Filariasis Report

A FINAL REPORT ON EPIDEMIOLOGICAL SURVEILANCE OF LYMPHATIC FILARIASIS IN MAKWANPUR, CHITWAN, RUPENDEHI AND NAWALPARASI DISTRICTS OF NEPAL

Submitted by MAHENDRA MAHARJAN LECTURER CENTRAL DEPARTMENT OF ZOOLOGY (PARASITOLOGY) TRIBHUVAN UNIVERSITY KIRTIPUR KATHMANDU

Submitted to WHO Filariasis Elimination Program Epidemiology and Disease Control Division / HMG, Nepal

Submitted through CENTRAL DEPARTMENT OF ZOOLOGY (PARASITOLOGY) TRIBHUVAN UNIVERSITY KIRTIPUR KATHMANDU NEPAL

2005 1|Page

TEAM MEMBERS IMPLEMENTING THE PROJECT : Project Team members Principal investigator Mahendra Maharjan Central Department of Zoology Tribhuvan University Kirtipur

Co-Investigator Satish Chandra Jha Tri- Chandra Multiple Collage Kathmandu

Parasitologists Maheshwer Khanal Bhoj Bdr. Bhat Chhetri Ashok Bahadur Bam Dina Nath Dhakal Budhan Chaudhari Yam Bahadur Pokhrel Rakhi G. Jha

Advisors Dr. Margarita Ronders WHO Technical Officer Dr. Shankar Bahadur Shrestha Sr. Medical officer EDCD, Teku NAME OF THE INSTITUTE IMPLEMENTING THE PROJECT: CENTRAL DEPARTMENT OF ZOOLOGY (PARASITOLOGY) TRIBHUVAN UNIVERSITY KIRTIPUR, KATHMANDU

Correspondence: Mahendra Maharjan ([email protected])

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ACKNOLEDGMENTS Lymphatic filariasis has been identified as the second leading cause of permanent and long-term disability and is one of six tropical diseases targeted by WHO/TDR. Because of public health importance of this disease in the national context, Nepal government has committed to eliminate filariasis by 2015. The present study is the situation analysis stage of the continuation of LF elimination programme under the WHO collaborative project run by EDCD, Teku. Due to nocturnal periodicity of the microfilaria, collection of the blood samples from the community people is not easy without the support of the health personels, social workers and community people. The dedication shown by the Epidemiology and Disease Control Division towards the success of this programme is exceptional. So that we are heartly grateful to Dr. Mahendra Bahadur Bista, Director, EDCD, Teku for moral support, financial arrangement, quick administrative process throughout the study period. We are equally grateful to the technical advisors Dr. Margarita Ronders, WHO Technical Officer and Dr. Shankar Bahadur Shrestha, filariasis elimination programme co-ordinator for their continuous monitoring and moral inspiration to assure the quality of the epidemiological survey from beginning to end. Directors of District Public Health Office, Rupandehi, Nawalparasi, Makwanpur and Chitwan are extremely thankful for their whole hearted support and arrangement of the community health personnel to involve in the field survey. We have really a sweet remembrance of working with the health post and sub-health post encharges, health workers, community leaders, social workers of the eight sentinel sites. Working together, eating together with sharing happy and sorrow moments of working day and night was really a marvelous. It was unexpected that in spite of uncomfortable political situation also community people never allow us to feel discomfort our stay and work. Their warm welcome, support, co-operation and inspiration boosted up all the team members working capacity up to the success. Its my privileged to be grateful with my project team members. I wish but don’t want to express other words to acknowledge them which never could represent their friendship spirit of working with keen interest in each and every steps. I would simply say “HI” to all team members particularly co-investigator and all parasitologists, who had sacrificed their several times warm beddings for the success of the work. It would be almost injustice not to write anything to the EDCD staffs particularly Mr. Narendra Tandukar, Dr. Ashok sharma and others. Their co-operative nature inspired us a lot to tackle various administrative difficulties easily. Ms Meena kumari Maharjan and Mr. Rabindra Maharjan, whose direct and indirect contribution in the project is remarkable. I owe my gratitude to both of them.

Mahendra Maharjan Principal investigator 3|Page

Introduction Lymphatic filariasis is a parasitic disease caused by nematodes inhabiting the lymphatic system. Filariasis, is one of six tropical diseases targeted by WHO/TDR The disease is widespread throughout the tropical and subtropical areas of Asia. Africa, the western pacific and some parts of the Americas(Michael et al.,1996)).Where it is a major cause of acute and chronic morbidity affecting persons of all ages and both sexes. Lymphatic filariasis is a dramatically disabling, disfiguring disease usually affecting one or both limbs, causing hydrocele and equally grotesque enlargement of male scrotum. Infection also causes acute fever, inflammation of the lymphatic system and the bronchial asthmatic condition known as tropical pulmonary eosinophilia (WHO, 1995). Not only does it lead to great personal suffering from its disabling and disfiguring lesions. But it is also a significant impediment to socioeconomic advancement, both locally and nationally (WHO, 1995). Lymphatic filariasis has been identified as the second leading cause of permanent and long-term disability (WHO, 1995). But the true amount of disability it causes is only beginning to be quantified accurately (Evans et al., 1993, Ramu et al., 1996). A total of 44 million persons currently suffer from one or more of the overt manifestations of the infection: lymhoedema and elephantiasis of the limbs or genitals. Hydrocele, chyluria, pneumonitis or recurrent infections associated with damaged lymphatics. The remainder of the 120 million infected have preclinical hidden damage of their lymphatic and renal systems (Otteson, 1994) and to this burden of disease must also be added the serious psychosocial consequences that these profoundly disabling lesions often have, including the seldom mentioned sexual/social dysfunction of men of all ages affected with hydroceles or other genital abnormalities and of young women with lymphoedema of the breasts or genitals(Dreyer et al., 1997). Other complication may include chyluria and chronic pulmonary fibrosis. The most prevalent of the chronic manifestations are hydrocele- grossly enlarged and hanging scrotum- and lymphoedema of the arms and legs, including the most advanced and feared stage, elephantiasis, other complications may include chyluria (milky urine), which is painless but results in weight loss and lethargy, and tropical Pulmonary eosinophilia (asthma and cough) which results in chronic pulmonary fibrosis, more than 30 million people suffer from chronic filarial disease and over one million with elephantiasis. The rest are infected, but symptomless (TDR report, 91-92). Little is known about the social and economic impact of lymphatic filariasis, which makes it difficult to assess what the above figures mean in terms of human suffering. Clearly, people with gross elephantiasis are severely impaired, both physically and socially, and the prevalence of elephantiasis alone makes lymphatic filariasis an important public health problem The highest number of infected persons is in the South-East Asia Region with India alone accounting for 45.5 million. In sub Saharan Africa the estimate of 41 million cases is less precise and there is a particular need to determine more accurately the distribution of infection and diseases in affected countries. Several countries in Asia have large numbers of cases and infection and disease are very prevalent in many of the pacific 4|Page

islands as well.( Michael et al.,1996WHO, 1995Evans et al., 1993, Ramu et al., 1996Otteson, 1994Dreyer et al., 1997TDR report, 91-92Ottesen et al., 1997) The infection of lymphatic filariasis in Nepal is one of the most neglected and hidden public health and socio-economic problem(WHO,2000). The first report on elephantiasis was given by Jung (1973) from Central-Nepal. He reported more prevalence of lymphatic filariasis in rural and semi urban areas in compared to the urban areas. In Gokarna VDC of KTM valley reported 24.6% endemicity rate with average mf density per person blood sample was recorded to be 22.40. (Pradhan et al. 1997). Bhusal et al., (2000) reported 5.8% microfilaremia and 13% crude disease rate and density of mf was to be 3/20 micro liter and 16/20 micro liter of blood in Tokha-Chandeshwari VDC. Bista et al. (2000) reported the existence of the filariasis in different parts of Nepal. Serially Michael et al.,1996WHO, 1995Evans et al., 1993, Ramu et al., 1996Otteson, 1994Dreyer et al., 1997TDR report, 91-92Ottesen et al., 1997Jung (1973) WHO,2000Pradhan et al. 1997). Bhusal et al., (2000) Bista et al. (2000) Manandhar (2001) reported large percentage of crude disease from Sipwa, Dovan and Bhaktapur. Sherchand et al. (2002) reported 13% of microfilaria from 37 districts. Jha et al.,(2003) reported that the overall endemicity rate of LF of 8 districts was 16.08%. The highest endemicity rate was found in Bhaktapur (28.36%) and the least in Saptari district (7.69%). Similarly crude disease rate was found to be the highest in Bhaktapur while the least in Rauthat. Still nation wise figure for the lymphatic filariasis is lacking. The climatic condition, temperature and rainfall in hills, mid terai and terai geographical regions of Nepal are much favorable for the breading of the mosquito vectors. The existence of the high prevalence of microfilaria disease rate in the country from the reported cases indicated that large number of the population are at the risk of getting infection. Hence now the disease had been considered as one of the major public health problem in the country and had been targeted to eliminate by the year 2015 with the financial support of WHO. Administratively Nepal is divided into five development region, fourteen zones and 75 districts. The district is further divided into several municipalities, sub municipalities and Village Development committees(VDCs). Makwanpur, Chitwan, Nawalparasi and Rupandehi are the adjoining districts extending from central mid terai regions to mid western terai region. The first phase of study and control programme had already been completed in Parsa district. In second phase of the filariasis elimination programme two more districts Chitwan and Makwanpur added. Just prior to the present phase of filariasis elimination programme, epidemiological survey had been carried out to figure out the exact situation of filariasis in four districts of the country, Rupandehi, Nawalparasi, Makwanpur and Chitwan applying the sentinel survey method. So that same population can be easily traced out throughout the elimination programme till the district is considered to be free of the disease.

