates for MDA for lymphatic filariasis were subsequently calculated using the reported number treated divided by the total population from: 1) the pre-MDA register and 2) national census projections. A survey was conducted to validate reported coverage data. 11,602 persons participated (response rate of 76.8%). Overall, reported coverage data aggregated to the national level were not significantly different from surveyed coverage (z-test >0.05). However, estimates based on pre-MDA registration have higher agreement with surveyed coverage (mean Kendall's W = 0.68) than coverage calculated with census data (mean Kendall's = 0.59), especially in districts with known large-scale migration, except in a highly urban district where it was more challenging to conduct a pre-MDA registration appropriately. There was no significant difference between coverage among males versus females when the analyses were performed excluding those women who were pregnant at the time of MDA. The surveyed coverage estimate was near or below the minimum 65% epidemiological coverage target for lymphatic filariasis MDA in all districts. CONCLUSION/SIGNIFICANCE: These results from Sierra Leone illustrate the importance of choosing the right denominator for calculating treatment coverage for NTD programs. While routinely reported coverage results using national census data are often good enough for programmatic decision making, census projections can quickly become outdated where there is substantial migration, e.g. due to the impact of civil war, with changing economic opportunities, in urban settings, and where there are large migratory populations. In districts where this is known to be the case, well implemented pre-MDA registration can provide better population estimates. Pre-MDA registration should, however, be implemented correctly to reduce the risk of missing pockets of the population, especially in urban settings.


Assuntos
Filariose Linfática/prevenção & controle , Helmintíase/prevenção & controle , Oncocercose/prevenção & controle , Adulto , Albendazol/uso terapêutico , Censos , Quimioprevenção/métodos , Filariose Linfática/epidemiologia , Feminino , Filaricidas/uso terapêutico , Helmintíase/epidemiologia , Humanos , Ivermectina/uso terapêutico , Masculino , Administração Massiva de Medicamentos/métodos , Doenças Negligenciadas/epidemiologia , Doenças Negligenciadas/prevenção & controle , Oncocercose/epidemiologia , Serra Leoa/epidemiologia , Inquéritos e Questionários
3.
PLoS Negl Trop Dis ; 13(11): e0007861, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31774820

RESUMO

BACKGROUND: The success of the global strategy to eliminate lymphatic filariasis (LF) through mass drug administration (MDA) campaigns is dependent on meeting high coverage levels over long periods of time. Community engagement plays a critical role in driving coverage and involvement of local communities in MDA for LF. This study explored how community engagement approaches used in MDA for LF shape participation in the programme, with a view of proposing effective engagement strategies. METHODS: The study was conducted in Luangwa, a rural District of Lusaka province, Zambia. An exploratory qualitative case study approach was employed. A total of nine focus group discussions, six in-depth and seven key informant interviews were conducted with various participants that included; community members, traditional leaders and programme managers, respectively. Data were analysed using a thematic approach, aided by NVivo 10 software. RESULTS: Three core thematic areas emerged from the data as priority focus areas for programme planners and implementers in designing effective community engagement strategies that facilitate participation. Firstly, employing of partnership approaches through adequate and timely engagement of traditional, government and non-governmental organisation structures. Secondly, use of appropriate and innovative health education initiatives to disseminate information about the programme. Thirdly, addressing context specific programme implementation barriers affecting community engagement in MDA for LF. CONCLUSION: Facilitating participation in MDA for LF will require designing and implementing effective community engagement strategies that take into account local context, but also seek to explore all avenues of maximizing participation for improved coverage levels. MDA for LF implementation teams should systematically consider the identified factors and seek to incorporate them in their implementation plans.


Assuntos
Participação da Comunidade , Transmissão de Doença Infecciosa/prevenção & controle , Filariose Linfática/tratamento farmacológico , Filariose Linfática/prevenção & controle , Filaricidas/uso terapêutico , Administração Massiva de Medicamentos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Educação em Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Zâmbia
4.
PLoS Negl Trop Dis ; 13(11): e0007836, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31765388

RESUMO

BACKGROUND: The objective of the Global Program to Eliminate Lymphatic Filariasis (GPELF) is to phase out this endemic disease as a public health problem by 2020. Validation of elimination is obtained from the World Health Organization through evidence of non-transmission in countries that have already been subjected to mass drug administration (MDA) and in places adjoining these endemic areas. While three municipalities in Brazil have completed MDA, the epidemiological situation remains uncertain in nine adjoining municipalities. To determine the epidemiological status, this study was to perform a review of the literature and a school-based survey to describe the past and recent endemicity of lymphatic filariasis (LF) theses nine municipalities in Brazil. METHODOLOGY/PRINCIPLE FINDINGS: For review of the literature, both formal and informal literature sources were accessed since the first reports of filariasis in the Metropolitan Region of Recife, Brazil. We conducted a school-based survey in 2016 using immunochromatographic card tests (ICTs) among schoolchildren aged 6-10 years living in nine municipalities contiguous with the endemic areas in which MDA was conducted. Our review of the literature identified eight studies involving surveys demonstrating that microfilariae had been circulating in eight of the municipalities since 1967, with a low prevalence of microfilaremia, isolated autochthonous cases, and treatment of individual cases. The school-based survey included 17,222 children in 185 urban schools in the nine areas of Brazil with uncertain endemicity. One child affected by allochthonous transmission was antigen positive based on ICT and lived in a municipality adjacent to Recife; this child's family came from Recife, but no other case was diagnosed within the family. CONCLUSIONS/SIGNIFICANCE: The study results suggest that there is no transmission of LF in the municipalities investigated. However, these areas have population migration and socioenvironmental conditions favorable to mosquito breeding grounds; therefore, surveillance is strongly recommended in these areas.


