A controlled trial of ivermectin and diethylcarbamazine in lymphatic filariasis

Avermectin Derivatives, Pharmacokinetics, Therapeutic and Toxic Dosages, Mechanism of Action, and Their Biological Effects

Avermectins are a group of drugs that occurs naturally as a product of fermenting Streptomyces avermitilis, an actinomycetes, isolated from the soil. Eight different structures, including ivermectin, abamectin, doramectin, eprinomectin, moxidectin, and selamectin, were isolated and divided into four major components (A1a, A2a, B1a and B2a) and four minor components (A1b, A2b, B1b, and B2b). Avermectins are generally used as a pesticide for the treatment of pests and parasitic worms as a result of their anthelmintic and insecticidal properties. Additionally, they possess anticancer, anti-diabetic, antiviral, antifungal, and are used for treatment of several metabolic disorders. Avermectin generally works by preventing the transmission of electrical impulse in the muscle and nerves of invertebrates, by amplifying the glutamate effects on the invertebrates-specific gated chloride channel. Avermectin has unwanted effects or reactions, especially when administered indiscriminately, which include respiratory failure, hypotension, and coma. The current review examines the mechanism of actions, biosynthesis, safety, pharmacokinetics, biological toxicity and activities of avermectins.

Review of Dancing Parasites in Lymphatic Filariasis

Lymphatic filariasis is an infection transmitted by blood-sucking mosquitoes with filarial nematodes of the species Wuchereria bancrofti, Brugia malayi und B. timori . It is prevalent in tropical countries throughout the world, with more than 60 million people infected and more than 1 billion living in areas with the risk of transmission. Worm larvae with a length of less than 1 mm are transmitted by mosquitoes, develop in human lymphatic tissue to adult worms with a length of 7-10 cm, live in the human body for up to 10 years and produce millions of microfilariae, which can be transmitted further by mosquitoes. The adult worms can be easily observed by ultrasonography because of their size and fast movements (the so-called "filarial dance sign"), which can be differentiated from other movements (e. g., blood in venous vessels) by their characteristic movement profile in pulsed-wave Doppler mode. Therapeutic options include (combinations of) ivermectin, albendazole, diethylcarbamazine and doxycycline. The latter depletes endosymbiotic Wolbachia bacteria from the worms and thus sterilizes and later kills the adult worms (macrofilaricidal or adulticidal effect).

Cervical Lymphatic Filariasis in a Pediatric Patient: Case Report and Database Analysis of Lymphatic Filariasis in the United States

Lymphatic filariasis is a mosquito-borne parasitic infection caused by Wuchereria bancrofti and Brugia spp. Commonly seen in tropical developing countries, lymphatic filariasis occurs when adult worms deposit in and obstruct lymphatics. Although not endemic to the United States, a few cases of lymphatic filariasis caused by zoonotic Brugia spp. have been reported. Here we present a case of an 11-year-old female with no travel history who was seen in our clinic for a 1-year history of painless left cervical lymphadenopathy secondary to lymphatic filariasis. We review the literature of this infection and discuss the management of our patient. Using the National Inpatient Sample (NIS), the largest publicly available all-payer inpatient care database in the United States, we also examine the demographics of this infection. Our results show that chronic lymphadenopathy in the head and neck is the most common presenting symptoms of domestic lymphatic filariasis. Diagnosis is often made after surgical lymph node excision. Examination of the NIS from 2000 to 2014 revealed 865 patients admitted with a diagnosis of lymphatic filariasis. Most patients are in the mid to late sixties and are located on the eastern seaboard. Eight hundred and twenty six cases (95.5%) were likely due to zoonotic Brugia spp. and 39 (4.5%) due to W. bancrofti. Despite being rare, these data highlight the need to consider filariasis in patients presenting with chronic lymphadenopathy in the United States.