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Objective General objective: Ø To determine the prevalence and density of microfilariaemia in selected sentinel areas of Makwanpur, Chitwan, Rupendehi and Nawalparasi districts Specific objectives: Ø To determine the prevalence of lymphatic filariasis in four districts. Ø To determine the microfilariaemia mean density in the study area. Ø To determine the potential risk factors in relation to filariasis transmission.

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Methodology Study areas: Four districts of country Ø Makwanpur Ø Chitwan Ø Rupandehi and Ø Nawalparasi In each of the district two sentinel sites were identified with the help of filariasis elimination program, Nepal, EDCD/HNG, Teku and District Public Health officers of respective districts. Among these districts, Makwanpur district lies in the Mid-terai region where as rest of three districts Chitwan, Nawalparasi and Rupandehi lies in the Terai region. Study design: Epidemiological descriptive study. Sampling Design: Under the epidemiological descriptive study, Sentinel surveillance method was applied which is the appropriate method to measure the chronic disease burden, sign and symptoms and asymptomatic microfilaria carrier in the community. Furthermore the study design is applicable to conduct the filariasis elimination program because of the focal nature of LF distribution. For the sentinel survey two VDCs were selected that is one from urban areas and one from rural areas. It was targeted to conduct the survey among 500 community people from each of the sentinel sites for the questionnaire survey and blood sample collection. Sentinel sites from each district was selected on the basis of identified factors like the presence of the visible sign and symptoms among the community people (elephantiasis or hydroceole) that were expected to increase the difficulty of eliminating transmission, such as area of high prevalence, with high vector densities. In each of the sentinel sites with the help of the community health workers wards having population of more than 1000 were identified to carry out the detail survey. In selected wards total households were marked where each and every family members above the age group of two were identified as the targeted study sample. So that same population can be traced out for the monitoring of the success of the treatment programme till the districts are considered as free from filariasis. Sample size : A total of 4084 community people were interviewed and night blood samples were collected. A total of 1019 from Makwanpur, 1006 from Chitwan, 1019 from Nawalparasi and 1040 from Rupandehi districts with the target of 500 blood samples in each of two sentinel sites from two districts. Criteria of inclusion and exclusion: Children below two years of age was excluded in the survey. Rest of the household members from each identified household were included in the study. 7|Page

Community awareness/ mobilization: One day community awareness and mobilization programme was organized in each of the sentinel sites just before the survey started. Community people were informed about the awareness programme through the community volunteers, heathworkers, political leaders. The tools used in for that purpose were, hand miking in some sentinel sites like Bairghat of Rupandehi district, Postering etc. Community people were gathered at a common community places of each sentinel sites, briefed about the aims and objectives of the programme, briefed on the disease transmission, pathogenecity and need of control programme, views expressed from community leaders, local health workers and social workers. As well as common consent taken to conduct the survey from the community people. Since the survey was done during the evening and night, it was essential to introduce the working team in front of the community people and requested to co-operate with the working team. Training: The training programme of one day each was organized in each of the district at four consecutive time interval for all the staffs involved in the project, prior to commencement of the survey. During the day time of the training all the field members were instructed to apply the technique precisely, well acquainted according to the survey methodology. Standard methods for the administration of the questionnaire in the field condition as well as easy and convincing techniques for the collection of the blood sample from the ear lobe was instructed with the help of theoretical and practical approach. The questionnaire was pre- tested among the participants and piloted during the practical session. All the participants was examined their practical knowledge of proper blood collection by means of pilot survey during the same night. Among the total of sixteen participants excellent eight of them were selected for the following days survey as the project staffs. The same methodology were applied for the rest of the three districts. Diagnostic tools: Consent from the sample population A set of written consent was given to sign mainly from the household head of each sentinel site before questionnaire administration and blood sample collection. Questionnaires administration A set of structured questionnaire was developed in order to determine the potential risk factors for filarial transmission. The survey team visited in each of the household and administered structured questionnaire from the household head (if not- one of the elder member of the household) during the day time. Blood sample collection Detection of microfilariaemia (mf) in the night blood is the only reliable method available for the diagnosis of filarial infection due to nocturnally periodic nature of Wuchereria bancrofti. The survey team visited the house holds in between 22.00 p.m. to 2.00 a.m. for the sample collection. The research assistant collected six drops of blood i.e. 8|Page

about 20 micro litter from each of the household members by pricking ear lobe with the sterilized lancet on thorough supervision of parasitologist. Blood smear was prepared in a slide from each sample individual keeping two drops of blood in each spot of the three side of the microslide (two drops at the center of the slide and two drops each on the sides of the slide). The drops of blood in the slides were spread with the help of the toothpick to prepare the thick smear and reduce the chances of breaking the microfilaria during the smear preparation. The thick smear were air dried, stickered with the detailed identification numbers written in the questionnaire form. Microfilaria is nocturnally periodic, reaching pick density in blood between 10.00 p.m. to 4.00 a.m. and slowly declining in density , during the day time (David T. Dennis, 1991).

Fixing and staining of the slides All the blood samples collected along with the questionnaire administration were properly marked with sticker each set in questionnaire and slides and brought to the laboratory. The blood smears were fixed dipping the slide for 10 seconds in methanol and air dried. The dehaemoglobinization was done keeping distilled water sufficient enough to cover the thick smear and keep for approximately 30 minutes till complete dehaemoglobinization. The slides were air dried and staining of the slides were performed dipping the dehaemoglobinized slides in the Giemsa stain for 25 to 30 minutes. The stain was washed and packed in the slide rack for the examination purpose. Microscopical Examination of the slides The examination of slides were done using binocular microscope with 5X, 10X, 40X and 100X objectives. Each and every field of the smear was thoroughly examined first in low power for the screening and high power for the confirmation. The slides checked by the parasitologists were rechecked and final conclusion for microfilaria positivity and density were drown. Result enterpretation The questionnaire along with the slide examined result were tabulated in the special format and analysed.

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Results The present epidemiological surveillance study result of lymphatic filariasis in four district of the country is divided into three parts (A) community mobilization/ awareness programme and training to the community health personnel. (B)questionnaire survey and parasitological examination

I-part: Community awareness/mobilization and Training A-1: District- Rupandehi Sentinel site I : Bairghat VDC Community awareness programme: The field Assistants of the project staffs were mobilized to inform community people to attend the awareness programme. Hand miking tool was used for this purpose. The community mobilization / awareness programme was conducted at training hall of the Sub-health post. The programme was participated by more than 40 adults and large number of children, which was very much encouraging.

Programme schedule Date : 24 May, 2005 Venue: Training hall , Bairghat VDC. Facilitator: Mr. Ramesh Nepal. Raporteur: Mr. Maheshor Khanal. 11:00- 11:30 – introduction, objective and project plan by Mahendra Maharjan (PI) 11:30 – 11:45 – few words on the programme – Ramesh Nepal (healthpost encharge) 11:45 – 12:15 – Information about the disease – Satish Chandra Jha (CI) 12:15 – 12:20 – Few words - Ram brij Chaudhari (Ex- ward chairman) 12:20 – 12:25 – Few words – Kamalawati Mishra ( community health volunteer) 12:25 – 12:30 – Survey plan – Maheshor Khanal (parasitologist, team leader) 12:30 – 1:00 – Tea and snacks This awareness programme played very important role to introduce the importance of the present survey, The disease, transmission pattern, pathology and importance of the night blood sample collection. The most important positive aspect of the awareness programme was to make familiar the team members in front of the community people, which was essential in this present political situation of the particular locality. Besides these, the awareness programme was intended to take common consent from the community leaders, social workers and health personnel to conduct the survey. In this sense, the outcome of the programme seemed extremely fruitful.

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Training programme: Date : 24 May, 2005 Venue: Training hall , Bairghat VDC. Experts/trainers: Mr. Mahendra Maharjan Mr. Satish Chandra Jha Participants : All the team members Time schedule: 1:00 – 2:30 – Training on Questionnaire survey 2:30 – 4:00 – Training on blood sample collection and smear preparation. In the first phase of the training, trainer translated the questions in Nepali language then explained in detail about the meaning of each and every question. Oriented towards the pattern of asking questions and expected answer from the respondents. Participants were informed about some basic DO ‘s’ and NOT to DO ‘s” DO ‘s’ - When entered the house, start with greetings, informal discussion to bring him/her normal answering environment. - Formally introduce yourself, who are you, purpose, what is your expectation of this visit. - Take oral consent to participant in this survey most probably from household head otherwise from elder person. - Write clearly the serial Number, your group identification alphabet, household number and sentinel site identification number which most be same with the slide number collected from the same individual. - Then ask about the family size- identify who among them are or will be present during survey period, where the rest family members are? etc. - Use their own language, use simple informal words so those respondents feel comfortable with your questions. - Fill all the known demographic information like district, VDC, ward, etc before entering the questions. - Cover each and every questions in sequence, start from household head followed by elderly persons. - Fill the questionnaire on behalf of the children with their parents or guardiants. - Be careful with the link questions. - Take consent from the respondent if he is above 15 if not take consent from the guardiants or the parents. - Inform each of them to remain in full relaxation or sleep and will visit about approximate time and don’t hesist to give blood samples.

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NOT to DO ‘s’ -

Don’t lead the question Don’t repeat the questions once you have got the answer i.e. if the answer of the question no. 11 is ‘No’ leave the question 12 and 13.

