Lymphatic Filariasis in Myanmar: Morbidity, Mass ...

Lymphatic Filariasis in Myanmar: Morbidity, Mass Drug Administration and Early Detection of Lymphatic Disease Jan Douglass, Ben Dickson, Susan Gordon, Patricia Graves Acknowledgements Myanmar MoH: Dr Ni Ni Aye, Dr Khin Nan Lon Myanmar VBDC: Dr Tint Wai, Dr Thet Nwe Wai Myanmar DMR: Dr Khin Saw Aye WHO SEARO: Dr San San Win JCU: Luke Becker, Maureen Roineau LSTM: Dr Louise Kelly-Hope, Dr Joseph Turner

JCU Collaborating Centre for the Control of Lymphatic Filariasis, Soil Transmitted Helminths and Other Neglected Tropical Diseases

Animations from The Vital Essence courtesy Professor Neil Piller

Image by Capoauno

Photo Washington Post

Fresh arterial flow

Capillaries

Empties into venous system

Lymph vessels & nodes

The Connective Tissue Bath

Venous return

Lymphoedema

Stage 0??

Outcomes of the Literature Review • Disparate range of measuring tools employed. • Current LFRL staging methods lack precision • Exercise can reduce BCRL limb volume in early stages • Hygiene based program reduced acute episodes but not limb size • Addition of remedial exercises, including deep breathing exercises, would be easy to implement in resource poor settings PloS NTD IF 4.46

No Stage 0 WHO guidelines for management of LF

Measure young people living in a LF endemic area with devices used to measure BCRL Minimal research on lymphoedema of the legs

Minimal research on lymphoedema in young people

“The mean tonometric measurements ……. ……..were significantly larger in participants with LF compared to the participants who had tested negative for LF”

Study - Aims 1. Determine if covert lymphedema can be detected in young people infected with LF 1. Identify the optimal point and form of intervention to prevent progression to chronic disease

The Prevalence of Lymphatic Filariasis Related Hydrocele, Lymphedema and Infection in Mandalay Region, Myanmar • Systematic Review and Meta Analysis • Primary aim • Determine prevalence of LF infection and morbidity in Mandalay Region • Secondary aim • Identify knowledge gaps in risk factors for LF infection • Explore risk factors non-participation in MDA

• >46% at risk of LF – South-East Asia – Bangladesh – North-East India

• Limited prevalence data – Infection – Morbidity

2015 Dickson BFR, Graves PM, McBride WJ. Lymphatic filariasis in mainland South-East Asia: a systematic review and meta-analysis of prevalence and disease burden. (Unpublished data)

Distribution of LF by WHO Regional Office

Systematic review & meta-analysis of LF prevalence & disease burden in mainland SEAsia

• Highly endemic in low-lying areas – Wuchereria bancrofti – Culex spp.

• Elimination program commenced in 2001 – Inconsistent coverage – Only Magwe Region had more than 6 rounds

• Lack of representative data – Very limited prevalence data

• Even less morbidity data – No formal morbidity management program 2015 Dickson BFR, Graves PM, McBride WJ. Lymphatic filariasis in mainland South-East Asia: a systematic review and meta-analysis of prevalence and disease burden. (Unpublished data)

Annals of Tropical Medicine and Parasitology, Vol. 96, Supplement No. 2, S3–S13 (2002).

LF in Myanmar

LF in Myanmar- Data Collection Timeline

Identification of study sites during 2013 MDA

Participant screening and selection Baseline measures and blood collection

Morbidity Survey LF prevalence and morbidity Second follow up

First follow up

September 2013

October 2014

December 2014 2014 MDA

January 2015

February 2015

March 2015

Treatment of +ve cases

June 2015

Morbidity Survey • Sentinel site records • 4/31 Townships in Mandalay Region – – – –

Amarapura Patheingyi Tada-U Wundwin

• Cross-sectional population-based household survey

Representative two step sampling

1014 Participants

Household Questionnaire

Testing for Infection

Physical Examination

Demographics of sample population Characteristics Villages

24

Households

430

1014 Participants (M: 368, F: 646) 36.3 Mean Age (M: 37.4, F: 35.6)

Infection Prevalence by Age and Sex Male

Female

20 15 10 5 0

1-14

15-29

30-44

45-59

Age (years)

60+

Total

Infection Prevalence by Township Infection Prevalence by ICT (%)

Adjusted Infection Prevalence by Mf (%)

ICT Average = 4.60%

16.00

Mf Average = 1.97%

14.00

Prevalence (%)