Adverse events following single dose treatment of lymphatic filariasis: Observations from a review of the literature

Background

WHO’s Global Programme to Eliminate Lymphatic Filariasis (LF) uses mass drug administration (MDA) of anthelmintic medications to interrupt LF transmission in endemic areas. Recently, a single dose combination of ivermectin (IVM), diethylcarbamazine (DEC), and albendazole (ALB) was shown to be markedly more effective than the standard two-drug regimens (DEC or IVM, plus ALB) for achieving long-term clearance of microfilaremia.

Objective and methods

To provide context for the results of a large-scale, international safety trial of MDA using triple drug therapy, we searched Ovid Medline for studies published from 1985–2017 that reported adverse events (AEs) following treatment of LF with IVM, DEC, ALB, or any combination of these medications. Studies that reported AE rates by treatment group were included.

Findings

We reviewed 162 published manuscripts, 55 of which met inclusion criteria. Among these, 34 were clinic or hospital-based clinical trials, and 21 were community-based studies. Reported AE rates varied widely. The median AE rate following DEC or IVM treatment was greater than 60% among microfilaremic participants and less than 10% in persons without microfilaremia. The most common AEs reported were fever, headache, myalgia or arthralgia, fatigue, and malaise.

Interpretation

Mild to moderate systemic AEs related to death of microfilariae are common following LF treatment. Post-treatment AEs are transient and rarely severe or serious. Comparison of AE rates from different community studies is difficult due to inconsistent AE reporting, varied infection rates, and varied intensity of follow-up. A more uniform approach for assessing and reporting AEs in LF community treatment studies would be helpful.

WHO’s Global Programme to Eliminate Lymphatic Filariais (LF) supports annual mass drug administration to over 400 million people in LF-endemic areas each year. Two drug combinations (either DEC or ivermectin, given with albendazole) have been recommended in most endemic areas. With the exception of well-described serious adverse events (AEs) occurring in patients with high level loiasis, severe AEs due to these medications are extremely rare. Mild to moderate AEs, however, are common, particularly in patients with active filarial infection. In this manuscript we synthesize published data on AEs following single-dose treatment of LF with ivermectin, DEC, or albendazole. This provides a background against which to compare the safety of triple drug therapy (ivermectin, DEC, and albendazole) recently endorsed by WHO, and provides a useful context for evaluating safety of new treatments for LF. The compiled data illustrate that transient, mild to moderate AEs following single-dose LF treatment are common in microfilaremic patients and are much less common in amicrofilaremic patients. They also show that passive surveillance for post-treatment AEs underestimates AE incidence and suggest that adherence to common reporting standards would improve the usefulness of AE reporting in filariasis studies.

A Splendid Gift from the Earth: The Origins and Impact of the Avermectins (Nobel Lecture)

Japanese soil was the origin of one of the most important drugs of the world: ivermectin. No other drug has such importance for the health of millions of people, particularly in the poor regions of the world. The discovery of the parent compounds of the avermectines is described first hand by S. Ōmura.

How do the macrocyclic lactones kill filarial nematode larvae?

The macrocyclic lactones (MLs) are one of the few classes of drug used in the control of the human filarial infections, onchocerciasis and lymphatic filariasis, and the only one used to prevent heartworm disease in dogs and cats. Despite their importance in preventing filarial diseases, the way in which the MLs work against these parasites is unclear. In vitro measurements of nematode motility have revealed a large discrepancy between the maximum plasma concentrations achieved after drug administration and the amounts required to paralyze worms. Recent evidence has shed new light on the likely functions of the ML target, glutamate-gated chloride channels, in filarial nematodes and supports the hypothesis that the rapid clearance of microfilariae that follows treatment involves the host immune system.

