Elimination by 2027? India’s Final Push Against Lymphatic Filariasis

“Jo bhi kamaya, iss bimari pe gawaya (Whatever I earned was spent on treatment),” Kumar says defeatedly, now resigned to his ‘fate’ of living with a condition he never fully seems to understand.

"LF is often seen as a disease of adulthood, but it actually begins in childhood for many, affecting the lymphatic system--our body's primary defense system," says Suma Krishnasastry, emeritus professor of medicine and director of the World Health Organization’s (WHO’s) Filariasis Research Centre unit in India. There is currently no definitive treatment or drug to effectively reduce or manage the recurrent lymphoedema (a swelling of the limbs, arms, breasts, or genitalia) in patients, she explains.

The country’s Accelerated Plan for LF Elimination, designed by the National Vector Borne Disease Control Programme (NVBDCP) in 2018, opens by acknowledging LF as a “serious public health problem in India” and as a major cause of poverty in the affected communities, in addition to inflicting stigma, mental suffering, social deprivation and economic loss.

India contributes the world’s highest LF burden, at nearly 40%, the Union health ministry told parliament in February 2020. As per latest WHO data, India is home to 404 million people of the 657 million population globally threatened by LF. To combat this, the Indian government launched the first nationwide mass drug administration (MDA) programme in 2004, targeting endemic areas while also introducing home-based morbidity management for patients. The 2018 Plan held the country’s population growth responsible for the massive increase in endemic population size and number of infected people, combined with lack of transmission control operations in several rural and urban areas.

This is the second in a two-part series on India’s fight against this neglected tropical disease. You can read the first part, on the suffering of women patients in Uttar Pradesh and how they are helping combat a long-standing public health crisis, here.

LF Elimination by 2027: An ambitious target

In 2023, India’s then Union Minister for Health and Family Welfare, Mansukh Mandaviya claimed, “For India, LF is not a neglected disease, as may be the case in some other countries, but a priority disease for elimination in a time-bound manner.” His ministry committed to eliminating LF by 2027, through a nationwide ‘Sarva Dawa Sevan’ or MDA campaign, three years ahead of the global target set for 2030 by the WHO. At this launch, Roli Singh, Additional Secretary and Mission Director (National Health Mission) addressed, “...in spite of 10-15 MDA rounds in the past, LF elimination could not be achieved due to sub optimal coverage.”

The 2027 elimination goal follows a series of missed and extended deadlines, with the earlier target set for 2015, later extended to 2017. Globally, WHO's Program to Eliminate LF set 2020 as the initial target, but persistent challenges led to a revised timeline of 2030.

A group of lymphoedema patients from Odisha gather, each showing visible signs of the condition. Their days bear the harsh reality of living with a neglected tropical disease in India.

The second phase of the bi-annual nationwide MDA campaign was launched in August this year. It targeted 63 high-risk districts across six states: Bihar, Jharkhand, Karnataka, Odisha, Telangana and Uttar Pradesh. This included 38 triple-drug and 25 double-drug districts, covering a total of 771 blocks. As per a press release from the Union health ministry, in 2023, MDA campaigns reached 82% national coverage across 170 districts in 12 states and the first phase of the 2024 MDA rounds achieved 95% coverage rate in 96 districts across 11 states.

"Epidemiologically, at least 65% of the total population needs to receive preventive drugs for effective control. Even if the adult worms are killed, complications persist due to lack of a microfilaricidal or adulticidal drug,” Krishnasastry explained. She added that studies were currently ongoing to identify adulticidal drugs, crucial for two reasons: reducing microfilariae transmission and alleviating disease symptoms in patients.

According to WHO’s Weekly Epidemiological Record, of the total 425 million population requiring MDA in 2023 in South East Asia, 404 million were in India. Further, the country achieved 69.1% MDA coverage in 2023, compared to the 34.2% achieved in 2022. The Record observed, “Despite coordinated efforts, achieving effective coverage remains a challenge in several Indian states, requiring more than 2 rounds of IDA”. It noted the country had stopped MDA in 40% of its endemic districts, while MDA is still required in 198 Indian districts.

