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Despite Earthquake, Lymphatic Filariasis Program in Haiti Continues

Dr. Els Mathieu works with an LF team.

Dr. Els Mathieu in Haiti working with an LF team. Credit: CDC

Even an earthquake can't stop an outstanding public health program. With strong support from U.S. partners, including CDC and active local leaders, despite a setback of unprecedented magnitude, the lymphatic filariasis program in Haiti has managed to stay on track, treating nearly 3 million persons since the earthquake. With new CDC commitment and technical assistance from CDC's Drs. Patrick Lammie and Madsen Beau de Rochars, the program is now poised to reach the entire population of Haiti for the first time. Elimination of the disease in Haiti is a component of CDC's "Winnable Battles."

Lymphatic filariasis (LF), a mosquito-borne parasitic infection, causes elephantiasis and hydrocele (fluid-filled sac surrounding a testicle). Both conditions prevent affected persons from living full and productive lives and isolate them from family and community. Haiti is one of only four countries left in the Americas where transmission of LF still occurs. The Culex mosquitoes that transmit LF are adapted to breed in conditions where the environment has been degraded, a description which, unfortunately, applies to much of Haiti.

According to the World Health Organization (WHO), more than 8.6 million Haitians are at risk for LF, with a national infection prevalence of approximately 10%. LF infection levels in some communities are among the highest in the world; 30% of children are infected by age 4.

Interrupt Transmission with MDA

Transmission of LF can be interrupted by treating the entire population in endemic communities once per year for 5 to 8 years with a combination of the drugs diethylcarbamazine (DEC) and albendazole, or by distributing salt fortified with DEC. GlaxoSmithKline has pledged to support the global campaign to eliminate LF by providing albendazole for the effort. Albendazole also targets intestinal worms that cause anemia and malnutrition in children.

Photo of various people involved in the Haiti LF Program.

Dr. Madsen Beau de Rochars (second from right) in Haiti with collaborators Dr. Abdel Direny (far left) of the USAID-funded IMA World Health LF program, and Jean Marc Brissau (far right) of the Notre Dame LF program, and an associate (second from left). Credit: CDC

Before the Jan. 12 earthquake, an effective partnership had been developed to carry out mass drug administration (MDA) in a simultaneous effort to eliminate LF and control intestinal worms. Partners included the Haitian Ministry of Health (Ministere de la Sante Publique et de la Population); University of Notre Dame (funded by the Bill & Melinda Gates Foundation); IMA World Health (funded by RTI/USAID); and CDC. In 2009, this partnership treated 3.2 million persons. At their partners meeting on Jan. 12 (the day of the earthquake), the group developed plans to cover all of Haiti in 2010, with the exception of Port au Prince, for which funds were lacking. The absence of MDA in Port au Prince was the last remaining barrier to achieving full country coverage. Newly committed funds from CDC and other partners will now close this treatment gap, setting the stage for an important step forward in Haiti's national campaign to eliminate LF.

The genesis of the LF program in Haiti was a research effort carried out by CDC scientists beginning in the 1980s. These studies contributed to understanding of the diagnosis and treatment of infection and informed the global strategy to eliminate LF. The CDC-funded LF demonstration project in Leogane was designed to provide a scientific framework to test and validate LF elimination strategies. Results from the Leogane project documented a dramatic decline in the infection levels in the blood. In parallel, hookworm – a major cause of anemia around the world – virtually disappeared and declines in levels of other intestinal worms were observed. Previous studies in Haiti and elsewhere have documented that children experience growth spurts after de-worming. This decrease in intestinal parasites makes the filariasis program one of the most cost effective nutritional programs around.

The Leogane project also served as the foundation of the Haitian LF program and provided training opportunities for the Haitian team, now responsible for running the LF elimination program in Haiti. Dr. Beau de Rochars, an Ob/Gyn who started working with the Leogane project in 2000, is now a CDC Epidemic Intelligence Officer, stationed in Florida.

CDC EIS Officer Beau de Rochars, Haitian Colleagues Key To Success

Enumerator supervisor training for WASH KAP Study, conducted in Delmas, Haiti, December 5, 2010. Credit: CDC

EIS Officer de Rochars (center) during his detail in Haiti in the early part of the cholera epidemic. Credit: CDC

"Dr. Beau de Rochars played a critical role in the success of the program in Leogane," explains CDC's Dr. Patrick Lammie, who has devoted most of his career in public health to LF in Haiti. In 2001, for the second round of drug distribution, an event that takes place over 4-5 days, community participation rates on the first day were disappointingly low. Dr. Beau de Rochars was quick to respond with man-in-the-street interviews in an effort to define the problem. When it became clear that concerns about side effects were a major reason for the low coverage, Dr. Beau de Rochars and his team canvassed radio stations, churches, schools, and community groups to correct misunderstandings and to mobilize the community. This round-the-clock effort salvaged the Leogane program in its second year and set the stage for improved social mobilization campaigns that dramatically increased coverage in subsequent years.

From this beginning, Beau de Rochars went on to play a key role in the development of the national filariasis program, Lammie says. "That the program in Haiti continues today is a testimony to the commitment and dedication of Dr. Beau de Rochars and a small group of Haitian colleagues who continued to keep the focus on the program at considerable personal risk during periods of political instability. Their commitment was a source of inspiration and a testimony to why the lymphatic filariasis program in Haiti is succeeding."

CDC EIS Officer Beau de Rochars, who was temporarily detailed to Haiti to assist with the cholera outbreak, describes the successful community mobilization: "We sensitized the staff to be confident, helped to overcome fear, and urged the population to take the treatment. We also created an LF soccer team and organized an LF-themed drawing contest in the schools.

"'Dr. Pat' has helped me mature scientifically," Beau de Rochars says affectionately of his mentor, Dr. Lammie "He helped hone my sense of critical analysis and discipline, which has had a huge impact on me personally and the LF program. Our collaboration has motivated me to make the maximum effort." The LF program has given Haitians good results, he says. "Patients with LF complications are treated with respect and dignity; prevention is emphasized, especially for children; and by protecting kids from intestinal parasites, the LF program is offering children a better future."

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