Assuntos
Transmissão de Doença Infecciosa/prevenção & controle , Filariose Linfática/epidemiologia , Filariose Linfática/transmissão , Adolescente , Brasil/epidemiologia , Criança , Erradicação de Doenças , Filariose Linfática/prevenção & controle , Feminino , Filaricidas/uso terapêutico , Humanos , Masculino , Administração Massiva de Medicamentos , Prevalência
5.
PLoS Negl Trop Dis ; 13(9): e0007687, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31513587

RESUMO

Lymphatic filariasis (LF), a morbid disease caused by the tissue-invasive nematodes Wuchereria bancrofti, Brugia malayi, and Brugia timori, affects millions of people worldwide. Global eradication efforts have significantly reduced worldwide prevalence, but complete elimination has been hampered by limitations of current anti-filarial drugs and the lack of a vaccine. The goal of this study was to evaluate B. malayi intestinal UDP-glucuronosyltransferase (Bm-UGT) as a potential therapeutic target. To evaluate whether Bm-UGT is essential for adult filarial worms, we inhibited its expression using siRNA. This resulted in a 75% knockdown of Bm-ugt mRNA for 6 days and almost complete suppression of detectable Bm-UGT by immunoblot. Reduction in Bm-UGT expression resulted in decreased worm motility for 6 days, 70% reduction in microfilaria release from adult worms, and significant reduction in adult worm metabolism as detected by MTT assays. Because prior allergic-sensitization to a filarial antigen would be a contraindication for its use as a vaccine candidate, we tested plasma from infected and endemic normal populations for Bm-UGT-specific IgE using a luciferase immunoprecipitation assay. All samples (n = 35) tested negative. We then tested two commercially available medicines known to be broad inhibitors of UGTs, sulfinpyrazone and probenecid, for in vitro activity against B. malayi. There were marked macrofilaricidal effects at concentrations achievable in humans and very little effect on microfilariae. In addition, we observed that probenecid and sulfinpyrazone exhibit a synergistic macrofilaricidal effect when used in combination with albendazole. The results of this study demonstrate that Bm-UGT is an essential protein for adult worm survival. Lack of prior IgE sensitization in infected and endemic populations suggest it may be a feasible vaccine candidate. The finding that sulfinpyrazone and probenecid have in vitro effects against adult B. malayi worms suggests that these medications have promise as potential macrofilaricides in humans.


Assuntos
Brugia Malayi/efeitos dos fármacos , Brugia Malayi/enzimologia , Glucuronosiltransferase/metabolismo , Albendazol/farmacologia , Animais , Antígenos de Helmintos/sangue , Brugia Malayi/imunologia , Brugia Malayi/metabolismo , Quimioterapia Combinada , Filariose Linfática/tratamento farmacológico , Filariose Linfática/prevenção & controle , Feminino , Filaricidas/farmacologia , Glucuronosiltransferase/antagonistas & inibidores , Glucuronosiltransferase/genética , Humanos , Imunoglobulina E/sangue , Intestinos/enzimologia , Microfilárias/efeitos dos fármacos , Movimento , Probenecid/farmacologia , RNA Interferente Pequeno , Sulfimpirazona/farmacologia
6.
Acta Trop ; 199: 105121, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31400299

RESUMO

Lymphatic filariasis (LF) has been known in Egypt since ancient times. By 1930s it was recognized to be a major public health problem in the Nile Delta, and to be caused by Wuchereria bancrofti and transmitted by Culex pipiens. Remarkably, as a result of widespread DEC treatment and intensive vector control by the Ministry of Health and Population (MoHP), the infection rate of LF declined in the 1960s. However, relaxation of these efforts resulted in resurgence of filariasis in the 1980s and 1990s. In 2000, Egypt was among the first countries to join the WHO global efforts to eliminate LF as a public health problem by initiating a national LF elimination programme (NLFEP). This article reviews the history of LF control activities and summarizes the NLFEP extensive interventions to eliminate LF in Egypt. Based on MoHP data, mass drug administration (MDA) with DEC and ALB was started in 2000 in 161 implementation units (IUs). Additional IUs were included in subsequent MDA rounds, with the last IU included in 2007. MDA stopping surveys were conducted based on WHO guidelines (2005; 2011). Information about the presence of those suffering from lymphoedema/elephantiasis and hydrocele patients was collected, and care provided to those needing care in five rural health units (RHU) by primary health care system providers who were given training on LF morbidity management and disability prevention (MMDP). The NLFEP made excellent progress due to strong collaboration between different ministries, through intensive training and supervision, and the use of advocacy for mobilization of endemic communities. The epidemiological coverage for all MDA rounds was effectively ≥80%. Antigenemia levels found in schoolchildren during transmission assessment surveys (TAS) in 166 IUs approximately 10 years after stopping MDA was 0%. In 2017, TAS conducted in additional 29 IUs indicated 0.1% antigenemia and 0% microfilaremia. In 2015, the registration of chronic LF patients was updated to 1472 lymphoedema and 18 hydrocele patients. Lymphoedema patients were trained on self-management, and hydrocele patients were referred to local General Hospitals for surgery. Thus, after over a decade of sustained effort, Egypt met the WHO criteria for successful elimination of LF as a public health problem. In December 2017, WHO validated Egypt as the first country in the Eastern Mediterranean Region to successfully achieve elimination.