Characterization of Haemonchus contortus P-glycoprotein-16 and its interaction with the macrocyclic lactone anthelmintics

Anthelmintic resistance in veterinary nematodes, including Haemonchus contortus, has become a limitation to maintaining high standards of animal health. Resistance in this parasite, to all drug families including the macrocyclic lactones (MLs) is a serious issue worldwide. Mechanisms of resistance to the MLs appear to be complex and to include the elimination of these compounds by ABC transporter-like proteins present in nematodes. In order to investigate the potential involvement of ABC transporters in ML resistance in H. contortus, we have characterized the functionality of the ABC transporter H. contortus P-glycoprotein-16 (Hco-PGP-16) expressed in mammalian cells. This has included a study of its interaction with different MLs, including the avermectins, abamectin (ABA) and ivermectin (IVM), and the milbemycin, moxidectin (MOX). Hco-PGP-16 transport activity was studied using the fluorophore Rhodamine 123 (Rho 123). Transfected cells expressing Hco-PGP-16 accumulated less than 50% of Rho 123 than control cells, suggesting an active transport of this tracer dye by Hco-PGP-16. The influence of the MLs on the Rho123 transport by Hco-PGP-16 was then investigated. A marked inhibition of Rho123 transport by ABA and IVM was observed. In contrast, MOX showed less effect on inhibition of Rho123 transport by Hco-PGP-16, and the inhibition was not saturable. The difference in the interaction of the avermectins and MOX with Hco-PGP-16 may help explain the slower rate of development of resistance to MOX compared with the avermectins in H. contortus.

Awareness and coverage of mass drug administration for elimination of lymphatic filariasis: a community based cross sectional study in Nepal

Lymphatic filariasis (LF) is among the major public health problems in Nepal. The disease is a major cause of morbidities primarily, lymphedema of legs and hydrocele and it impedes socio economic development in many endemic areas of the country. This study is aimed at exploring the understanding of people about mass drug administration (MDA) of the said disease and the status of compliance of MDA in Nepal. This study is a cross sectional study carried out among 894 household samples in three of the sixty LF endemic districts. The selected districts were Dhading, Kapilvastu and Kailali. The sentinel surveillance of sites in three districts constituted the sampling frame at the first stage. The peripheral health care centers in the sentinel sites constituted the sampling frame at the second stage of sampling. The coverage of MDA was 95.5 %. However, the compliance was less. Only 71.6 % of the respondents who took the drugs from health workers swallowed the diethyl carbamazine (DEC) completely, other did not swallow. In the present study, majority of respondents reported that they had heard or seen persons with side effects of DEC in their community. A total of 20 % of respondents reported that they had side effects after having DEC and only 3.9 % of these side effects were treated. The Female Community Health volunteers (FCHVs), health workers and radio/Television (TV) were the chief sources of MDA related information. This study recommends for a concerted public health action combining effective drug delivery mechanism and sound public awareness campaigns. The community people need to be made aware beforehand about the location, time of drug distribution. Also public awareness of the DEC should be conducted so that people would trust it and comply with the drug regime. Along with the health workers and radio/TV that has been used traditionally, we recommend mobilization of FCHVs in the public awareness campaigns the MDA campaigns.

In vivo protection against strychnine toxicity in mice by the glycine receptor agonist ivermectin

The inhibitory glycine receptor, a ligand-gated ion channel that mediates fast synaptic inhibition in mammalian spinal cord and brainstem, is potently and selectively inhibited by the alkaloid strychnine. The anthelminthic and anticonvulsant ivermectin is a strychnine-independent agonist of spinal glycine receptors. Here we show that ivermectin is an effective antidote of strychnine toxicity in vivo and determine time course and extent of ivermectin protection. Mice received doses of 1 mg/kg and 5 mg/kg ivermectin orally or intraperitoneally, followed by an intraperitoneal strychnine challenge (2 mg/kg). Ivermectin, through both routes of application, protected mice against strychnine toxicity. Maximum protection was observed 14 hours after ivermectin administration. Combining intraperitoneal and oral dosage of ivermectin further improved protection, resulting in survival rates of up to 80% of animals and a significant delay of strychnine effects in up to 100% of tested animals. Strychnine action developed within minutes, much faster than ivermectin, which acted on a time scale of hours. The data agree with a two-compartment distribution of ivermectin, with fat deposits acting as storage compartment. The data demonstrate that toxic effects of strychnine in mice can be prevented if a basal level of glycinergic signalling is maintained through receptor activation by ivermectin.