12.00

11.11

10.00 8.00 6.00

5.19 4.60

4.00

3.00

2.00

0.88

0.88

0.86

1.23

1.97 0.31

0.00

Amarapura

Patheingyi

Tada-U

Wundwin

Total

Chronic Scrotal Morbidity by Township Hydrocoele Prevalence in Males ≥ 15yrs (%) n = 269 35.0

Prevalence (%)

30.0 25.0 20.0

18.6

15.0

10.0 5.9

3.7

5.0

1.6

1.7

0.0 Amarapura

Patheingyi

Tada-U

Wundwin

Total

Chronic Scrotal Morbidity by Stage

Chronic Limb Morbidity Chronic Limb Morbidity

Tota Prevalenc Pos. l e (%)

Lower Limb Oedema

1.3 11 824 (0.6 – 2.4)

LF-related Lymphoedema

0

0 824 (0 – 0.45)

Estimation of morbidity prevalence in 4 Townships • High prevalence of hydrocele – 5.91% (3.34 – 9.55%) – 12 000 – 34 000 cases

• Low prevalence of lymphedema – 0 (0 – 0.45%) – Up to 3000 cases

Early Detection Study • Reliability Study – Use of the devices in novel populations

• Comparative Study – Determine anthropometric differences between young people in Australia and Myanmar – Establish population norms for the devices

• Cross sectional Survey – Comparison of LF infected / uninfected young people in Central Myanmar

• Longitudinal Study – Follow up after MDA and deworming medication

Mechanical Tonometry • Tonometry since 1976 – Objective measure tissue compressibility • (Clodius et al 1976)

• Mechanical Tonometer – – – –

Flinders Biomedical Engineering, SA 200gm weight, central plunger Must be held vertically Analogue readout

• Fair to good reliability – requires standardised procedure/user training • (Chen et al 2008, Moseley et al 2008)

Digital Tonometry • Indurometer – – – –

Flinders Biomedical Engineering, SA 200gm weight, central plunger Can be held at any angle Digital read out

• Previous reliability studies – Fair to good reliability • (Pallotta et al 2011, Vanderstelt et al 2015)

Digital Tonometry • SkinFibroMeter – Delfin Technologies, Finland – Smaller plunger which delivers 50gms

• No previous reliability studies • Measurement at mid point of – Anterior thigh – Posterior thigh – Calf

Bio-impedance Spectroscopy • SBF7 – Impedimed Australia – Multifrequency analyser – Intracellular:extracellular fluids

• Excellent reliability – Influenced by age, gender & body mass • (Dittmar M., 2003)

– Children • (Avila et al, 2015)

– Detection of latent BCRL • (Cornish et al, 2001)

Two Tropical Populations • Young people aged 8 – 18 years – No lower limb injuries – No lymphatic disturbance

• Amarapura Township – Central Myanmar – 21.9038840 North

• Townsville – North Queensland – 19.2576220 South

Reliability Study

Intraclass Correlation Coefficient (ICC) • • • • •

0 = no correlation < 0.4 = poor agreement 0.4 – 0.75 = fair to good > 0.75 = excellent 1 = absolute agreement • (Fleiss, 1999)

• All BIS measures were approaching 1, many >0.9999

SFB7

1.2 1 0.8 0.6 0.4 0.2

0 Re

Ri

Dominant leg

Myanmar n = 36

Re

Ri

Fai

Non dominant le Non dominant leg

Australia n = 32

ICC – Tonometry devices

ICC – Tonometry devices

Comparative Study p= Device Tape (circumference)

BIS SFM

IND

TON

Location

All Participants

Myanmar Cohort

Australian Cohort

Myanmar Males

Australian Males

Myanmar Females

Australian Females

Calf

0.825

0.786

0.341

0.781

0.871

0.899

0.148

Thigh

0.000

0.015

0.010

0.277

0.142

0.032

0.032

Leg

0.000

0.000

0.951

0.054

0.228

0.000

0.783

Ant thigh

0.001

0.002

0.135

0.043

0.092

0.022

0.170

Post thigh

0.004

0.869

0.000

0.431

0.012

0.525

0.000

Calf

0.055

0.007

0.925

0.156

0.953

0.015

0.944

Ant thigh

0.036

0.000

0.446

0.005

0.875

0.004

0.170

Post thigh

0.001

0.020

0.011

0.039

0.132

0.163

0.042

Calf

0.042

0.000

0.256

0.081

0.490

0.000

0.379

Ant thigh

.