Assuntos
Culex/parasitologia , Filariose Linfática/prevenção & controle , Filaricidas/administração & dosagem , Mosquitos Vetores/parasitologia , Wuchereria bancrofti , Animais , Criança , Egito/epidemiologia , Filariose Linfática/epidemiologia , Filariose Linfática/transmissão , Filaricidas/farmacologia , Filaricidas/uso terapêutico , Humanos , Masculino , Administração Massiva de Medicamentos , Saúde Pública , Saúde da População Rural , Inquéritos e Questionários , Wuchereria bancrofti/efeitos dos fármacos
7.
PLoS Negl Trop Dis ; 13(8): e0007115, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31398203

RESUMO

BACKGROUND: Ghana started its national programme to eliminate lymphatic filariasis (LF) in 2000, with mass drug administration (MDA) with ivermectin and albendazole as main strategy. We review the progress towards elimination that was made by 2016 for all endemic districts of Ghana and analyze microfilaria (mf) prevalence from sentinel and spot-check sites in endemic districts. METHODS: We reviewed district level data on the history of MDA and outcomes of transmission assessment surveys (TAS). We further collated and analyzed mf prevalence data from sentinel and spot-check sites. RESULTS: MDA was initiated in 2001-2006 in all 98 endemic districts; by the end of 2016, 81 had stopped MDA after passing TAS and after an average of 11 rounds of treatment (range 8-14 rounds). The median reported coverage for the communities was 77-80%. Mf prevalence survey data were available for 430 communities from 78/98 endemic districts. Baseline mf prevalence data were available for 53 communities, with an average mf prevalence of 8.7% (0-45.7%). Repeated measurements were available for 78 communities, showing a steep decrease in mean mf prevalence in the first few years of MDA, followed by a gradual further decline. In the 2013 and 2014 surveys, 7 and 10 communities respectively were identified with mf prevalence still above 1% (maximum 5.6%). Fifteen of the communities above threshold are all within districts where MDA was still ongoing by 2016. CONCLUSIONS: The MDA programme of the Ghana Health Services has reduced mf prevalence in sentinel sites below the 1% threshold in 81/98 endemic districts in Ghana, yet 15 communities within 13 districts (MDA ongoing by 2016) had higher prevalence than this threshold during the surveys in 2013 and 2014. These districts may need to intensify interventions to achieve the WHO 2020 target.


Assuntos
Erradicação de Doenças/métodos , Filariose Linfática/tratamento farmacológico , Filariose Linfática/epidemiologia , Albendazol/uso terapêutico , Animais , Criança , Pré-Escolar , Filariose Linfática/diagnóstico , Filariose Linfática/prevenção & controle , Doenças Endêmicas , Feminino , Gana/epidemiologia , Pesquisa sobre Serviços de Saúde , Humanos , Ivermectina/uso terapêutico , Masculino , Administração Massiva de Medicamentos/métodos , Microfilárias/patogenicidade , Prevalência , Inquéritos e Questionários , Organização Mundial da Saúde
8.
Infect Dis Poverty ; 8(1): 66, 2019 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-31387644

RESUMO

BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in response to the call proposed at the 50th World Health Assembly. The goal of the GPELF is to ensure that all the countries where the disease is endemic would have been transmission-free or would have entered post-intervention mass drug administration (MDA) surveillance by 2020. However, several countries are still not on track to discontinue MDA as planned. Thus, issues remain regarding the achievement of stated goals and how to effectively monitor the disease in the post-control and post-elimination phases. MAIN TEXT: China was once a lymphatic filariasis (LF) endemic country with heavy disease burden. There were three milestones in the LF control phase of China, including: the proposal that the major focus of the control strategy should be on infectious sources; the three regimens of diethylcarbamazine (DEC) administration according to LF endemic extent; and the establishment of the threshold for LF transmission interruption. It has been ten years since China entered the post-elimination stage (declaration of LF elimination in China was in 2007). Two schemes and a diagnostic criterion were issued to guide all levels of disease control and prevention workers that conduct LF surveillance, as well as those caring for chronic filariasis patients. Regular training courses are held to maintain LF control skills in grass-root institutions. The Notifiable Diseases Reporting System, which included LF in 2004, plays an important role in LF post-elimination surveillance. Until now, no resurgence of LF cases has been detected, except for LF residue foci being found in Fuchuan County of the Guangxi Zhuang Autonomous Region. To confirm that transmission is no longer achievable after a decade since the declaration of LF elimination in China, it is expected within the next two years a transmission assessment survey, conducted in previous LF-endemic areas. CONCLUSIONS: DEC-fortified salt can help accelerate the progress of GPELF before the sprite phase. Sophisticated diagnostic criteria, systematic surveillance regimes, the Direct Network Report system, and regular trainings can effectively prevent the recrudescence of LF during surveillance phases.


Assuntos
Erradicação de Doenças/estatística & dados numéricos , Filariose Linfática/prevenção & controle , Monitoramento Epidemiológico , Vigilância da População/métodos , China , Dietilcarbamazina/uso terapêutico , Filaricidas/uso terapêutico , Humanos
9.
PLoS Negl Trop Dis ; 13(7): e0007094, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31260444