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After these information participants were asked questions as they are the household members. They were informed to behave as the community members of the different nature. The trainees were practically taught how to tackle with the different situation. Then the questions were practiced among themselves. Refreshment break In second phase of the training the participants were practiced to collect the blood samples The participants were oriented to the materials needed to bring with them during the field visit/ preparation before field visit. They are as follows: - Wear apron and gloves for safety and also keep their identity card with them - Arrange the slide collection packet i.e appropriate number of slide box, cotton swab, lancet, glass slides, wooden sticks. Besides these field bag including the torch light etc. - Arrange the questionnaire according to the household number. - Prepare the appropriate number of the spirit cotton swab. - Prepare the appropriate number of the glass slides(clean) and keep sticker label on the one side of the slide. Arrange the sticker labeled slides in the slide box. - Arrange the questionnaire set of the particular household, keep serial number, group identification number, household number and sentinel site identification number on the label of the individual to whom you are going to collect the blood samples. Blood collection methods: - Clean the lower ear lobe with the cotton swab, in case of ladies, be sure that request her or her gaurdiants to take out the ear rings and other ornaments from the ear lobes. - Prick the ear lobe with the sterilized lancet, don’t touch the tip of the lancet with your hand or don’t keep the lancet opened. Take out just prior to the pricking. - Squeez the ear lobe slowly so that a big drop of blood comes out. - Drop the two drops of blood in the centre of the slide, spread spherically but blood should not touch the margin of the slide. - Squeez second time the ear lobe , drop again the two drops of blood on the one side and spread as previously, similarly repeat for the third time and keep on the another end but don’t touch the labeling sticker. - Clean the ear lobe with the spirit cotton swab. - Make the slide air dry. 12 | P a g e

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Arrange the slide in sequencing manner in the slide box. Repeat the same method of the blood collection and slide preparation from the another family member.

After these information, the trainer had shown practically the preparation of the field bag and arrangement method of the materials needed during night blood sampling. When every thing is ready. Each and every participants were allowed to write their serial number one each of the questionnaire set, supposing that each of the participants are of the same family members. Trainer had requested to take the blood sample from one of the participants. He had shown practically how to collect blood samples and how to make the thick blood film in the slide and then to arrange in the slide box. The method was practiced among each other by the participants. The trainer pointed out their wrong methods and repeatedly practiced to make them perfect. The participants were divided into two groups each of the two members guided by parasitologist, and expert, group A and B respectively.

Field questionnaire survey

After 4:00 PM, each of the group selected their household and became ready for the questionnaire survey upto 8:00 PM. Arrangement for blood collection Came back from the field and took dinner After dinner each of the group arranged their survey bag for the blood collection. Arranged necessary materials i.e. spirit swab preparation, labeling stickers on glass slides etc. Night blood collection Since the community people sleep late during these days, blood collection was started only after 12:00 mid night. As in questionnaire survey, during the night blood collection also the twogroups were guided by the parasitologist and expert. Each of the team moved towards the same household from where they have administered the questionnaire. The groups started to collect the blood samples using the appropriate techniques. They were guided by the experts in each and every steps. After the training programme, each of the project staffs were informed their responsibility during the survey period. Inform them to use the same methodology, not to compromise with the quality of the survey. Same methodology was applied in rest of all the sentinel sites for the community awareness/mobilization programme and the training to the community health workers.

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(See the preliminary report submitted to the lymphatic filariasis programme, EDCD/HMG, Teku) Briefly

Sentinel site II Mangal pur, Bishnu Pura VDC-4, Rupandehi district. Date: 15th jesth 2062 Team formation: The field working team was formed before the survey was started. The team composition was as follows: Parasitologist: Research assistant Field assistant

Mr. Bhoj Bahadur Bhat Chhetri (Team leader) Mr. Ram Prasad Gautam (HA, health-post encharg) Mr. Bishnu Prasad Upadyaya (CMA) Mrs.Rashika Gautam (AHW) Mr. Ahamad Husain(VHW)

Community awareness programme: The field Assistants of the project staffs were mobilized to inform community people to attend the awareness programme. The community mobilization / awareness programme was conducted at training hall of the Sub-health post. The programme was participated by large number of community people. The awareness programme was addressed by the investigators, team leader, healthpost encharge, community leaders and social workers of the community. Similar training method was applied as described above in this site too District: Nawalparasi Sentinel site I Rani nagar, Triveni VDC- 6, Nawalparasi district. Date: 12th jesth 2062. Team formation: The field working team was formed before the survey was started. The team composition was as follows: Parasitologist: Research assistant Field assistant

Mr. Ashok Bahadur Bam (Team leader) Mr. Indra Mahato (CMA, sub-health-post encharg) Mr. Sunil Gautam (Lab-assistant) Mr.Brij Bihari Chaudhari (VHW) Mrs. Indira Joshi(CMA)

Sentinel site: Ward no 6 of the triveni VDC Community awareness programme: The field Assistants of the project staffs were mobilized to inform community people to attend the awareness programme. Hand miking 14 | P a g e

tool was used for this purpose. The community mobilization / awareness programme was conducted at training hall of the Sub-health post. The programme was participated by more than 60 adults and large number of children, which was very much encouraging. The awareness programme was addressed by the investigators, team leader, healthpost encharge, community leaders and social workers of the community. Similar training method was applied as described above Sentinel site II Tharu gaun, Kudia VDC- 7, Nawalparasi district. Date: 13th jesth 2062 Team formation: The field working team was formed before the survey was started. The team composition was as follows: Parasitologist: Research assistant

Mr. Yam Bahadur pokhrel (Team leader) Mr. Rishi Kafle (CMA, sub-health-post encharg) Mr. Padam Bahadur Chettri (Lab-assistant) Field assistant Mr.Ram Prasad Panjiyar (VHW) Mrs. Goma Pandey(CHV) Community awareness programme: The field Assistants of the project staffs were mobilized to inform community people to attend the awareness programme. The community mobilization / awareness programme was conducted at training hall of the Sub-health post. The programme was participated by large number of community people which was very much encouraging. The awareness programme was addressed by the investigators, team leader, healthpost encharge, community leaders and health and social workers of the community. Similar training method was applied as described above District: Makawanpur Sentinel site I Patkeri-7, Hatia VDC, Date: 5th, Ashad 2062 Team formation: The field working team was formed before the survey was started. The team composition was as follows: Parasitologist: Research assistant

Mr. Yam Bahadur pokhrel (Team leader) Mr. Pushpa Ram Gallu (health-post encharg) Mr Uttam Aryal (Lab-assistant) Field assistant Ms.Kamala Subedi (ANM) Ms. Basu Subedi (ANM) Community awareness programme: The field Assistants of the project staffs were mobilized to inform community people to attend the awareness programme. The 15 | P a g e

community mobilization / awareness programme was conducted at training hall of the Sub-health post. The programme was participated by large number of community people which was very much encouraging. The awareness programme was addressed by the investigators, team leader, healthpost encharge, community leaders and health and social workers of the community. Similar training method was applied as described above District: Makawanpur Sentinel site II Gopali gaun, Palung Daman VDC, Date: 8th, Ashad 2062 Team formation: The field working team was formed before the survey was started. The team composition was as follows: Parasitologist: Research assistant Field assistant

Mr. Ashok Bahadur Bam (Team leader) Mr. Kedar lama (CMA) Mr Durga Dhakal (ANM) Ms.Pabita K.C (CHW) Ms. Kanchan K.C (CHW)

Community awareness programme: The field Assistants of the project staffs were mobilized to inform community people to attend the awareness programme. The community mobilization / awareness programme was conducted at training hall of the Sub-health post. The programme was participated by large number of community people which was very much encouraging. The awareness programme was addressed by the investigators, team leader, healthpost encharge, community leaders and health and social workers of the community.

Similar training method was applied as described above District: Chitwan Sentinel site I Beldiha, Bhandara VDC-7, Date: 2th, Ashad 2062 Team formation: The field working team was formed before the survey was started. The team composition was as follows: Parasitologist: Research assistant

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Mr. Budhan Chaudhari (Team leader) Mr. Deepak Paudel (CMA) Mr Indra Prasad Silwal (Lab assistant)

Field assistant

Mr .Agni Prasad Silwal (CHW) Ms. Santosi Silwal (CHW) Community awareness programme: The field Assistants of the project staffs were mobilized to inform community people to attend the awareness programme. The community mobilization / awareness programme was conducted at training hall of the Sub-health post. The programme was participated by large number of community people which was very much encouraging. The awareness programme was addressed by the investigators, team leader, healthpost encharge, community leaders and health and social workers of the community. Similar training method was applied as described above District: Chitwan Sentinel site I Tandi, Ratna nagar municipality-8, Date: 3rd, Ashad 2062 Team formation: The field working team was formed before the survey was started. The team composition was as follows: Parasitologist: Research assistant Field assistant

Mr. Dina Nath Dhakal (Team leader) Ms. Rekha Shrestha (CMA) Ms Shanti Paudel (Lab assistant) Ms .Sudha Bohara (CHW) Ms. Shalik Ram Adhikari (CHW)

Community awareness programme: The field Assistants of the project staffs were mobilized to inform community people to attend the awareness programme. The community mobilization / awareness programme was conducted at training hall of the Sub-health post. The programme was participated by large number of community people which was very much encouraging. The awareness programme was addressed by the investigators, team leader, healthpost encharge, community leaders and health and social workers of the community.

Similar training method was applied as described above (B) Questionnaire survey and parasitological examination All together 4084 community people permanently inhabiting the eight sentinel sites of four districts of Nepal were interviewed (with themselves or with their gradients) using structural questionnaire and night blood samples were collected and examined for

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analysis of the filariasis situation from all those volunteers prior to the control programme. DEMOGRAPHIC CHARACTERISTIC 1. DISTRICT-WISE SAMPLE COLLECTION In all the four districts, questionnaire survey and night blood samples were collected from two each sentinel sites: sentinel sites were as follows Rupandehi: Sentinel site I – Bairghat Sentinel site II – Bishnupura Nawalparasi: Sentinel site I – Raninagar,Triveni Sentinel site II – Kudiya Chitwan Sentinel site I – Bhandara Sentinel site II – Ratnanagar Makwanpur Sentinel site I – Hatiya Sentinel site II – Palung

Districts 1. Rupendehi Total 2, Nawalparasi Total 3, Chitwan Total 4, Makwanput

Sentinel Sites 1a, Bairghat 1b, Bishnupura 2a, Raninagar 2b, Kudiya 3a,Bhandara 3b,Ratnanagar 4a, Hatiya 4b, Palung

Total TOTAL

Total 510 530 1040 508 511 1019 504 502 1006 512 507 1019 4084

Male(%) 282(55.3) 246(46.4) 528(50.8) 233(45.9) 252 (49.1) 485(47.5) 246(48.8) 247(49.2) 493(49) 226(51.9) 235(46.4) 501(49.1) 2007(49.15)

Female(%) 228(44.7) 284( 53.6) 512(49.2) 275(54.1) 259(50.7) 534(52.4) 258(51.2) 255(50.8) 513(51) 246(48.1) 272(53.6) 518(50.9) 2077(50.85)

Table no. 1 : Total no. of blood samples collected from four districts. A total of 4084 community people were interviewed and night blood samples were collected from two each sentinel sites of the four districts. Among them males were 2007 (49.15%) male and 2077(50.85%) female. From each of the sentinel sites more than 500 community people were involved in the survey.