0.000

.

0.016

.

0.000

.

Post thigh

.

0.910

.

0.543

.

0.516

.

Calf

.

0.010

.

0.578

.

0.004

.

Early Detection Study • Young people aged 10-21years – Amarapura Township

• Screened for eligibility – No clinical symptoms – No injuries

Early Detection Study • Tested for LF infection – Binax Now ICT card

Early Detection Study • Age and gender matched pairs – Physical measures

Early Detection Study • Age and gender matched pairs – Blood samples

Screening for LF Infection n=317 141

140

22.0%

29.9%

M=22.6%

M=40.0%

25.0%

14.0%

18.5%

34.5%

24.4%

54.5%

49.1%

120 100

95

87

80

F=21.1%

105 84

F=25.3% 59

60 47

40 20

30 19 21

27

21

20 8

12

0

10 - 17 year olds

35

18 - 21 year olds

12

10 2 3 0

Amarapura

Males -ve

11 9

8

0

Thar Le Swart

Sar Kyin Wa

Females -ve

3

26

31

25

30

7

4 1 2 4

Other Villages

Males +ve

33

Eligible

Females +ve

Included

Excluded

Baseline – October 2014 n=98 • Invited (114) – Returned for measures (104)

• Excluded – Too old (4) – Pregnant (1) – Artificial leg (1)

• No significant differences by ICT – Height – Weight

• No significant differences in gender groups – Height – Weight

160

140 120 100 80 60

40 20 0

Age in years

Height in cm

Weight in kg

Negative Males n=21

Positive Males n=21

Negative Females n=30

Positive Females n=25

Comparison of +ve & -ve cases Circumference (cm)

BIS (Ri:Re)

60.00

4

50.00

3.5

3

40.00

2.5

30.00

2

20.00

1.5

10.00

1

0.00

42.52 41.98

42.19 41.69

24.82 24.70

24.84 24.71

Dominant Nondominant Dominant Nondominant Thigh Thigh Calf Calf

Negative n=52

Positive n=46

2.549

2.837 2.436

2.628

0.5

0 Dominant Leg

Negative n=49

Nondominant Leg

Postive n=43

SkinFibroMeter 0.160 0.140 0.120 0.100 0.080 0.060 0.040 0.020 0.000

0.072 0.076

0.064 0.068

0.085 0.084

0.084 0.089

0.095 0.103

0.106 0.106

Dominant Anterior Thigh

Non Dominant Anterior Thigh

Dominant Posterior Thigh

Nondominant Posterior Thigh

Dominant Calf

Nondominant Calf

Negative n= 52

Positive n=46

Mechanical Tonometer

TON Higher = Softer

9.00 8.00 7.00

6.00 5.00 4.00 3.00 2.00

1.00 0.00

6.53

6.56


7.10

7.02

Nondominant Anterior Thigh

5.59

5.64


Negative n=52

5.57

5.47


Positive n=46

4.26

4.26

Dominant Calf

4.04

4.14

Nondominant Calf

Indurometer

IND Higher = Softer

7.00 6.00

10%

5.00

p=0.045 95% CI (0.469, 0.005)

4.00

*

3.00

2.00 1.00 0.00

4.72

4.83


5.02

5.08


4.07

4.13


Negative n= 52

3.88

3.85


Positive n=46

2.73

2.89

Dominant Calf

2.49

2.73

Nondominant Calf

Grouped by Gender Indurometer – Nondominant Calf 3.50

14% p = 0.032 *

3.00 2.50

IND Higher = Softer 8% p = 0.044 *

2.00 1.50 1.00 0.50

0.00

2.20

2.50

2.70

Male n= 22/21

2.92

Female n=30/25 Negative

Positive

October 2014, February 2015, June 2015 180 152 153 154

160

151 152 150

140 120 100 80 60 42

44

44

40 20

16

15

16

15

18

42

43

49 40

53 46

44

45

42

15

0

Age in years Age in years Height in cm Height in cm Weight in kg Weight in kg -ve +ve -ve +ve -ve +ve

October 2014 n=98

February 2015 n=88

% Male +ve

June 2015 n=79

% Female +ve

Skin FibroMeter Negative cases

Positive cases p=0.015 *

0.16 0.14 0.12 0.1

p=0.000 *

p=0.014 *

0.16 0.14 0.12

p=0.011 *

0.1

0.08

0.08

0.06

0.06

0.04

0.04

0.02

0.02

0

0 Dominant Nondominant Dominant Nondominant Dominant Calf Nondominant Anterior Thigh Anterior Thigh Posterior Thigh Posterior Thigh Calf