In August 2024, Pratprao Jadhav, Minister of State for Health and Family Welfare, announced that efforts will be made to develop a vaccine for LF, which currently has no definitive cure, and to ensure pucca houses for people living in mud houses to reduce their exposure to vectors.

Looking south: Successful models for LF elimination

A May 2023 article authored by researchers from the Directorate of Health Services, Kerala and the Directorate, NVBDCP examined Kerala’s model for LF elimination. Unlike the earlier national three-day MDA norm, Kerala extended its MDA campaign to run for three weeks.

During the entire three weeks, booths were kept open in all health institutions to provide health education and drug administration, with participation from private hospitals and medical colleges. The state’s strategy included gaining support of practitioners of Ayurveda and homoeopathy despite their initial resistance to endorse the MDA. Medical and nursing students were mobilised to help reach patients, staff, and visitors in medical colleges, along with special, targeted campaigns conducted in tribal areas and urban slums.

The study states that, “Duplication of drug consumption and double counting were avoided during reporting.” It additionally reports that MMDP clinics were established in 37 institutions across all 11 endemic districts, and today, a total of 84 MMDP clinics are operational in general hospitals, district hospitals, and taluk hospitals across Kerala.

“Implementation of MDA in 11 endemic districts of Kerala has led to a reduction in the average microfilaria rate from 0.8% in 2004 to 0.1% in 2014,” stated the study. By 2020, Kerala had successfully met its major targets, reducing the microfilaria rate below 1% in all endemic districts and scaling the outreach of MMDP activities. P.K. Srivastava, former joint director, NVBDCP and one of the authors of the study, credited it to the state’s literacy rate and a greater faith among people in Indian medicine. “They gave preventive drugs to popular figures and also involved the Kudumbashree workers of Kerala’s poverty eradication mission. The national programme runs by rule of thumb, although states are given flexibility to adapt the MDA guidelines to their own needs,” he stated.

While India contributes the highest LF burden in the South-East Asia region, Sri Lanka emerged as one of the first countries in the region as a successful case study in the fight against LF, achieving its elimination as a public health problem in 2016. The country’s national programme implemented five rounds of MDA from 2002 to 2006 across three endemic provinces, reaching 10.7 million people with a two-drug combination of diethylcarbamazine and albendazole. The microfilaria prevalence rates plummeted from 0.21% in 2001 before the mass chemotherapy, to 0.06% in 2016, in a display of comprehensive and community-focused campaigns.

A key strength of Sri Lanka’s Anti-Filariasis Campaign was its network of specialised filariasis clinics, providing free treatment and health education for patients with lymphoedema and elephantiasis. These clinics offered biweekly, weekly, or monthly sessions, depending on local needs, ensuring care access for thousands of patients. They supplied medications and bandages at no cost and referred complex cases for inpatient care when necessary.

A crucial aspect of their functioning was delivering up-to-date health education in the form of verbal advice, IEC material in native languages and demonstrations to clinic attendees and their caregivers on lymphoedema management. Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region, attributed Sri Lanka’s success to intensified mosquito control efforts, treatment of the infected population, disability prevention/control, strengthening surveillance and close monitoring of all elimination efforts.

India’s familiar challenges and the way ahead

India has over 23 million patients suffering with lifelong disability as a result of LF and it inflicts an annual economic loss of about $1 billion in India. As per the WHO, indirect losses due to diminished productivity act as a severe drain on local and national economies. Acute attacks are estimated to be responsible for losses of $60-85 million per year in India.

“Earlier, a budget for filariasis did not even exist. A single District Malaria Officer, who can be medical or non-medical staff, ends up handling entire districts with both rural and urban populations. Research studies were shut down or delayed because funds weren’t released on time. It goes beyond programme challenges--they're countrywide and behavioural challenges,” underlined Srivastava, formerly of the NVBDCP, who has worked on LF for over two decades. The 2018 Plan also acknowledged how past attempts to control LF had limited impact due to low commitment, scaling up challenges, operational issues and poor implementation.