RESUMO

BACKGROUND: Salt fortified with the drug, diethylcarbamazine (DEC), and introduced into a competitive market has the potential to overcome the obstacles associated with tablet-based Lymphatic Filariasis (LF) elimination programs. Questions remain, however, regarding the economic viability, production capacity, and effectiveness of this strategy as a sustainable means to bring about LF elimination in resource poor settings. METHODOLOGY AND PRINCIPAL FINDINGS: We evaluated the performance and effectiveness of a novel social enterprise-based approach developed and tested in Léogâne, Haiti, as a strategy to sustainably and cost-efficiently distribute DEC-medicated salt into a competitive market at quantities sufficient to bring about the elimination of LF. We undertook a cost-revenue analysis to evaluate the production capability and financial feasibility of the developed DEC salt social enterprise, and a modeling study centered on applying a dynamic mathematical model localized to reflect local LF transmission dynamics to evaluate the cost-effectiveness of using this intervention versus standard annual Mass Drug Administration (MDA) for eliminating LF in Léogâne. We show that the salt enterprise because of its mixed product business strategy may have already reached the production capacity for delivering sufficient quantities of edible DEC-medicated salt to bring about LF transmission in the Léogâne study setting. Due to increasing revenues obtained from the sale of DEC salt over time, expansion of its delivery in the population, and greater cumulative impact on the survival of worms leading to shorter timelines to extinction, this strategy could also represent a significantly more cost-effective option than annual DEC tablet-based MDA for accomplishing LF elimination. SIGNIFICANCE: A social enterprise approach can offer an innovative market-based strategy by which edible salt fortified with DEC could be distributed to communities both on a financially sustainable basis and at sufficient quantity to eliminate LF. Deployment of similarly fashioned intervention strategies would improve current efforts to successfully accomplish the goal of LF elimination, particularly in difficult-to-control settings.


Assuntos
Dietilcarbamazina/economia , Erradicação de Doenças/economia , Filariose Linfática/tratamento farmacológico , Filaricidas/economia , Medicina Social/economia , Cloreto de Sódio na Dieta/administração & dosagem , Administração Oral , Análise Custo-Benefício , Dietilcarbamazina/administração & dosagem , Erradicação de Doenças/métodos , Filariose Linfática/prevenção & controle , Filaricidas/administração & dosagem , Haiti , Recursos em Saúde/economia , Humanos , Administração Massiva de Medicamentos , Modelos Teóricos , Doenças Negligenciadas/tratamento farmacológico , Medicina Social/métodos , Cloreto de Sódio na Dieta/economia
10.
PLoS Negl Trop Dis ; 13(7): e0007541, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31314753

RESUMO

BACKGROUND: The World Health Organization (WHO) currently recommends height or age-based dosing as alternatives to weight-based dosing for mass drug administration lymphatic filariasis (LF) elimination programs. The goals of our study were to compare these alternative dosing strategies to weight-based dosing and to develop and evaluate new height-based dosing pole scenarios. METHODOLOGY/PRINCIPAL FINDINGS: Age, height and weight data were collected from >26,000 individuals in five countries during a cluster randomized LF clinical trial. Weight-based dosing for diethylcarbamazine (DEC; 6 mg/kg) and ivermectin (IVM; 200 ug/kg) with tablet numbers derived from a table of weight intervals was treated as the "gold standard" for this study. Following WHO recommended age-based dosing of DEC and height-based dosing of IVM would have resulted in 32% and 27% of individuals receiving treatment doses below those recommended by weight-based dosing for DEC and IVM, respectively. Underdosing would have been especially common in adult males, who tend to have the highest LF prevalence in many endemic areas. We used a 3-step modeling approach to develop and evaluate new dosing pole cutoffs. First, we analyzed the clinical trial data using quantile regression to predict weight from height. We then used weight predictions to develop new dosing pole cutoff values. Finally, we compared different dosing pole cutoffs and age and height-based WHO dosing recommendations to weight-based dosing. We considered hundreds of scenarios including country- and sex-specific dosing poles. A simple dosing pole with a 6-tablet maximum for both DEC and IVM reduced the underdosing rate by 30% and 21%, respectively, and was nearly as effective as more complex pole combinations for reducing underdosing. CONCLUSIONS/SIGNIFICANCE: Using a novel modeling approach, we developed a simple dosing pole that would markedly reduce underdosing for DEC and IVM in MDA programs compared to current WHO recommended height or age-based dosing.


Assuntos
Cálculos da Dosagem de Medicamento , Filariose Linfática/prevenção & controle , Filaricidas/administração & dosagem , Administração Massiva de Medicamentos/métodos , Razão Cintura-Estatura , Adolescente , Adulto , Estatura , Peso Corporal , Criança , Estudos de Coortes , Dietilcarbamazina/administração & dosagem , Feminino , Saúde Global , Humanos , Ivermectina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Prevalência , Análise de Regressão , Adulto Jovem
11.
PLoS Negl Trop Dis ; 13(7): e0007542, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31306409

RESUMO

BACKGROUND: The Bangladesh Lymphatic Filariasis (LF) Elimination Programme has made significant progress in interrupting transmission through mass drug administration (MDA) and has now focussed its efforts on scaling up managing morbidity and preventing disability (MMDP) activities to deliver the minimum package of care to people affected by LF clinical conditions. This paper highlights the Bangladesh LF Programme's success in conducting a large-scale cross-sectional survey to determine the number of people affected by lymphoedema and hydrocoele, which enabled clinical risk maps to be developed for targeted interventions across the 34 endemic districts (19 high endemic; 15 low endemic). METHODOLOGY/PRINCIPAL FINDINGS: In the 19 high endemic districts, 8,145 community clinic staff were trained to identify and report patients in their catchment area. In the 15 low endemic districts, a team of 10 trained field assistants conducted active case finding with cases reported via a SMS mHealth tool. Disease burden and prevalence maps were developed, with morbidity hotspots identified at sub-district level based on a combination of the highest prevalence rates per 100,000 and case-density rates per square kilometre (km2). The relationship between morbidity and baseline microfilaria (mf) prevalence was also examined. In total 43,678 cases were identified in the 19 high endemic districts; 30,616 limb lymphoedema (70.1%; female 55.3%), 12,824 hydrocoele (29.4%), and 238 breast/female genital swelling (0.5%). Rangpur Division reported the highest cases numbers and prevalence of lymphoedema (26,781 cases, 195 per 100,000) and hydrocoele (11661 cases, 169.6 per 100,000), with lymphoedema predominately affecting females (n = 21,652). Rangpur and Lalmonirhat Districts reported the highest case numbers (n = 11,199), and prevalence (569 per 100,000) respectively, with five overlapping lymphoedema and hydrocoele sub-district hotspots. In the 15 low endemic districts, 732 cases were identified; 661 lymphoedema (90.2%; female 39.6%), 56 hydrocoele (7.8%), and 15 both conditions (2.0%). Spearman's correlation analysis found morbidity and mf prevalence significantly positively correlated (r = 0.904; p<0.01). CONCLUSIONS/SIGNIFICANCE: The Bangladesh LF Programme has developed one of the largest, most comprehensive country databases on LF clinical conditions in the world. It provides an essential database for health workers to identify local morbidity hotspots, deliver the minimum package of care, and address the dossier elimination requirements.