October n=52

February n=48

June n=45

p=0.034 *

p=0.033 *

p=0.019 *

p=0.029 *

p=0.026 *

Dominant Nondominant Dominant Nondominant Dominant Calf Nondominant Anterior Thigh Anterior Thigh Posterior Thigh Posterior Thigh Calf

October n=46

February n=40

June n=34

Indurometer Negative cases

Positive cases

7 6

p=0.000 *

p=0.000 *

5

7

p=0.000 *

6

p=0.009 *

p=0.000 *

p=0.000 * p=0.000 *

5

4

p=0.000 *

3

p=0.000 *

1

1

0

0

Hotter

February n=48

Hot

p=0.000 *

p=0.000 *

3 2


p=0.000 *

4

2

October n=52

IND Higher = Softer


June n=45

October n=46

Hottest

Hotter

February n=40

Hot

June n=34

Hottest

Tonometer Negative cases

Positive cases

10

10

9

p=0.000 *

p=0.001 *

9

8

8

7

7

6

6

5

5

4

4

3

3

2

2

1

1

0

0 Dominant Nondominant Dominant Nondominant Dominant Calf Nondominant Anterior Thigh Anterior Thigh Posterior Thigh Posterior Thigh Calf

October n=52

February n=48

June n=45

TON Higher = Softer

p=0.000 *


October n=46

February n=40

June n=34

BIS Negative cases

Positive cases

4

3.5

4

p=0.001 *

p=0.001 *

p=0.016 *

Nondominant

Dominant

Nondominant

June n=45

October n=43

p=0.001 *

3.5

3

3

2.5

2.5

2

2

1.5

1.5 Dominant October n=49

February n=48

February n=38

June n=33

2nd Follow Up – June 2015 Circumference (cm)

BIS (Ri:Re)

60.00

4

50.00

3.5 3

40.00

2.5

30.00

2

20.00

1.5

1

10.00 0.00

43.21 40.52

Dominant Thigh

43.30 40.66

25.33 24.92

25.24 24.81

Nondominant Dominant Calf Nondominant Thigh Calf

Negative n=45

Positive n=34

0.5 0

2.826

2.872

Dominant Leg Negative n=45

2.893

2.941

Nondominant Leg Postive n=33

SkinFibroMeter June 2015 0.16 0.14 0.12

p = 0.014 * 11%

0.10 0.08 0.06 0.04 0.02

0.00

0.061 0.067

0.061 0.068

0.088 0.090

0.082 0.073

0.115 0.108

0.090 0.088


Non Dominant Anterior Thigh



Dominant Calf

Nondominant Calf

Negative n=45

Positive n=34

Tonometer – June 2015 10

TON Higher = Softer

p=0.000 *

9 8 7 6 5 4 3

2 1 0

7.741 7.457

7.703 7.301

6.058 6.052

5.922 6.028





Negative =45

Positive n=34

4.376

4.375

Dominant Calf

4.426 4.451 Nondominant Calf

Indurometer – June 2015

IND Higher = Softer

7.00 6.00 5.00 4.00 3.00 2.00

1.00 0.00

5.23

5.14


5.13

5.02


4.18

4.14

Dominant Posterior Thigh Negative n=45

4.05

4.11

Nondominant Posterior Thigh Positive n=34

2.69

2.85

Dominant Calf

2.74

2.77

Nondominant Calf

Grouped by Gender

IND Higher = Softer

Indurometer – Dominant Calf 4 3.5 3

24% p = 0.08 *

2.5 2 1.5 1

0.5 0

2.139

2.652

2.974

Male n=15/12

2.956

Female n=29/22

Negative

Positive

Outcome of Longitudinal Results • Reversal of early changes through • MDA or deworming medication? • Seasonal? • Individual hydration? • Menstrual cycles? • Occupation? • Age?