18 | P a g e

2, AGE AND SEX-WISE SAMPLE COLLECTION: Each and every household members above the age group two in the identified sentinel sites were included. Table no. 2 age and sex wise collection of blood samples Age Total Male Female group Yrs

No. of % samples

No. of % samples

No. of % samples

Under 10 11-20 21-30 31-40 41-50 51-60 61-70 > 70

762

18.66

391

19.48

371

17.86

958 712 543 445 273 210 181

23.46 17.43 13.30 10.90 6.68 5.14 4.43

469 308 242 206 154 123 114

23.37 15.35 12.06 10.26 7.67 6.13 5.68

489 404 301 239 119 87 67

23.54 19.45 14.49 11.51 5.73 4.19 3.23

Total

4084

100.00

2007

100.00

2077

100.00

The maximum study population belongs to age group 11-20 i.e. 23.54% and least above 70 i.e. 3.23%

3,EDUCATION AND DISTRICT WISE SAMPLE COLLECTION

Table no. 3 education and district wise Education Illiterate

Chitwan

distribution of study population.

Rupandehi

Nawalparasi

Makawanpur

Total

Bhandara

Rathanagar

Bairghat

Bishnupur

Raninagar

Kudiya

Hatiya

Palung

289(17.31)

72(4.31)

360(12.57)

365(21.87)

113(6.77)

143(8.57)

145(8.69)

182(10.90)

1669(40.87)

Literate

45(16.54)

56(20.59)

22(8.09)

19(6.99)

26(9.56)

26(9.56)

38(13.97)

40(14.74)

272(6.66)

Primary

72(8.65)

86(10.34)

97(11.66)

103(12.380

138(16.59)

69(8.29)

130(15.63)

137(16.47)

832(20.37)

Secondary

98(7.48)

288(20.97)

31(3.66)

43(3.28)

231(17.62)

273(20.82)

199(15.18)

148(11.29)

1311(32.10)

Distribution of educational level of the study population showed that maximum samples were collected from the illiterate groups in Bhandara just reverse in Ratnanagar in case of Chitwan, while in Rupandehi, maximum samples were collected from illiterate group in both sentinel sites. In Nawalparasi, maximum samples were collected from literate groups but in Makwanpur, maximum smples were collected from theliterates in palung and least form the Hetaunda. 19 | P a g e

4) OCCUPATION AND DISTRICTWISE SAMPLE COLLECTION Table no. 4, Occupation and district wise collection of blood sample occupation Farmer Student Labour Housewife Businessman Unemployed Teacher Other Child Total

Chitwan Bhandara 229 146 11 85 4 1 5 8 15 500

Rathanagar 43 248 19 72 65 9 9 21 16 500

Rupandehi Bairghat Bishnupur 276 330 117 79 18 9 38 20 8 6 4 10 1 2 11 35 37 39 500 500

Nawalparasi Rohinagar Kudiya 53 282 225 4 14 2 62 185 88 12 8 12 10 3 33 3 35 8 500 500

Makawanpur Hatiya Palung 237 205 146 165 11 3 85 55 4 43 1 12 5 0 8 8 15 16 500 500

The table indicated that large number of people in the study area engaged in agriculture(40.55%) than other occupation.

KNOWLEDGE AND PRECAUTION OF FILARIASIS AMONG DIFFERENT EDUCTIONAL STATUS Educational level of the community people are categorized illiterate, who cann’t read and write, literate- who had taken adult education courses and remaining according to the schoolings. Knowledge determines the people who had seen elephantiasis or hydrocele people either around their community or somewhere else. Precaution determines the community people’s practice of using bednets, ointments or some other measures against mosquito bite. Table 5 : Distribution of knowledge and precaution of filariasis among peoples belonging to different economic status. Precaution(%) Education Total No Of person Knowledge(%) Illiterate 1669 222 (13.30) 41 (2.46) Literate 272 79 (29.04) 27 ( 9.93) Primary 832 95 (11.42) 29 (3.49) Secondary + higher 1311 540 (41.19) 288(21.97) studies The highest knowledge about elephantiasis was found among secondary educational status population in which highest number of precaution was also found to be taken by same status population it was found that there is statically significant difference of knowledge and precaution among different educational status

20 | P a g e

Total 1655(40.56) 1130(27.70) 87(2.13) 602(14.75) 230(5.64) 57(1.40) 35(0.86) 127(3.11) 161(4.03) 4000

PREVALANCE OF MICROFILARIA GENERAL PREVALANCE : A total of 4084 individual were examined from four district of Nepal of which overall crude disease rate was 67 ( 1.68%) and individuals 103(2.58%) had microfilaria, 14(0.35%) had microfilaria with sign and symptoms of LF . Hence endemicity rate was found to be 4.6% of 184 samples

DISTRICT – WISE DISTRIBUTION OF LYMPHATIC FILERIASIS Table:6(I):- Distrist wise distribution of Sign and Symptom of Lymphatic filariasis

Sentinal site Rupendehi Nawalparasi

Chitwan Makwanpur

Total Sign and Symptoms E H B C L T

Total Sample

CDR%

Bairghat

510

1

2

0

3

1

0

7

Bishnupura

530

5

15

0

4

0

0

24

Raninagar

508

3

3

1

0

1

0

8

Kudia

511

1

10

0

2

0

1

14

Bhandara

504

1

2

0

1

0

0

4

Ratnanagar

502

1

0

0

1

0

0

2

Hatiya

512

0

0

0

0

1

0

1

Palung

507

5

1

0

0

1

0

7

4084

17

33

1

11

4

1

67

Total

Table:6(II):- Distrist wise and sexwise distribution of Sign and Symptom of Lymphatic filariasis Male Sentinal site Bairghat Rupendehi

Bishnupura Raninagar

Nawalparasi

Kudia Bhandara

Chitwan

Ratnanagar Hatiya

Makwanpur Total

21 | P a g e

Palung

Total Sample

282 246 233 252 246 247 266 235 2007

E

H

C

Female L

CDR%

1

2

1

0

4

0

15

0

0

15

2

3

0

0

5

0

10

0

0

10

0

2

0

0

2

0

0

0

0

0

0

0

0

0

0

1

1

0

0

2

4

33

1

0

38

Total Sample

C

L

T

B

CDR%

228 0 2 284 5 4 275 1 0 259 1 2 258 1 1 255 1 1 246 0 0 272 4 0 2077 13 10

E

1

0

0

3

0

0

0

9

1

0

1

3

0

1

0

4

0

0

0

2

0

0

0

2

1

0

0

1

1

0

0

5

4

1

1

29

Rupandehi A total of 1040 night blood samples were collected from the two sentinel sites of the Rupandehi district, Bairghat and Bishnupura respectively. Table 7. Prevalence of microfilaria in Rupendehi district Sentinel site Total sample Total positive Percentage Bairghat 510 14 2.74% Bishnupura 530 40 7.55% Total 1040 54 5.19% Among the total 1040 night blood sample, microfilaria prevalence was found to be 5.19% (54/1040) in Rupandehi district. Among them highest prevalence was recorded in the Bishnupura sentinel site i.e 7.55%(40/530). Table 8. Endemicity rate of Lymphatic filariasis in Rupandehi district Sential site Total MF CDR MF + ER(%) sample CDR Sentitialsite Bairghat 510 14 7 21(4.1%) Bishnupur 530 37 24 3 64 (12.1%) Total 1040 51 31 3 85 (8.2%) The highest knowledge about elephantiasis was found among secondary educational status population in which highest number of precaution was also found to be taken by same status population it was found that there is statically significant difference of knowledge and precaution among different educational status PREVALANCE OF MICROFILARIA GENERAL PREVALANCE : A total of 4084 individual were examined from four district of Nepal of which overall crude disease rate was 67 ( 1.68%) and individuals 103(2.58%) had microfilaria, 14(0.35%) had microfilaria with sign and symptoms of LF . Hence endemicity rate was found to be 4.6% of 184 samples Educational level of the community people are categorized illiterate, who cann’t read and write, literate- who had taken adult education courses and remaining according to the schoolings. Knowledge determines the people who had seen elephantiasis or hydrocele people either around their community or somewhere else. Precaution determines the community people’s practice of using bednets, ointments or some other measures against mosquito bite. The table indicated that large number of people in the study area engaged in agriculture(40.55%) than other occupation. Distribution of educational level of the study population showed that maximum samples were collected from the illiterate groups in Bhandara just reverse in Ratnanagar in case of Chitwan, while in Rupandehi, maximum samples were collected from illiterate group in both sentinel sites. In Nawalparasi, maximum samples were collected from literate