Assuntos
Sistemas de Gerenciamento de Base de Dados , Filariose Linfática/epidemiologia , Filariose Linfática/prevenção & controle , Filariose Linfática/terapia , Objetivos , Animais , Bangladesh/epidemiologia , Controle de Doenças Transmissíveis , Estudos Transversais , Análise de Dados , Doenças Endêmicas , Feminino , Pessoal de Saúde/educação , Humanos , Linfedema/epidemiologia , Masculino , Administração Massiva de Medicamentos , Microfilárias , Morbidade , Prevalência , Telemedicina/métodos , Hidrocele Testicular/epidemiologia
12.
PLoS Negl Trop Dis ; 13(7): e0007337, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31276494

RESUMO

Lymphatic filariasis (LF) elimination as a public health problem requires the interruption of transmission by administration of preventive mass drug administration (MDA) to the eligible population living in endemic districts. Suboptimal MDA coverage leads to persistent parasite transmission with consequential infection, disease and disability, and the need for continuing MDA rounds, requiring considerable investment. Routine coverage reports must be verified in each MDA implementation unit (IU) due to incorrect denominators and numerators used to calculate coverage estimates with administrative data. IU are usually the health districts. Coverage is verified so IU teams can evaluate their outreach and take appropriate action to improve performance. Mozambique and the Democratic Republic of Congo (DRC) have conducted MDA campaigns for LF since 2009 and 2014, respectively. To verify district reports and assess the declared achievement using administrative data of the minimum 80% coverage of eligible people (or 65% of the total population), both countries conducted rapid probability surveys using Lot Quality Assurance Sampling (LQAS)(n = 1102) in 2015 and 2016 in 58 IU in 49 districts. The surveys identified IU with suboptimal coverage, reasons residents did not take the medication, place where the medication was received, information sources, and knowledge about diseases prevented by the MDA. LQAS identified four inadequately covered IU triggering district team performance reviews with provincial and national teams and district retreatment. Provincial estimates using probability samples (weighted by populations sizes) were 10 and 17 percentage points lower than reported coverage in DRC and Mozambique. The surveys identified: absence from home during annual MDA rounds as the main reason for low performance and provided valuable information about pre-campaign and campaign activities resulting in improved strategies and continued progress towards elimination of LF and co-endemic Neglected Tropical Diseases.


Assuntos
Erradicação de Doenças/normas , Filariose Linfática/prevenção & controle , Filaricidas/administração & dosagem , Administração Massiva de Medicamentos/normas , Garantia da Qualidade dos Cuidados de Saúde , Animais , República Democrática do Congo/epidemiologia , Erradicação de Doenças/métodos , Doenças Endêmicas/prevenção & controle , Humanos , Moçambique/epidemiologia , Doenças Negligenciadas/epidemiologia , Doenças Negligenciadas/prevenção & controle , Saúde Pública , Wuchereria bancrofti/efeitos dos fármacos
13.
Parasitol Res ; 118(6): 1849-1863, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31055672

RESUMO

In the search for immunoprophylactics for the control of human lymphatic filariasis, we recently identified troponin 1 (Tn1) in Brugia malayi adult worms. The present study reports the cloning and expression of the B. malayi Tn1 (Tn1bm), its immunoprophylactic efficacy against B. malayi infection, and the immunological responses of the host. The Tn1bm gene was cloned (Acc no. JF912447) and expressed, and the purified recombinant Tn1bm (rTn1bm) presented a single ~ 27 kDa band. Parasite load in rTn1bm-immunized BALB/c mice challenged with B. malayi infective larvae (L3) was assessed. In rTn1bm-immunized animals, IgE, IgG, and IgG subclasses in the serum, cell proliferative response, Th1 and Th2 cytokine secretion (from splenocytes), and NO release (from peritoneal macrophages) were determined. Antibody-dependent cell-mediated cytotoxicity (ADCC) to L3 was assayed using rTn1bm-immune serum. The innate immune response markers MHC class-I, MHC class-II, TLR2, TLR4, and TLR6 expression in peritoneal macrophages and CD3+, CD4+, CD8+, and CD19+ in the splenocyte population were determined in Tn1bm-exposed cells from naïve mice. rTn1bm-immunized L3-challenged animals showed a 60% reduction in parasite burden. Immunization upregulated cellular proliferation, cytokine (IFN-γ, TNF-α, IL-1ß, IL-4, IL-6, and IL-10) secretion, NO release, and antigen-specific IgG, IgG1, and IgG2b antibody levels. rTn1bm-immune serum killed > 65% of L3 in the ADCC assay. Increased MHC class-II, TLR2, and TLR6 expression and the relative CD4+ and CD19+ cell populations of naïve animal cells indicated the ability of rTn1bm to mobilize innate immune responses. This is the first report of the immunoprophylactic potential of rTn1bm against B. malayi.


