Africa’s First Generation Free from Lymphatic Filariasis: Togo’s Triumph over an Infectious Disease

July 30th, 2016

Severe swelling from lymphatic filariasis and lymphedema in the leg of a Togolese man. Photo: HDI

Togo’s lymphatic filiariasis (LF) story began in 1997, when the World Health Assembly (WHA) passed a resolution calling for the “elimination of lymphatic filariasis as a public health problem.”[1] Although the idea of eliminating neglected tropical diseases (NTDs) such as LF was, at the time, unprecedented in Africa, and funding for such an endeavor was quite limited, Togo seized on WHA’s announcement and committed itself wholeheartedly to eliminating this debilitating disease.

Lymphatic filariasis (LF) is a parasitic disease that can cause massive, painful swelling of the legs, arms, breast, or genitals, potentially leading to permanent disfiguration, disability and social isolation. People who develop this type of swelling may be unable to work, till their fields, or care for their families. Children with the disease may not be able to go to school, run or play.

Afi, a 28-year-old Togolese woman who suffers from LF-related swelling known as lymphedema, says the disease has had a tremendously negative impact on her life, both economically and socially.

Meet Afi, a 28-year-old Togolese lymphastic filariasis victim and mother of two, who used to be a hairdresser before getting LF. Photo: HDI

“I have suffered from this disease for at least ten years,” she said. “I am a hairdresser, but because of this disease I am no longer able to work or to do my trade. This disease disturbs me, because every time I am short of money, well, I am poor, but there is nobody to help me.”

Afi says that the disease, which has also afflicted her mother and both her brothers, has affected her relations with her in-laws. “I’m not at ease because my in-laws, well, people say what they want, as they want, so that is the problem.”

Togo’s Fight against LF

Togo started working toward combatting LF in 1998, launching surveys to determine the distribution of the disease in the country. The prevalence of LF was as high as 36% among the surveyed population, and nearly one million people were at risk of infection, overall.

In 2000, the same year that the World Health Organization (WHO) established the Global Programme to Eliminate Lymphatic Filariasis, Togo’s Ministry of Health (MOH) took the huge step of launching its first mass campaign against LF. Under this campaign, the MOH treated the eligible population in one of the country’s eight endemic districts with a single dose of two LF-preventive medicines–albendazole and ivermectin.

From 2000 to 2009, the MOH distributed preventive medicines to nearly a million people per year to kill the parasite that causes LF. Over this time, ongoing surveillance began to show that fewer and fewer people were getting the disease. In 2009, a thorough survey showed that infection levels had dropped so low that it was finally safe for the MOH to stop mass drug treatments in Togo.

Leading the Way from Mass Treatment to Surveillance for LF

Once mass treatment was stopped, the country needed to make certain that the disease would not return, as it could easily be imported from neighboring countries that still have LF. However, since Togo was leading the continent in LF elimination, there was no established protocol for surveillance. As such, the country had to develop a system to track the disease on its own.

Dr. Ameyo Dorkenoo, the chief of the Programme for the Elimination of Lymphatic Filariasis in Togo, describes how the country developed an innovative surveillance system for tracking the disease.

Dr. Ameyo Dorkenoo, Programme Manager, Programme for the Elimination of Lymphatic Filariasis in Togo

“The WHO recommends putting in place surveillance to make certain that the disease does not come back once mass treatment has stopped,” she explained. “We examined some of the populations that had been proposed by experts as groups of people that might be easy to access and use for conducting effective surveillance, such as the military, university students, or blood donors.”

“But as we carefully studied these groups, including where these people live and their likely exposure to LF, we found that they did not represent the general population of Togo in their distribution or their risk for LF,” Dr. Dorkenoo continued. “Instead, we developed a surveillance system that relies on laboratories in every part of the country to examine blood films already being tested for malaria, and we used those to develop a highly effective surveillance system [for LF].”

Togo Is LF-Free…but Work Still Remains

During the course of eight years of ongoing surveillance for LF, two additional surveys in 2012 and 2015 (supported by the US Agency for International Development’s (USAID) END in Africa project, managed by FHI 360 and implemented in Togo by Health and Development International, or HDI, and the Task Force for Global Health) showed that there was no longer any transmission of the disease within Togo. In March 2016, Togo submitted a lengthy dossier of evidence to the WHO, clearly showing that the country had successfully addressed the two WHO-recommended pillars for LF elimination—interrupting LF transmission with mass drug administration and alleviating and preventing disability associated with the disease.

Togo is proving that with consistent effort and careful follow-up, LF can be eliminated as a public health problem. Feedback from WHO on Togo’s dossier is expected soon. Once Togo has received WHO’s certificate of verification of elimination of LF, Togo will officially be the first country in Africa where children can look forward to a life free of this debilitating disease.

Dr. Yao Sodahlon, who headed the Programme for the Elimination of Lymphatic Filariasis when it began 18 years ago, reflects on the significance of his country’s accomplishment. “No one could ask for a more successful outcome for the Togolese Programme, for the people of Togo. The Programme started in a period when the country was going through more than a decade of an international embargo and funding of lymphatic filariasis elimination activities was very low on the health priority list. Nevertheless, political will, consistently strong leadership, and innovative partnerships and strategies were some of the driving forces of this success. It is very rewarding for me to be part of this effort.”

Although LF is no longer a threat to the Togolese people, Togo’s MOH has no intention of resting on the laurels of its tremendous accomplishment while there’s still work to be done. Currently, the MOH is working to provide surgery to all individuals with hydrocele (i.e. scrotal swelling) and to provide care and training to individuals with lymphedema to reduce their pain, swelling, and risk of infection, and improve their quality of life.

In spite of the work that still needs to be done, the fact remains that every child born in Togo today can look forward to a life free from lymphatic filariasis. Currently pregnant with her third child, Afi couldn’t have been more thrilled to learn that her homeland is now free of LF.

“I am happy…. The problem that I’ve had with this disease, well, if my children would not have [these problems], I would be very happy,” she exclaimed. “It’s very good!”

Togo is set to become the first country in Africa to eliminate lymphatic filariasis as a public health problem.

[1] According to a 2014 World Health Organization (WHO) report on LF, 73 countries are considered to be endemic for LF. The WHO’s goal is to eliminate the disease as a public health problem by 2020.