22 | P a g e

groups but in Makwanpur, maximum smples were collected from theliterates in palung and least form the Hetaunda. The maximum study population belongs to age group 11-20 i.e. 23.54% and least above 70 i.e. 3.23% A total of 4084 community people were interviewed and night blood samples were collected from two each sentinel sites of the four districts. Among them males were 2007 (49.15%) male and 2077(50.85%) female. From each of the sentinel sites more than 500 community people were involved in the survey. Among the total 1040 night blood sample, microfilaria prevalence was found to be 5.19% (54/1040) in Rupandehi district. Among them highest prevalence was recorded in the Bishnupura sentinel site i.e 7.55%(40/530). Table 9. Endemicity rate of Lymphatic filariasis in Rupendehi district Sential site Total MF CDR MF + ER(%) sample CDR Sentitialsite Bairghat 510 14 7 21(4.1%) Bishnupur 530 37 24 3 64 (12.1%) Total 1040 51 31 3 85 (8.2%) The highest knowledge about elephantiasis was found among secondary educational status population in which highest number of precaution was also found to be taken by same status population it was found that there is statically significant difference of knowledge and precaution among different educational status PREVALANCE OF MICROFILARIA GENERAL PREVALANCE : A total of 4084 individual were examined from four district of Nepal of which overall crude disease rate was 67 ( 1.68%) and individuals 103(2.58%) had microfilaria, 14(0.35%) had microfilaria with sign and symptoms of LF . Hence endemicity rate was found to be 4.6% of 184 samples Educational level of the community people are categorized illiterate, who cann’t read and write, literate- who had taken adult education courses and remaining according to the schoolings. Knowledge determines the people who had seen elephantiasis or hydrocele people either around their community or somewhere else. Precaution determines the community people’s practice of using bednets, ointments or some other measures against mosquito bite. The table indicated that large number of people in the study area engaged in agriculture(40.55%) than other occupation. Distribution of educational level of the study population showed that maximum samples were collected from the illiterate groups in Bhandara just reverse in Ratnanagar in case of Chitwan, while in Rupandehi, maximum samples were collected from illiterate group in both sentinel sites. In Nawalparasi, maximum samples were collected from literate groups but in Makwanpur, maximum smples were collected from theliterates in palung and least form the Hetaunda. 23 | P a g e

The maximum study population belongs to age group 11-20 i.e. 23.54% and least above 70 i.e. 3.23% A total of 4084 community people were interviewed and night blood samples were collected from two each sentinel sites of the four districts. Among them males were 2007 (49.15%) male and 2077(50.85%) female. From each of the sentinel sites more than 500 community people were involved in the survey. Among the total 1040 night blood sample, microfilaria prevalence was found to be 5.19% (54/1040) in Rupandehi district. Among them highest prevalence was recorded in the Bishnupura sentinel site i.e 7.55%(40/530). Endemicity rate of the lymphatic filariasis includes the microfilaria positive cases with or without sign and symptoms as well as the crude disease rate (CDR) which includes chronic elephantiasis, limbs swelling, breast swelling, chyluria, skin thickness, lymphoedema etc too. Overall endemicity rate of lymphatic filariasis also showed very high in the Rupandehi district i.e. 8.2%(85/1040). Endemicity rate of the lymphatic filariasis includes the microfilaria positive cases with or without sign and symptoms as well as the crude disease rate (CDR) which includes chronic elephantiasis, limbs swelling, breast swelling, chyluria, skin thickness, lymphoedema etc too. Overall endemicity rate of lymphatic filariasis also showed very high in the Rupandehi district i.e. 8.2%(85/1040).

Table 10. Sexwise prevalence of microfilaria Sex Bairghat

Male Female Total

Total sample 282 228 510

Mf positive 7 7 14

percentage Total sample 2.48% 246 3.07% 284 2.74% 530

Bishnupura Mf positive 19 21 40

percentage 7.7% 7.4% 7.5%

Sex wise prevalence of the microfilaria positivity and endemicity rate in the Bairghat and Bishnupura sentinel sites of the Rupandehi district revealed no significant difference. Table 11. Sex wise endemicity rate of lymphatic filariasis in Rupandehi district Sex Bairghat Bishnupura Rupandehi MF CDR MF ER(%) MF CDR MF ER(%) Total + + ER(%) CDR CDR Male 7 4 0 11 17 15 2 34 48(9.35%) Female 7 3 0 10 20 9 1 30 37(7.44%) Total 14 7 0 21(4.1%) 37 24 3 64(12.8%) 85(8.4%)

24 | P a g e

Night blood samples were collected from each and every family members above the age group two of the identified households in the sentinel sites. Table 12. Age wise prevalence of microfilaria in Rupandehi district. Age Bairghat Bishnupura group Total Mf Percentage Total Mf Percentage sample positive sample positive <10 11-20 21-30 31-40 41-50 51-60 61-70 >70

118 139 64 67 64 26 20 12

0 3 5 1 2 3 0 0

0 2.15 7.81 1.49 3.12 11.53 0 0

178 115 84 58 29 30 25 11

5 11 7 4 4 2 4 0

2.80 9.56 8.33 6.89 13.79 6.66 16 0

Maximum prevalence of the microfilaria in case of Bairghat revealed among the age group 51-60 years while in Bishnupura sentinel site revealed maximum in age group 4150 i.e 11.53% and 13.79% respectively. Prevalence of microfilaria was found to be minimum among the age group of below 10 and above 70. Table 13. Age wise endemicity rate of Lymphatic filariasis in Rupandehi district Age group

<10 11-20 21-30 31-40 41-50 51-60 61-70 >70

Total

Bairghat

Bishnupura

Total Sample

Total ER

Total ER(%)

Total sample

Mf

CDR

Mf + CDR

ER

ER (%)

296 254 148 125 93 56 45 23 1040

6 18 17 14 14 7 5 4 85

2.03 7.09 11.49 11.20 15.05 12.50 11.11 17.39 87.86

118 139 64 67 64 26 20 12 510

0 3 5 1 2 3 0 0 14

0 0 0 3 3 0 0 1 7

0 0 0 0 0 0 0 0 0

0 3 5 4 5 3 0 1 21

0.00 2.16 7.81 5.97 7.81 11.54 0.00 8.33 43.63

Total sample

Mf

CDR

Mf + CDR

ER

ER(%)

178 115 84 58 29 30 25 11 530

5 11 7 4 4 2 4 0 37

1 3 5 5 5 2 1 2 24

0 1 0 1 0 0 0 1 3

6 15 12 10 9 4 5 3 64

3.37 13.04 14.29 17.24 31.03 13.33 20.00 27.27 39.58

But endemicity rate of the lymphatic filariasis was found to be higher in the age group above 70 i.e. 17.39% that is due to the presence of the sign and symptoms, Crude Disease Rate (CDR). Most of the chronic elephantiasis cases are found among the elderly age group people while hydrocele cases were revealed maximum among the young age group people. 25 | P a g e

Nawalparasi A total of 1019 night blood samples were collected from the two sentinel sites of the Nawalparasi district. Prevalence of microfilaria in this district is also found to be very high 4.9%(50/1019). Among the two sentinel sites higher prevalence of microfilaria in the blood samples was found in Tharu gaun of the Kudia VDC than Rani nagar of the Triveni VDC. The crude disease rate also found maximum in Kudia VDC. Due to the large no. of the crude diseases rate particularly hydrocele and elephantiasis and chyluria the endemicity rate of the lymphatic filariasis increased upto the 7.06%. Table 14. Prevalence of microfilaria in Nawalparasi district Sentinel site Total sample Total positive Percentage Rani nagar 508 19 3.74% Kudia 511 31 6.06% Total 1019 50 4.9%

Table 15. Endemicity rate of Lymphatic filariasis in Rupendehi district Sential site Total MF CDR MF + ER(%) sample CDR Sentitialsite Rani nagar 508 18 8 1 27(5.31%) Kudia 511 28 14 3 45(8.8%) Total 1019 46 22 4 72(7.06%)

Analysis of the distribution of the microfilaria and lymphatic endemicity rate in Nawalparasi district revealed reverse result i.e. the higher prevalence revealed among the males in Rani nagar of the Triveni VDC and minimum in Kudia. But overall endemicity rate of lymphatic filariasis indicated similar distribution among both sex groups. Table 16. Sexwise prevalence rate of microfilaria Sex Raninagar Kudia

Male Female Total

26 | P a g e

Total sample 233 275 508

Mf positive 13 6 19

percentage Total sample 5.57% 252 2.18 259 3.74 511

Mf positive 8 23 31

percentage 3.18 8.88 6.06%

Table 17. Sex wise endemicity rate of lymphatic filariasis in Nawalparasi district Sex Rani nagar Kudia Nawalparasi MF CDR MF ER(%) MF CDR MF ER(%) Total + + ER(%) CDR CDR Male 12 5 1 18 6 10 2 18 36(7.43%) Female 6 3 0 9 22 4 1 27 36(6.74%) Total 18 8 1 27 28 14 3 45 72(7.06%) In Nawalparasi district, agewise distribution of microfilaria in community people with or without crude disease as well as the sign and symptoms indicated maximum prevalence in age group21-23 and 51-60 in case of Triveni VDC while similar result revealed among the elderly age group people in Kudia VDC too. The result is also similar with the endemicity rate in both of the sentinel sites of the Nawalparasi district. There were 8 cases of only crude disease rate found in Triveni while 14 cases of crude disease rate observed in Kudia. Regarding CDR maximum elephantiasis cases as well as hydrocele cases found in both of this sentinel sites. Most interestingly in both of these sites large numbers of young men and boys came to consult about their hydrocele problems. Some of them had removed water with the help of physicians not only in Nepal but also in India but the problem is still existing and suffering. These people had clearly presented their views regarding their psychological and social problem because of hydrocele problem and its negative impact in their marriage life. Table 18. Age wise prevalence of microfilaria in Nawalparasi district. Age Rani nagar Kudia group Total Mf Percentage Total Mf Percentage sample positive sample positive <10 20-Nov 21-30 31-40 41-50 51-60 61-70 >70

27 | P a g e

125 148 48 56 70 24 17 20 508

0 6 5 1 3 3 1 0 19

0.00 4.05 10.42 1.79 4.29 12.50 5.88 0.00

90 181 55 60 60 30 15 20 511

3 4 5 3 8 1 5 2 31

3.33 2.21 9.09 5.00 13.33 3.33 33.33 10.00

Table 19. Age wise endemicity rate of Lymphatic filariasis in Nawalparasi district Age group