Assuntos
Anticorpos Antiprotozoários/sangue , Brugia Malayi/imunologia , Filariose Linfática/imunologia , Filariose Linfática/prevenção & controle , Troponina I/genética , Troponina I/imunologia , Animais , Citotoxicidade Celular Dependente de Anticorpos/imunologia , Brugia Malayi/genética , Clonagem Molecular , Citocinas/sangue , Citocinas/imunologia , DNA Complementar/metabolismo , Humanos , Imunoglobulina E/sangue , Imunoglobulina G/sangue , Macrófagos Peritoneais/imunologia , Camundongos , Camundongos Endogâmicos BALB C , Carga Parasitária , Células Th1/imunologia , Células Th2/imunologia , Vacinação
14.
Infect Dis Poverty ; 8(1): 38, 2019 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-31130143

RESUMO

BACKGROUND: Lymphatic filariasis is endemic in nine of the eleven Member States of the World Health Organization South East Asia Region. This article describes the intensive interventions with the National Programme for Elimination of Lymphatic Filariasis in Thailand since its launch in 2001 till the validation of its elimination in 2017. METHODS: A baseline epidemiological survey was initiated in 2001 to identify both brugian and bancroftian filarial areas and delineate its endemicity. Mass drug administration (MDA) with diethylcarbamazine citrate (DEC) and albendazole (ALB) was implemented in a total of 357 implementation units (IUs) in 11 lymphatic filariasis (LF) endemic provinces. The implementing unit (IU) was a sub-village. Stop-MDA surveys were conducted in 2006 in the 11 LF endemic provinces among population over 6 years of age and children of ≤6 years using immunochromatographic test (ICT) for Wuchereria bancrofti antigen and microfilariae (mf) detection for Brugia malayi. In Narathiwat province, Stop-MDA surveys were done in 2011 using ELISA. Transmission assessment surveys (TAS) were conducted in 2012-2013, 2015 and 2016-2017 among school students in the 6-7-year age-group. Surveillance of migrant populations through the national migrant health checkup were intensified in seven provinces over 2002-2017 for LF antigenaemia using ICT test cards. In four B. malayi endemic provinces, annual surveys to detect LF reservoir in domestic cats commenced in 1994. A 2001 survey of the chronic disease burden for LF established a register of the cumulative number of people with lymphedema/elephantiasis. RESULTS: A total of five rounds of MDA annually were implemented over 2002-2006 in all IUs. Additional annual rounds of MDA were required in 87 IUs of Narathiwat province from 2007 to 2011 due to persistent infection. The annual national drug coverage with MDA over 2002-2012 was in the range of 68.0 to 95.4%. Stop-MDA surveys in 2006 in the 11 LF endemic provinces found nine mf positive cases in seven IUs in Narathiwat province with the highest prevalence of 0.8% (range: 0.1-0.8%). In Narathiwat TAS-1, TAS-2 and TAS-3 detected below transmission threshold rates for B. malayi mf among antibody positive children (0.3, 0.2 and 0.7% respectively). Contact tracing both all mf cases in all three TAS yielded no positive cases. Through the migrant health checkup, a total of 23 477 persons were tested, showing a positive rate of 0.7% (range: 0.1-2.7%) over years 2002-2017. In Narathiwat province, annual ivermectin treatment among cats commenced in 2003 resulting in a decline of mf prevalence among cats from 8.0% in 1995 to 0.8% in 2015. As of April 2017, a total of 99 lymphoedema/elephantiasis patients were registered and followed-up under 34 health facilities. CONCLUSIONS: Thailand over the years 2002 to 2011 conducted extensive MDA with high coverage rates. Through periodic and regular monitoring surveys it delineated LF transmission areas at sub-village level and demonstrated through its evaluation surveys - the Stop-MDA surveys and TAS, below transmission threshold rates that enabled its validation of LF elimination. In September 2017, World Health Organization acknowledged the Ministry of Health Thailand had eliminated lymphatic filariasis as a public health problem.


Assuntos
Albendazol/uso terapêutico , Anti-Helmínticos/uso terapêutico , Dietilcarbamazina/uso terapêutico , Filariose Linfática/tratamento farmacológico , Filariose Linfática/prevenção & controle , Administração Massiva de Medicamentos/métodos , Adolescente , Adulto , Animais , Anticorpos Anti-Helmínticos , Antígenos de Helmintos , Doenças do Gato/parasitologia , Gatos , Criança , Pré-Escolar , Erradicação de Doenças/métodos , Reservatórios de Doenças/parasitologia , Uso de Medicamentos , Doenças Endêmicas , Feminino , Filaricidas/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Prática de Saúde Pública , Inquéritos e Questionários , Tailândia , Migrantes , Wuchereria bancrofti/efeitos dos fármacos , Wuchereria bancrofti/imunologia , Adulto Jovem
15.
Am J Trop Med Hyg ; 101(1): 271-278, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31115301