“The drug administration coverage and compliance should remain sufficiently high to achieve the goals of elimination,” explained Kavita Singh, South Asia Director of Drugs for Neglected Diseases initiative (DNDi), a global non-profit organisation that develops treatments for neglected diseases. The lack of understanding among communities about the pressing need or reasons for drug consumption creates both distribution and consumption gaps. Singh emphasised what the data reveal--the success of the MDA programme at the primary healthcare level relies on both the beneficiaries’ adherence and the motivation of physicians to monitor and encourage frontline workers.

Srivastava attributes it to the disease’s perception--as there is no immediate mortality, there is no real fear until a patient reaches the acute stages. He recalls initially campaigning for the 'Neglected Tropical Disease' to be referred as a 'Priority Tropical Disease' to convey the requisite urgency. “Villagers still ask if the 'sarkari dawai' (filaria medicine) is the 'garam dawai' (sterilisation medicine)”. He illustrated how every attempt to earn the community’s trust could help improve coverage. “By 2004, we switched to strip packed tablets instead of loose tablets. When you’re about to reach the finish line, suddenly, everyone claims it’s because of them.”

As part of a branding attempt, a logo and tagline have been developed for the national Filaria Eradication Campaign. The tagline reads “Safe drug, assurance for better health”.

The major challenge also lies in diagnostics, said Krishnasastry. “We need better tools and R&D to detect microfilariae, including more rapid tests like the Quick Filariasis Antigen Test (QFAT) which is currently not being used in India, in addition to the Filariasis Test Strip (FTS). WHO supplies test kits based on each country's stipulated needs and MDA results, but supply and production issues can arise," she added. "As alternative diagnostics are being explored, they need to be affordable, scalable, and keep in mind the country's huge population," she said.

“The night blood surveys are expensive, time-consuming, and poorly accepted by the community and if done at the wrong time, can often have misleading results,” Singh of DNDi pointed out. Since filarial worms are nocturnally periodic, they only move in blood at nighttime and hence one needs to get their blood drawn at night. Singh suggested how the development of any tests for clinicians to identify and diagnose viable adult filarial worms could greatly support the advance and use of macrofilaricidal drugs.

For years, LF elimination faced neglect in the national public health agenda, with limited public figures for discussion and support, as per a study by the NVBDCP assessing the lessons learnt from the 2018 Plan. It cited how national decision-making was slow, hindered by “frequent leadership changes and delayed advisory committee meetings”. It observed, at the implementation level, delays in scheduling MDA rounds in endemic districts led to delays in drug inventory projections, development of district micro-plans, and training plans. Urban and rural population counts were often inaccurate, and family registers for health staff were unavailable.

“By 2027, we may achieve the elimination target and there’s no choice but to be optimistic,” says Srivastava, underlining a huge “work culture issue”--including gaps in administrative supervision, hiring and service delivery. “The night blood collection cannot be done at 6 p.m. instead of the scheduled 8.30 p.m. to midnight. The strengthening of capacity has to be systemic; start with paying the ASHA workers on time, otherwise the staff have no incentive to keep working.”

We have reached out via email to the NCVBDC Director’s Office, Union Health Ministry, and State Program Officer of Uttar Pradesh for comment on the implementation of national guidelines for LF elimination and the feasibility of achieving the 2027 target with the current rates of MDA compliance. In addition, a progress update has also been sought into any ongoing research for macrofilaricidal drugs, as well as on efforts to develop a vaccine for LF and simplified diagnostic methods for detecting microfilariae. We will update the story when we receive a response.

Series concluded. You can read the first part here. Reporting for this story was supported by the MSF-DNDi Grant on Neglected Tropical Diseases as part of the Without Borders Media Fellowship. The fellowship encourages independent, impartial and neutral reporting on health and humanitarian crises.