Total Total Sample

<10 11-20 21-30 31-40 41-50 51-60 61-70 >70

Rani Nagar

Total ER 215 329 103 116 130 54 32 40

1019

Total ER(%) 3 17 15 9 13 5 8 2 72

1.40 5.17 14.56 7.76 10.00 9.26 25.00 5.00

Total sample

Kudia

Mf

CDR

Mf + CDR

ER

125

0

0

0

0

148

6

2

0

48

4

1

56

1

70

ER (%)

Total sample

Mf

CDR

Mf + CDR

ER

ER(%)

0.00

90

3

0

0

3

3.33

8

5.41

181

3

5

1

9

4.97

1

6

12.50

55

5

4

0

9

16.36

3

0

4

7.14

60

2

2

1

5

8.33

3

0

0

3

4.29

60

8

2

0

10

16.67

24

3

1

0

4

16.67

30

1

0

0

1

3.33

17

1

1

0

2

11.76

15

4

1

1

6

40.00

20

0

0

0

0

0.00

20

2

0

0

2

10.00

508

18

8

1

27

511

28

14

3

45

Chitwan A total of 1006 night blood samples were collected from the two sentinel sites of the Chitwan district, Bhandra and Ratna nagar. In comparision to the Rupandehi and Ratna nagar municipality microfilaria prevalence rate is found to be very less. Only one each samples found to be positive for the microfilaria in the night blood samples. But the rate of the crude disease is not less. In most of the cases community people don’t wish to explain there secrete problems, although it is evident that a total of six people had mentioned their secret problems and some of them talked about their elephantiasis problem. Hence the total lymphatic filariasis endemicity rate is about one percent. It is remarkable that those community people had already received first phase treatment against the lymphatic filariasis before more than one year and going to receive second phase of the treatment after the survey.

Table 20. Prevalence of microfilariaemia in Chitwan district Sentinel site Total sample Total positive Percentage Bhandra 504 1 0.19% RatnaNagar 502 1 0.19% Total 1006 2 0.19% Table 21. Endemicity rate of Lymphatic filariasis in Chitwan district. Sential site Total MF CDR MF + ER(%) sample CDR Sentitialsite Bhandra 504 1 4 0 5(0.99%) RatnaNagar 502 1 2 0 3(0.59%) Total 1006 2 6 0 8(0.79%) 28 | P a g e

Each case of the microfilaria infection in both of the sentinel sites showed only in the males. None of the cases in the females observed. Large numbers of crude disease rate observed in both of the sentinel sites compared to the microfilaria infection rate. Among CDR most cases were of chronic elephantiasis. Table 22. Sex-wise prevalence rate of microfilaria Sex Bhandara

Male Female Total

Total sample 246 258 504

Mf positive 1 0 1

percentage Total sample 0.4% 247 0% 255 0.19% 502

RatnaNagar Mf positive 1 0 1

percentage 0.40% 0% 0.19%

Table 23. Sex wise endemicity rate of lymphatic filariasis in Chitwan district Sex Bhandara RatnaNagar Chitwan Mf CDR MF ER(%) MF CDR MF ER(%) Total + + ER(%) CDR CDR Male 1 2 0 3(1.21%) 1 0 0 1(0.4%) 4(0.81%) Female 0 2 0 2(0.77%) 0 2 0 2(0.78%) 4(0.77%) Total 1 4 0 5(0.99%) 1 2 0 3(0.59%) 8(0.79%) Each cases of microfilaria found among the age group 51-60 in Bhandara and 31-40 in Ratnanagar. CDR was observed in all age groups in case of Bhandara. Hence overall endemicity rate of the lymphatic filariasis was about one percent.

Table 24. Age wise prevalence of microfilaria in Chitwan district. Age Bhandara RatnaNagar group Total Mf Percentage Total Mf Percentage sample positive sample positive <10 20-Nov 21-30 31-40 41-50 51-60 61-70 >70

29 | P a g e

90 149 85 62 49 31 25 13

0 0 0 0 0 1 0 0

504

1

0.00 0.00 0.00 0.00 0.00 3.23 0.00 0.00

72 125 100 88 54 24 27 12

0 0 0 1 0 0 0 0

502

1

0.00 0.00 0.00 1.14 0.00 0.00 0.00 0.00

Table 25. Agewise endemicity rate of Lymphatic filariasis in Chitwan district. Age group

Total Total Sample

Bhandara

Total ER 0

Total ER(%)

Total sample

Mf

CDR

Mf + CDR

ER

0.00

90 149 85 62 49 31 25 13

0 0 0 0 0 1 0 0

0 0 2 0 0 1 1 0

0 0 0 0 0 0 0 0

0 0 2 0 0 2 1 0

504

1

4

0

5

<10

162

11-20

274

1

0.36

21-30

185

2

1.08

31-40

150

2

1.33

41-50

103

0

0.00

51-60

55

2

3.64

61-70

52

1

1.92

25 1006

0

0.00 8.34

>70

RatnaNagar

8

ER (%) 0.00

Total sample

Mf

CDR

Mf + CDR

ER(%)

0 0 0 1 0 0 0 0

0 1 0 1 0 0 0 0

0 0 0 0 0 0 0 0

0 1 0 2 0 0 0 0

0.00

0.00

72 125 100 88 54 24 27 12

12.80

502

1

2

0

3

3.07

0.00 2.35 0.00 0.00 6.45 4.00

Makwanpur A total of 1019 night blood samples were collected from the two sentinel sites of the Makwanpur district, Hatiya and Palung respectively. Microfilaria prevalence was found only in Hatiya i.e. 2.14% but nil in Daman VDC palung. Makwanpur district is also one of the district where first phase of control programme had already been conducted before more than one year along with the Chitwan. Overall microfilaria prevalence in Makwanpur district is 1.07% while the lymphatic filariasis endemicity rate was 1.86% since large number of crude disease rate in both of the sentinel sites of this district. In Hatiya VDC, maximum 7 cases of the CDR including with the microfilaria was recorded. Table 26. Prevalence of microfilariaemia in Makwanpur district Sentinel site Total sample Total positive Percentage Hatiya 512 11 2.14% Palung 507 0 0% Total 1019 11 1.07% Table 27. Endemicity rate of Lymphatic filariasis in Makwanpur district. Sential site Total MF CDR MF + ER(%) sample CDR Sentitial site Hatiya 512 4 1 7 12(2.34%) Palung 507 0 7 0 7(1.38%) Total 1019 4 8 7 19(1.86%) Sexwise prevalence rate of the microfilaria result revealed that the cases were equally distributed in both of the sex. But maximum CDR found to be distributed among the 30 | P a g e

ER

0.80 0.00 2.27 0.00 0.00 0.00 0.00

females than that of the males i.e. due to the chronic elephantiasis among the females more than that of the males. Table 28. Sex-wise prevalence rate of microfilaria Sex Hatiya

Male Female Total

Total sample 266 246 512

Mf positive 6 5 11

percentage Total sample 2.25% 235 2.03% 272 2.14% 507

Palung Mf positive 0 0 0

percentage 0 0 0

Table 29. Sex wise endemicity rate of lymphatic filariasis in Makwanpur district Sex Hatiya Palung Makwanpur M CD MF ER(%) M CD MF ER(%) Total f R + F R + ER(%) CD CD R R Male 3 0 3 6(2.25%) 0 2 0 2(0.85%) 8(1.59%) Female 1 1 4 6(2.43%) 0 5 0 5(1.83%) 11(2.12%) Total 4 1 7 12(2.34%) 0 7 0 7(1.38%) 19(1.86%)

Regarding agewise distribution of the microfilaria infection in Makwanpur district, maximum cases were observed in the younger age groups while sign and symptom cases were found to be higher in elderly age group people.

Table 30. Age wise prevalence of microfilaria in Makwanpur district. Age Hatiya Palung group Total Mf Percentage Total Mf Percentage sample positive sample positive <10 11-20 21-30 31-40 41-50 51-60 61-70 >70

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44 49 127 79 62 53 60 38 512

2 4 2 2 0 1 0 0 11

4.55 8.16 1.57 2.53 0.00 1.89 0.00 0.00

45 52 149 73 57 55 21 55 507

0 0 0 0 0 0 0 0 0

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Table 31. Agewise endemicity rate of Lymphatic filariasis in Makwanpur district. Age group

Total Total Sample

<10

Total ER

Bhandara Total ER(%)

Total sample

Mf

CDR

Mf + CDR

ER

44 49 127 79 62 53 60 38

0 1 2 1 0 0 0 0

0 1 0 0 0 0 0 0

2 3 0 1 0 1 0 0

2 5 2 2 0 1 0 0

512

4

1

7

12

89

3

3.37

11-20

101

5

4.95

21-30

276

3

1.09

31-40

152

2

1.32

41-50

119

1

0.84

51-60

108

4

3.70

61-70

81

0

0.00

93 1019

1

1.08 16.34

>70

19

RatnaNagar ER (%) 4.55

Total sample

Mf

CDR

Mf + CDR

ER

0 0 0 0 0 0 0 0

1 0 1 0 1 3 0 1

0 0 0 0 0 0 0 0

1 0 1 0 1 3 0 1

2.22

0.00

45 52 149 73 57 55 21 55

20.74

507

0

7

0

7

11.92

10.20 1.57 2.53 0.00 1.89 0.00

DISTRIBUTION OF SIGN AND SYMPTOM CASES IN FOUR DISTRICTS Chitwan: Out Of 1006 Examined persons, 6 (0.6%) showed signs and symptoms of lymphatic filariasis in which 2 had elephantiasis, 2 has hydrocoele and 2 had chyluria. Rupandehi: The overall crude disease rate in this district was found to be 3.26% of 34 persons in which 5 had elephantiasis, 17 had hydroecoele 9 had chiluria 1 had lymphoedema, 1 had elephansitiasis whith chyluria and 1 had swelling of lymphnode with chyluria. Nawalparasi: In this discrict the crude disease rate was 2.6% of 26 samples in which 3 had elephantiasis, 16 had hydroecoele, 1 had chyluria, 1 had lymphnode, 1 had thick skin 1 had elephantiasis with breast swelling 1 had elephantiasis with thick skin and 1 had chyluria with thick skin Makawanpur: The crude disease rate was found to be 1.07% (15 individuals ) in which 5 had elephantiasis, 1 had hydrocoele, 1 had chyluria, 7 had swelling of lymphnode and 1 had thick skin