RESUMO

The transmission assessment survey (TAS) is recommended to determine whether cessation of mass drug administration (MDA) for lymphatic filariasis (LF) is warranted. Ministries of health typically implement TASs in evaluation units (EUs) that have had more than five rounds of annual MDA. Under TAS guidelines, sample size calculations determine a decision value: if the number of individuals testing positive exceeds this threshold, then MDA continues in the EU. The objective of this study was to determine whether fine scale geospatial covariates could be used to identify predictors of TAS failure. We geo-referenced 746 TAS EUs, of which 65 failed and extracted geospatial covariates using R to estimate odds of failure. We implemented stepwise backward elimination to select covariates for inclusion in a logistic regression to estimate the odds of TAS failure. Covariates included environmental predictors (aridity, distance to fresh water, elevation, and enhanced vegetation index), cumulative rounds of MDA, measures of urbanicity and access, LF species, and baseline prevalence. Presence of Brugia was significantly associated with TAS failure (odds ratio [OR]: 4.79, 95% CI: 2.52-9.07), as was population density (OR: 2.91, 95% CI: 1.06-7.98). The presence of nighttime lights was highly protective against failure (OR: 0.22, 95% CI: 0.10-0.50), as was an increase in elevation (OR: 0.36, 95% CI: 0.18-0.732). This work identifies predictors associated with TAS failure at the EU areal level, given the data presently available, and also identifies the need for more granular data to conduct a more robust assessment of these predictors.


Assuntos
Transmissão de Doença Infecciosa/prevenção & controle , Filariose Linfática/prevenção & controle , Filariose Linfática/transmissão , Monitoramento Epidemiológico , Coleta de Dados , Ecossistema , Filariose Linfática/tratamento farmacológico , Filaricidas/administração & dosagem , Filaricidas/uso terapêutico , Humanos , Administração Massiva de Medicamentos/economia , Fatores Socioeconômicos , Organização Mundial da Saúde
16.
PLoS Negl Trop Dis ; 13(3): e0007267, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30908495

RESUMO

INTRODUCTION: The Global Strategy to Eliminate Lymphatic Filiariasis (GFELF) through Mass Drug Administration (MDA) has been implemented in Ghana since the year 2000 and transmission has been interrupted in 76 of 98 endemic districts. To improve the MDA in the remaining districts with microfilaria (MF) prevalence above the 1% threshold for the interruption of transmission, there is a need to identify and implement appropriate quality improvement (QI) strategies. This paper describes the use of intervention mapping to select QI strategies to improve an existing evidence-based MDA program in Northern Ghana. METHODS: Due to the complexities associated with implementing evidence-based programs (EBP) such as the lymphatic filariasis MDA and variability in the context, an initial assessment to identify implementation bottlenecks associated with the quality of implementation of lymphatic filariasis MDA in the Bole District of Ghana was conducted using a mixed methods approach. Based on the findings of the initial assessment, a context specific QI strategy was designed and operationalized using intervention mapping strategy in terms of seven domains: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. RESULTS: The initial needs assessment shows that the persistent transmission of lymphatic filariasis in the Bole District is characterized by high levels of refusal to ingest the drug, high levels of reported adverse drug reactions, low MDA coverage at community level, poor adherence to the MDA protocol and non-participants' responsiveness. CONCLUSION: This study has shown that it is feasible to develop a context specific QI strategy for an existing evidence-based intervention based on an initial needs assessment through stakeholder participation using the IM approach. However, working (towards) QI requires more time than is usually available in public health service. Sufficient theoretical knowledge of implementation research and experience with technical IM experts must be available.


Assuntos
Filariose Linfática/prevenção & controle , Administração Massiva de Medicamentos , Melhoria de Qualidade , Adulto , Animais , Erradicação de Doenças , Filariose Linfática/tratamento farmacológico , Filariose Linfática/epidemiologia , Filariose Linfática/parasitologia , Feminino , Gana/epidemiologia , Humanos , Masculino , Microfilárias , Pessoa de Meia-Idade , Prevalência
17.
Adv Parasitol ; 103: 117-149, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30878056

RESUMO

STUDY OBJECTIVES: This article presents findings from a rapid review of qualitative research conducted to inform decision makers about community and drug distributor perceptions and experiences of mass drug administration campaigns for the elimination of lymphatic filariasis. We focused on questions related to acceptability of the mass drug administration campaigns within these groups and their thoughts around the feasibility of planning and carrying out the campaigns. METHODS: We carried out a systematic search in five databases to identify potential studies. We included studies that focused on community members and drug distributors and used qualitative methods for data collection and analysis. We conducted a thematic framework analysis using the Supporting the Use of Research Evidence framework. Due to time constraints, one author conducted the screening, extraction and data analysis. FINDINGS: Studies found that communities lack knowledge and information about lymphatic filariasis and the mass drug administration campaigns and that this can have an impact on how many community members choose to take medication. Health workers often had a good understanding that lymphatic filariasis was a problem in their setting, of its cause and mode of transmission and that hydrocele and elephantiasis had the same cause. However, this knowledge was not as prevalent amongst community drug distributors who often had misconceptions surrounding the topic. Furthermore, studies found that the length, timing, level of community and health system involvement, access to care for side effects, inadequate numbers of drug distributors and supervisors and motivation of drug distributors influenced participation in mass drug administration campaigns. Finally, the inadequate training of drug distributors could influence community trust in the mass drug administration program and the drug distributor themselves if there was a perception that the person was uninformed or not trained to carry out their tasks.


