**6. Discussion**

Now India is on a critical phase for ELF facing serious challenges. The main challenge is the implementation of MDA with improved actual drug compliance so as to cover >80% at-risk population. It is required to have continued IEC activities, community engagement and all-round support [27]. It is really a huge operational and logistical challenge to cover about 650 million populations for the MDA programme.

In June 2018, in the 10th GPELF meeting at New Delhi, India, the government of India launched Accelerated Plan for Lymphatic Filariasis Elimination (APELF). A triple-drug therapy or IDA (IVM, DEC and ALB) along with community engagement has been planned for accelerating the LF elimination in India [28, 29]. As a pilot project, IDA has been rolled out successfully across four districts in India. These districts are Arwal in Bihar (20 December 2018), Simdega in Jharkhand (10 January 2019), Nagpur in Maharashtra (20 January 2019) and Varanasi in Uttar Pradesh (20 February 2019). A total of 8.07 million people out of 10.7 million vulnerable people (75.4%) were benefitted with the IDA medicines. The IDA approach is to be scaled up in all endemic districts to eliminate LF by 2021. It is expected that with triple-drug combination, if effective, actual drug compliance is achieved; the MDA districts may qualify for TAS and also clear the TAS successfully.

Another important issue is asymptomatic cases in children age group. In some endemic areas, about 30% of children have acquired LF by the age of 4 years either with the presence of Mf or *W. bancrofti* antigen in their blood [30]. Similarly, in a *B. malayi* area in Kerala, asymptomatic Mf has been demonstrated in children through LSG [31]. LF parasites in human do not have animal reservoirs. But human dirofilariasis, i.e. zoonotic transmission to human, cannot be ruled out. This thing should be kept in mind after successful ELF in human [32]. There are other issues of management of acute and chronic filariasis cases and treatment of adenolymphangitis (ADL) cases with antibiotics since the majority of acute episodes are bacterial origin. The APELF provides free morbidity management and disability prevention services through kits and corrective surgeries [28].

Vector surveillance is another important tool to facilitate in instituting vector control measures as well as to assess the infection in vectors in the areas. Xenomonitoring, in other words, the presence of Mf larvae in vector mosquitoes, is a method to assess the effectiveness of the post-MDA and TAS. Specific PCR technique is applied [33]. Recently Khatri et al. screened the presence of *W. bancrofti* L3-specific *Ssp1* gene in trapped mosquitoes by PCR in certain districts in Maharashtra and Karnataka. This indicated that MDA needed to be strengthened [33]. Scaling up xenomonitoring is a big challenge in existing infrastructure with weak strength of skilled entomologists. At present IVM has been planned to introduce in all LF endemic districts in India covering many districts endemic for malaria also. IVM introduction in context of malaria control is towards targeting their vector populations [34]. It is important to assess the impact of other coexistent diseases in the same eco-endemic regions [35].

#### **7. Conclusion**

India is on a very strong ground to achieve lymphatic elimination [19]. Several efforts are now in place. The total disability-adjusted life years (DALYs) lost due to LF is around 2.06 million, resulting in an annual wage loss of US \$811 million [36]. A special emphasis has been given on the general hygiene and environmental management of mosquito vectors under the *Swachh Bharat Mission* (Clean India Movement) and also to provide special incentive under the *Ayushman Bharat* to make the programme effective and successful [37].

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**Author details**

Susanta Kumar Ghosh1

\* and Pradeep Kumar Srivastava<sup>2</sup>

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 ICMR-National Institute of Malaria Research, Bengaluru, India

2 National Vector Borne Disease Control Programme, Delhi, India

\*Address all correspondence to: ghoshnimr@gmail.com

provided the original work is properly cited.

*A New Outlook in Lymphatic Filariasis Elimination in India*

The authors declare no conflict of interest.

*DOI: http://dx.doi.org/10.5772/intechopen.92454*

**Conflict of interest**

*A New Outlook in Lymphatic Filariasis Elimination in India DOI: http://dx.doi.org/10.5772/intechopen.92454*