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ER(%)

0.00 0.67 0.00 1.75 5.45 0.00 1.82

LYMPHATIC FILARIASIS IN STUDY AREA Microfilaria prevalence showed increasing trend from the eastern part of mid terai geographical region, Makwanpur to the western terai region. In this present study comparatively least prevalence found in the Chitwan(0.19%) and miximum in Rupandehi district(5.19%). But the prevalence of the microfilaria infection in two sentinel sites of the same districts also showed marked variation.

p e r c e n ta g e

Microfilariemia prevalence in four districts of Nepal 8 7 6 5 4 3 2 1 0

7.55% 6.06% 4.9% 3.74%

Sentinel I Sentinel II

2.74%

2.14% 0 0.01% Makwanpur

5.19%

Total

0.19 0.19% Chitwan

Nawalparasi

Rupandehi

Districts Figure 1: Prevalence of microfilaria in four districts of Nepal

The distribution pattern of the endemicity rate of the lymphatic filariasis in four districts also showed the similar to that of the microfilaria distribution.

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Endemicity rate(ER) of Lymphatic filariasis in four districts of Nepal

percentage

10

8.2% 7.06%

8 6 4 2

1.86% 0.79%

0 Makwanpur

Chitwan

Nawalparasi

Rupandehi

Districts

Figure2. : Lymphatic filariasis endemicity in four districts of Nepal Sex wise comparative endemicity rate of lymphatic filariasis showed more cases in the male than female in all three districts besides the Makwanpur district. But distribution pattern in male and females were not significant. Both male and female were found to be more or less equally infected either with the microfilaria in their blood or with the chronic elephantiasis or with the hydroceole or chyluria.

Sex wise endemicity rate of lympatic filariasis in four districts of Nepal 9.35%

Percentage

10 7.43% 6.74%

8

7.44%

6 4 2

Male 2.12% 1.59%

Female 0.81%0.77%

0 Makwanpur

Chitwan

Nawalparasi

Rupandehi

Districts

Figure 3. : Sex wise endemicity rate of lymphatic filariasis in four districts of Nepal Agewise endemicity rate showed markedly variation in four districts. In Nawal parasi and Rupandehi where maximum microfilaria as well as CDR was recorded showed maximum in 61-70 age group in Nawalparasi district while situation in Rupandehi showed increasing number of cases from the younger age group to the elderly age group.

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Age wise endemicity Rate of Lymphatic filariasis in four districts of Nepal

Percentage ( % )

30 25

Makwanpur

20

Chitwan

15

Nawalparashi

10

Rupandehi

5 0 <10

.11-20 21-30 31-40 41-50 51-60 61-70

>70

Age Group

Figure. 4: Agewise endemicity rate of lymphatic filariasis in four districts of Nepal.

Table 32 Lymphatic filariasis endemicity rate in four districts of Nepal District Sential MF CDR MF + ER(%) CDR Sentitialsite Chitwan Bhandara 1 4 5 Ratnanager 1 2 3 Rupandehi Bairghat 14 7 21 Bishnupur 37 24 3 64 NawalParasi Raninager 18 8 1 27 Kudiya 28 14 3 45 Makwanpur Hatiya 4 1 7 12 palung 7 7 103 67 14 184(4.6)

ER(%) District 8(0.8) 85(8.5) 72(7.2) 19(1.9) 184(4.6)

Overall endemicity rate of lymphatic filariasis in four districts of Nepal was found to be 4.6% of Rupandehi was recorded to be highly prevalent district and Chitwan as the least prevalent district. Possible sign and symptoms of the lymphatic filariasis like chronic elephantiasis, hydroceole or chyluria cases were common in all the districts.

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AGE AND SEX-WISE ENDEMICITY RATE The overall study showed that the highest endemicity rate was found in the age group 4049. Sex wise endemicity rate highest in age group 30-39 in male and age group 60 -69 in females.The ratio of microfilariaemia, crude disease amd microfilariaemia with clinical symptom in both sexes was found almost same OCCUPATION-WISE ENDEMICITY RATE Represents the distribution of endemicity rate in different occupation. The highest infection was found in labour 10.34%(9/87) of a samples followed by farmers and others 6.94% (115/1657). Table 33. Occupational Distribution of endemicity rate of lymphatic filariasis in four districts of Nepal. Occupation Total No of Infected Person % Person Farmer Student Labour Housewife

1657 1130 87 602

115 24 9 13

6.94 2.12 10.34 2.16

Busnessman

230

10

4.35

Unemployed

57

3

5.26

35 125 161 4084

8 2 184

6.29 0.012 37.472

Teaching Other Child Total

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MEAN MICROFILARIA DENSITY IN STUDY AREA The youngest person found infected with microfilaria was 6 yrs old girl with mean density of 0.33 per 20µlt blood and the oldest person was 75 yrs old man with mean density of 26.66 per 20µlt blood. The highest microfilaria density of 47 per 20 blood. Table 34. District – wise, microfilaria density District Sential Average Average mf sites mf density density in 2nd in 1st 20µl 20 µl blood blood Chitwan Bhandara 1 0 Ratnanager 0 3 2.43 1.21 Rupandehi Bairghat Bishnupura 5.41 NawalParasi Raninagar Kudiya Makwanpur Hatiya palung

4.72 4.53 2.73 1.09

0

Average Mean Mf mf density/ 20 density in µl blood 3rd 20 µl blood 0 0 1.28

0.33/20µl 1/20µl 1.64 /20µl

5.41

5.18/20µl

3.63 2.13 0.00

0

4.79 2.53 0.64

0

4.32/20µl 2.47/20µl 0.58/20µl

0/20µl

The survey result revealed that maximum microfilaria density was found in Bishnupura sentinel site of the Rupandehi district i.e. 5.18/µlt blood sample. While least density found only one per 20µlt blood in chitwan.

CLUSTERING IN FAMILY The ratio of the positive families was 5.16% (23/446) with an average of 2.6 cases per family.

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Discussion and Conclusion Community awareness and mobilization of the community people play a key role in the success of the community based health programme. Participation of the community people including with the social and community leaders, community health workers were much encouraging during the study period in all the eight sentinel sites of the four districts. These awareness programme played very important role to introduce the importance of the present survey, The disease, transmission pattern, pathology and importance of the night blood sample collection. The most important positive aspect of the awareness programme was to make familiar the team members in front of the community people, which was essential in this present political situation of the particular locality. Besides these, the awareness programme was intended to take common consent from the community leaders, social workers and health personnel to conduct the survey. In this sense, the outcome of the programme seemed extremely fruitful. Focusing to the community health workers filariasis survey training programme was organized which boosted up the night blood sampling programme upto the success.

During the survey a total of 4084 community people were interviewed and night blood samples were collected from two each sentinel sites of the four districts. Among them males were 2007 (49.15%) male and 2077(50.85%) female. Overall microfilaria prevalence revealed 2.86% in four district. District wise distribution of microfilaria was varied, highest prevalence was observed in Bishnupura VDC of the Rupandehi district i.e. 5.19% (54/1040). Among them highest prevalence was recorded in the Bishnupura sentinel site i.e 7.55%(40/530). Endemicity rate of the lymphatic filariasis includes the microfilaria positive cases with or without sign and symptoms as well as the crude disease rate (CDR) which includes chronic elephantiasis, limbs swelling, breast swelling, chyluria, skin thickness, lymphoedema etc too. Overall endemicity rate of lymphatic filariasis also showed very high in the Rupandehi district i.e. 8.2%(85/1040) followed by Nawalparasi and Makwanpur district while least in Chitwan district. Although the endemicity rate revealed in the present study also indicated higher than the microfilaria infection in all the district, still the endemicity data might not be the clear picture. Since most of the cases during the questionnaire survey don’t wish to expose their internal health problems. Earlier reports on microfilaria infection and disease endemicity rate in various districts of the country indicated 7.1-9.16% mf among urban population, 10.0311.3% in semi urban and 0.8-17.69% mf in rural population (Jung 1973). While in Gokarna VDC of the kathmandu valley reported 22.4% mf in blood samples of community people (Pradhan et al., 1997). Bhusal et al., (2000) reported 5.8% microfilaremia in Tokha-Chandeshwari VDC of kathmandu. Sherchand et al. (2002) reported 13% of microfilaria from 37 districts of the country. In present study, out of 4084 study population 24 had the elephantiasis, maximum 36 hydroceole, 13 chyluria cases in eight sentinel sites of the four districts of the country.