Assuntos
Erradicação de Doenças , Filariose Linfática/prevenção & controle , Administração Massiva de Medicamentos/psicologia , Voluntários/psicologia , Assistência à Saúde , Filariose Linfática/tratamento farmacológico , Humanos , Administração Massiva de Medicamentos/estatística & dados numéricos , Pesquisa
18.
Infect Dis Poverty ; 8(1): 9, 2019 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-30717788

RESUMO

BACKGROUND: Mass drug administration (MDA) programmes for the control of lymphatic filariasis in Ghana, have been ongoing in some endemic districts for 16 years. The current study aimed to assess factors that govern the success of MDA programmes for breaking transmission of lymphatic filariasis in Ghana. METHODS: The study was undertaken in two "hotspot" districts (Ahanta West and Kassena Nankana West) and two control districts (Mpohor and Bongo) in Ghana. Mosquitoes were collected and identified using morphological and molecular tools. A proportion of the cibarial armatures of each species was examined. Dissections were performed on Anopheles gambiae for filarial worm detection. A questionnaire was administered to obtain information on MDA compliance and vector control activities. Data were compared between districts to determine factors that might explain persistent transmission of lymphatic filariasis. RESULTS: High numbers of mosquitoes were sampled in Ahanta West district compared to Mpohor district (F = 16.09, P = 0.002). There was no significant difference between the numbers of mosquitoes collected in Kassena Nankana West and Bongo districts (F = 2.16, P = 0.185). Mansonia species were predominant in Ahanta West district. An. coluzzii mosquitoes were prevalent in all districts. An. melas with infected and infective filarial worms was found only in Ahanta West district. No differences were found in cibarial teeth numbers and shape for mosquito species in the surveyed districts. Reported MDA coverage was high in all districts. The average use of bednet and indoor residual spraying was 82.4 and 66.2%, respectively. There was high compliance in the five preceding MDA rounds in Ahanta West and Kassena Nankana West districts, both considered hotspots of lymphatic filariasis transmission. CONCLUSIONS: The study on persistent transmission of lymphatic filariasis in the two areas in Ghana present information that shows the importance of local understanding of factors affecting control and elimination of lymphatic filariasis. Unlike Kassena Nankana West district where transmission dynamics could be explained by initial infection prevalence and low vector densities, ongoing lymphatic filariasis transmission in Ahanta West district might be explained by high biting rates of An. gambiae and initial infection prevalence, coupled with high densities of An. melas and Mansonia vector species that have low or no teeth and exhibiting limitation.


Assuntos
Anopheles/parasitologia , Filariose Linfática/prevenção & controle , Filariose Linfática/transmissão , Filaricidas/uso terapêutico , Administração Massiva de Medicamentos/estatística & dados numéricos , Mosquitos Vetores/parasitologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Filariose Linfática/epidemiologia , Filariose Linfática/parasitologia , Feminino , Gana/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Adulto Jovem
19.
Parasit Vectors ; 12(1): 14, 2019 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-30621774

RESUMO

BACKGROUND: Loiasis, an often-neglected tropical disease, is a threat to the success of lymphatic filariasis and onchocerciasis elimination programmes in rainforest areas of the central and western Africa. Its control and even its elimination might be possible through the use of a safe macrofilaricide, a prophylactic drug, or perhaps a vaccine. This present study evaluated the effect of flubendazole (FLBZ) on the development of Loa loa L3 in vitro and in vivo. METHODS: Infective stages of L. loa were isolated and co-cultured in Dulbecco's Modified Eagle's Medium in the presence of monkey kidney epithelial cells (LLC-MK2) feeder cells. FLBZ and its principal metabolites, reduced flubendazole (RFLBZ) and hydrolyzed flubendazole (HFLBZ), were screened in vitro at concentrations 0.05, 0.1, 0.5, 1 and 10 µg/ml. The viability of the parasites was assessed microscopically daily for 15 days. For in vivo study, a total of 48 CcR3 KO mice were infected subcutaneously with 200 L. loa L3 and treated with 10 mg/kg FLBZ once daily for 5 consecutive days. Twenty-four animals were used as control and received L3 and vehicle. They were dissected at 5, 10, 15 and 20 days post-treatment for worm recovery. RESULTS: The motility of L3 larvae in vitro was reduced from the second day of incubation with drugs at in vivo plasma concentration levels, with a strong correlation found between reduced motility and increased drug concentration (Spearman's rho = -0.9, P < 0.0001). Except for HFLBZ (0.05 µg/ml and 0.01 µg/ml), all concentrations of FLBZ, HFLBZ and RFLBZ interrupted the moulting of L. loa infective larvae to L4. In vivo, regardless of the experimental group, there was a decrease in parasite recovery with time. However, at each time point this reduction was more pronounced in the group of animals treated with FLBZ compared to equivalent control. Parasites were recovered from the flubendazole-treated groups only on day 5 post-inoculation at an average rate of 2.1%, a value significantly lower (Mann-Whitney U-test, U = 28, P = 0.0156) than the average of 31.1% recovered from the control group. CONCLUSIONS: This study reveals the ability of flubendazole to inhibit the development of L. loa L3 both in vitro and in vivo, and in addition validates the importance of in vitro and animal models of L. loa as tools for the development of drugs against loiasis.


Assuntos
Filaricidas/farmacologia , Estágios do Ciclo de Vida/efeitos dos fármacos , Loa/efeitos dos fármacos , Loíase/parasitologia , Mebendazol/análogos & derivados , África Central/epidemiologia , África Ocidental/epidemiologia , Animais , Linhagem Celular , Filariose Linfática/epidemiologia , Filariose Linfática/prevenção & controle , Filaricidas/química , Filaricidas/uso terapêutico , Hidrólise , Larva/efeitos dos fármacos , Loa/crescimento & desenvolvimento , Loíase/tratamento farmacológico , Mebendazol/química , Mebendazol/farmacologia , Mebendazol/uso terapêutico , Camundongos , Camundongos Endogâmicos BALB C , Camundongos Knockout , Movimento/efeitos dos fármacos , Oncocercose/parasitologia , Oncocercose/prevenção & controle , Oxirredução
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