Research Outcomes – so far • The devices are reliable in novel populations • Established population norms for the devices • There is a difference in the legs of young people who are infected with LF • Some changes after MDA and deworming medication – but not complete reversal

MDA Consumption (%) 80

70

68.2 66.7

61.9

59.1

60

50

50 40

43.3 35.3

41.48

30

30 20 8

10 0

Male +ve

Male -ve Female +ve Female -ve

MDA 2013

MDA 2014

Total

% Persons who consumed the MDA

% MDA Participation, Mandalay Region 30

28.19

27.78

25 20 15 10

13.17 7.82

7.51

8.33

7.2

5 0

0

1

2 3 4 5 Number of time the MDA was consumed

n=1041

6

Meeting of WHO Regional Programme Review Group (RPRG) for Elimination of Lymphatic Filariasis and Soil Transmitted Helminthiasis Bangkok, June, 2016

Implications for the National Program Poor MDA Coverage (2.9 visits of 6)

Absenteeism 12%

MDA Refusal 8%

Low Ingestion of MDA Persistent Infection (4.60%)

Further Rounds of MDA Required Focus on Improved Coverage

Initiate Education Programs

PLoS Negl Trop Dis. 2010;4(6):e728.

Is the GPELF Standing on One leg? MDA

Photo: Sengai Podhuvan

MMDP

Interruption of transmission Elimination by 2020 by 2020 • 73 countries were considered to be endemic – 18 countries have already progressed to the surveillance phase – 55 countries continue to require MDA – 11 countries have not yet started MDA – 23 countries MDA in only a fraction of the endemic areas

• 73% endemic countries have initiated any MDA • 36% endemic countries have an active MMDP program • MDA typically precedes MMDP by several years

• 62 countries are considered not on track to eliminate LF by 2020 WHO: Global programme to eliminate lymphatic filariasis: progress report, 2014. Wkly Epidemiol Rec. 2015;38(90 ):489-504.

Morbidity Survey - 4 Townships • High prevalence of hydrocele – 12 000 – 34 000 cases • Surgical program

• Low prevalence of lymphedema – 3000 cases • MMDP program

• MDA consumption – Social Engagement • Training volunteer drug distributors • Education of quarter leaders

Early Detection Study – Amarapura Township • Uniform trend of tissue softening – Infected participants

• Amend MMDP guidelines to – Include Stage 0 – Include preventative practices

• Further research on – Identification of people at risk – Proactive intervention in early stages

CBHC training in Tada U and Patheingyi

Community Based Home Care

Per-person savings are more than 130 times the per-person cost of the program

Biochemical Analysis • Department of Medical Research, Yangon – Og4C3 and Bm14 ELISA

Biochemical Analysis • LSTM, Parasitology Laboratory – Julio Furlong-Silva

• Multiplex ELISA – Pro-inflammatory cytokines – Vascular endothelial growth factors

Whole blood samples were collected in chilled EDTA tubes and kept on ice until separation (< 4 hours after collection)

Duplicate plasma samples (2 x 2ml vials) were stored short term at -20C at Public Health Laboratory, Mandalay

Frozen samples were transported by car to Yangon (48kg dry ice, < 48 hours )

One sample was aliquot into 1ml vial to be transported to Australia on freezer blocks (blocks frozen to -80C)

then stored long term at Department of Medical Research, Yangon ( -80C freezer)

One set of 2ml samples was transferred to -80C freezer, LSTM

Acknowledgements - Institutions • Ministry of Health and Sports, Union of the Republic of Myanmar • Vector Borne Disease Control, Mandalay Regional Office • Public Health Laboratory, Mandalay • Department of Medical Research, Yangon • WHO, Myanmar Regional Office • Australian Embassy, Yangon

Memorandum of Understanding JCU – Myanmar MoHS

JCU WHO Collaborating Centre for the Control of Lymphatic Filariasis, Soil Transmitted Helminths and other Neglected Tropical Diseases

Local Research Assistants

Funding and Support Services •

Prevalence survey – – – –

•

Australian Institute of International Affairs (AIIA) College of Medicine, JCU Mr Euan Crone Royal Australasian College of Pathologists (RACFunding)

Early Detection Study – 237 Individuals - $10 - $1000 • Many have made multiple donations

– Donated and discounted goods and pro bono services • • • • • • •

Impedimed Australia, loan BIS unit and supply of electrodes Delfin Technologies Finland, loan SkinFibroMeter Cellabs Australia, provision of BM14 ELISA kits Singapore Airlines, discount airfares Nation Advertising, pro bono fundraising campaign Aetherstudios, free web design Pentagon Freight, free placement of N2 Shipper

Funding and Support Services • LSTM Parasitology Laboratory – Transport of samples • Myanmar to UK

• Funding for two Myanmar scientists – Travel and accommodation

Blog www.myanmar-project.com/blog Facebook, Jan Douglass (Myanmar Project) Twitter @JanDouglass_JCU Tax deductible donations www.alumni.jcu.edu.au/TheMyanmarProject

Questions? Cheizu Tinbarte (Thank You)