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Microfilaria infection rate and endemicity rate of lymphatic filariasis is low in Makwanpur and Chitwan compared to Nawalparasi and Rupandehi district. The reason behind the low prevalence of the disease might be the treatment of the community people against the lymphatic filariasis in the first phase of the elimination programme about one year before. The analysis of these various data on microfilaria infection and endemicity rate in different districts revealed wide variation but the ultimate conclusion is that the disease is most prevalent in all the hilly and terai districts of the country. Still large numbers of the chronic elephantiasis cases can be observed in most of the hilly and terai regions. Hydroceole another hidden public health problem existing in the society creating not only individuals health problems but also psycho- social disturbance among the married couples. During the field observation and interaction with the hydroceole patient both young unmarried and married men revealed piteous and pessimistic thinking regarding sexual and marriage life. This still needs to study in detail to explore the sociological problems and psychological problem along with the public health problem particularly in the countries like Nepal. The survey result revealed that maximum microfilaria density was found in Bishnupura sentinel site of the Rupandehi district i.e. 5.18 mf/20µlt blood sample. While least density found only one per 20µlt blood in Chitwan. The youngest person found infected with microfilaria was 6 yrs old girl with mean density of 0.33 per 20µlt blood and the oldest person was 75 yrs old man with mean density of 26.66 per 20µlt blood. The highest microfilaria density of 47 per 20µlt blood revealed from Rupandehi district. In rest of the districts Nawalparasi, Makwanpur and Chitwan showed mean microfilaria density of 05/20µlt blood. In some cases microfilaria density was found very high showing direct relationship with the risk group of that community. The earlier reports sex wise infection with microfilaria showed higher in males than females. In present study there is no marked difference between both sexes was observed in all the sentinel sites of the four districts. But age wise infection rate showed gradual increment with increase in age while gradually decreases with further increase in age i.e after 50 years. This might be due to fact that positive rate of MF in children as well as old age people are less due to less exposed to mosquito biting because because of their nature of the responsibility. The LF can be acquired in younger age group, can remain hidden for a long period of time without showing any clinical symptoms. In this study also CDR was also increasing with increase in age group 30-39 years to 50-59 years age groups. Sherchand et al., (2002 ) also showed insignificant distribution of the microfilaria antigenaemia in relation to the sex but regarding the age group highest positivity rate was shown in 46-50 age group. The highest knowledge about elephantiasis was found among secondary educational status population in which highest number of precaution was also found to be taken by same status population it was found that there is statistically significant difference of knowledge and precaution among different educational status people. In this case knowledge indicates the people who had either seen or heard regarding the elephantiasis 39 | P a g e

or the hydroceole around their community or somewhere else. Precaution refers the measures taken by the community people against mosquito biting such as the use of the bednets, ointments, mosquito mats, chemical spray etc. It has been observed that in terai region due to the hot temperature during nights, most of the community people belonging to the low economic conditions use to sleep outside the house without sleeved cloths which increases the chances of getting mosquito bite and transmission of the filariasis very much easily. Distribution of educational level of the study population showed that maximum samples were collected from the illiterate groups in Bhandara just reverse in Ratnanagar in case of Chitwan, while in Rupandehi, maximum samples were collected from illiterate group in both sentinel sites. In Nawalparasi, maximum samples were collected from literate groups but in Makwanpur, maximum samples were collected from the literates in palung and least form the Hetaunda. Although the distribution of the filariasis is not significantly related to the educational level, it was clear that it has direct impact on the knowledge of the vector borne diseases and practices towards the preventive measures taken against it. Distribution of endemicity rate in different occupational groups showed highest infection among the labour 10.34%(9/87) followed by farmers 6.94% (115/1657). Comparatively low endemicity rate observed among the other occupational groups directly related to the higher economic conditioned occupational groups like businessmen, teachers etc. In this report indicated that the educational level, occupation as well as the application of the preventive measures were considered as the potential risk factors of getting the filarial infection among the community people of the study area. Ninety percent of filarial infections are caused by Wuchereria bancrofti, and most of the remainder by Brugia malayi, for Wuchereria bancrofti humans are the exclusive host, and even though certain strain of B. malayi can also infect some feline and monkey species, life cycle in human and other animals generally remain epidemiologically distinct (Bista et al., 2000). But still filarial infections due to the Wuchereria bancrofti and Brugia malayi is not quantified. None of the taxonomic report exist yet in the context of Nepal. In this survey we have collected microfilaria with varied density range from 184 individuals from four districts of the country. During the microscopic examination of the microfilaria we have reported two distinct morphological structures of the microfilaria basically regarding the shape, size and extension of the nucleus. Some of the structures are more or less identical with the Brugia malayi {The photograph is attached with the report). The result indicates that filarial infection in Nepal is not only due to the Wuchereria bancrofti but also due to the Brugia malayi. But the result still needs to be verified with the molecular taxonomic methods.

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Recommendations v The mass drug administration, control programme must be regularized along with the monitoring of the same study population of the sentinel area throughout the elimination programme in order to assess the success of programme v Sentinel survey result can’t be generalized or representative of the whole district situation so that to figure out exact filariasis prevalence in the potentially risk district, wide and large scale randomized should be carried out. v Not only the treatment of the human beings but also needs to control the vectors side by side throughout the elimination programme. v Still the major cause of the filarial infection in the country has not been quantified, hence taxonomic research should be carried out which may help a lop in the elimination programme.

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References Bhusal, K. P., Joshi, A. B., Mishra, P. N. and Bhushal, K. (2000). Prevalence of Wuchereria bancrofti Infections of Tokha – Chandeshwori VDC Kathmandu Vallley, Nepal. J Inst Med; 22: 204-211. Bista, M. B., Banerjee, M.K., Thakur, G.D. and Shrestha, S.B. (2000). Lymphatic filariasis: Review of literature and Epidemiological analysis of the situation in Nepal 1994-1999. Epidemiology and Disease control division, Department of Health Service,Ministry of Health , HMG –Nepal. David T. Dennis, 1991. Lymphatic filariasis. VBC Tropical disease paper No. 9 Dreyer G, Noroes J, Addiss D. (1997).The silent burden of sexual disability associated with lymphatic filariasis. Acta tropica 63:57-60 Evans D, B., Gelband H, Vlassoff C. (1993). Social and economic factors and the control of lymphatic filariasis a review. Acta tropica,53:1-26. Jha S. C. (2003). An epidemiological study of microfilarial infection in eight districts of Nepal. Dissertation presented to CDZ (Parasitology). Jung, R. K. (1973). A brief study on the epidemiology of filariasis in Nepal. J Nep Med Ass; 11: 155-168. Manandhar, R. (2000). Epidemiological Study of Microfilariasis in three different geographical Region of Nepal. Dept Micro IOM; 112: 1-10. Michael, E., Bundy, D.A.P, Grenfel B.T., (1996). Re –assessing the global prevalence and distribution of lymphatic filariasis. Parasitology,112:409-428. Otteson, E.A (1994). The human filariasis, new understanding, new theurapeutic strategies. Current opinion in infectious diseases. 7:550-558.

Ottesen, E.A., Duke B. O. L, Karam, M and Behbenhani, K. (1997). Strategies and tools for the control/elimination of lymphatic filariasis. Bulletin of the World Health Organization. 75:491-503 Pradhan, S.P., Shrestha, I., Palikhey, N. and Uppretty,R.P. (1998). Epidemiological study of lymphatic filariasis in Gokarna VDC of Kathmandu Valley during august and September, 1997. J. NHRC; 2 (1): 13-17.

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Ramu et al., (1996). Impact of lymphatic filariasis on the productivity of male weavers in a south Indian village. Transaction of the Royal Society of Tropical Medicine and Hygiene 90:669-670. Sherchand, J.B., Obsomer, V., Thakur, G.D. and Hommel, M. ( 2002). Mapping of lymphatic filariasis in Nepal; Filaria J.WHO;www.filariajournal.com/content/2/1/7 . Thakur,G.D.(2000). Epidemiological Situation of Lymphatic filariasisin Nepal, Report submitted to Ministry of Health, Vector born Disease,Reaearch and Training Centre, Hetauda Nepal. Weerasooriya, M.V., Weerasooriya, T.R., Gunawardeha, N.K., Samarawickrema, W.A. and Kimura, E. (2001). Epidemiology of bancroftian filariasis in three suburban areas of Matara, Sri-Lanka, Ann Trop Med Parasitol; 95: 263-273. Witt, C. and Ottesen, E.A. (2001). Lymphatic Filariasis : An infection in Childhood. Trop Med and International Health ; 6: 582-606. World Health Organization. (1995). Lymphatic. filariasis and Onchocerociasis. TDR Twelfth Programme Report; 10532: 87-100. World Health Organization. (1997). Lymphatic filariasis Research onhope,CTD/FIL; 4: 1-20.

World Health Organization. (2000). 5: 1-35.

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Eliminate Filariasis Attack Poverty. CDS/SPE;

Photographs of Community awareness/mobilization programme

Bairghat: Rupandehi

Triveni: Nawalparasi

Bhandara: Chitwan 44 | P a g e

Triveni: Nawalparasi

Bhandara: Chitwan

Kudia: Nawalparasi

Photographs of Training Programme

Demons. Of blood collection from ear lobe

Reseach asst. -blood collection practice

45 |Demons. P a g e Of thick blood film

Training on questionnaire fillup

Demons. Of three drops of blood

Pricking ear lobe with lancet

Photographs of questionnaire survey

Questionnaire Survey in Bairghat of Rupendehi

Questionnaire Survey in Bishnupura of Rupendehi

Questionnaire Survey in Kudia of Nabalparasi

Questionnaire Survey in Bhandara of Chitwan

Questionnaire Survey in Ratnanagar of Chitwan

Questionnaire Survey in Hatiya VDC of Makwanpur

46 | P a g e

Photographs Of Night Blood Sample Collection

Blood Sample in Bairghat of Rupandehi

Blood Sample in Raninagar of Nawalparasi

Blood Sample in Bhandara of Chitwan

47 | P a g e

Blood Sample in Bishnupura of Rupandehi

Blood Sample in Ratnanagar of Chitwan

Blood Sample in Palung of Makwanpur

Photographs Of Clinical Symptoms

Brest Swelling in 52 yrs old Woman

Swelling in Hydrocoel

48 | P a Hand g e swelling in young age girl

Right Hand Swelling in 52 yrs old Woman

Swelling in Hydrocoel

Swelling in left lage

Photographs Of Slide Staining And Examinations

Dehaemolisation Prosses of blood flim

Cleaning the stained blood flim with distilled water

Examination of thick blood flim Under light Microscope

49 | P a g e

Adding the Giemsa Stain on blood flim

Drying the Blood flim in laboratory

Verifying the microfilaria under Phase Contrast Microscope

Photographs of microfilaria

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