A double-blind controlled field trial of doxycycline and albendazole in combination for the treatment of bancroftian filariasis in India

In a placebo controlled field trial, the effects of doxycycline (200mg/day) for 23 days followed by doxycycline (200mg/day) in combination with albendazole (ABZ) (400mg/day) for 7 days on depletion of Wolbachia endobacteria from Wuchereria bancrofti and microfilaricidal activity were studied in 68 patients (34 males and 34 females) from West Bengal, India. The drugs in combination (i.e., doxycycline+ABZ) provided the best efficacy by totally eliminating the circulating microfilaria (mf) (in 42% cases) on day 365 with (99.8%, P<0.05) suppression even on day 365 post-treatment compared to both exclusive doxycycline (69%, P<0.05) and ABZ (89%, P<0.05) groups. Thus, our results have established that a 30-day course of doxycycline in combination with a 7-day course of ABZ is sufficient to ensure long-term reduction in mf level by depleting Wolbachia from worm tissues. Doxycycline combined with ABZ led to a greater reduction in mf density in blood at 4 months (post-treatment) in comparison to doxycycline or ABZ alone. There were significant differences between the three treatments after 12 months (post-treatment). Further, the impact of a 7-day regimen of ABZ was surprisingly good in reducing mf compared to doxycycline-alone group. Adverse reactions were mild. A 30-day course of doxycycline and ABZ in combination is a safe and well-tolerated treatment for lymphatic filariasis with significant activity against microfilaremia.

The Global Programme to Eliminate Lymphatic Filariasis: History and achievements with special reference to annual single-dose treatment with diethylcarbamazine in Samoa and Fiji

Diethylcarbamazine (DEC), first introduced in 1947, was shown to have strong efficacy and safety for treatment of human lymphatic filariasis, which is caused mostly by a species Wuchereria bancrofti. Many studies to optimize the dosage and treatment schedule of DEC followed, and, based on the results, control programs with various regimens were implemented in different endemic areas/countries. By the mid 1970s, with endorsement by the WHO Expert Committee on Filariasis (3rd report, 1974), the standard DEC regimen for W. bancrofti infection in mass treatment had been established in principle: a total dose of 72 mg/kg of body weight given in 12 divided doses, once weekly or monthly, at 6 mg/kg each. Not long after the committee report, the efficacy of annual single-dose treatment at 6 mg/kg, which is only one twelfth of the WHO-recommended dose in a year, was reported effective in French Polynesia (study period: 1973-78), and later in Samoa (study period: 1979-81). These results were published between 1978 and 1985 in the Bulletin of WHO but received little attention. In the mid 1980s, the efficacy of ivermectin, the first-choice drug for onchocerciasis, against lymphatic filariae came to light. Since the effect at a single dose was remarkable, and often better than DEC, it was predicted that the newly introduced drug would replace DEC. Treatment experiments with ivermectin increased quickly in number. Meanwhile, annual single-dose mass drug administration (MDA) with DEC at 6 mg/kg was under scrutiny in Samoa and Fiji. In the early 1990s, the Samoan study, which covered the entire population of 160,000 with 3 annual MDAs, reported a significant reduction in microfilaria (mf) prevalence and mean mf density, while in Fiji, the efficacy of 5 rounds of annual MDA (total dose, 30 mg/kg) was shown to be as effective as 28 multi-dose MDA spread over 2 years (6 weekly plus 22 monthly treatments at 5 mg/kg; total dose, 140 mg/kg). Several additional studies carried out in Samoa in relation to the annual single-dose MDAs revealed that low density mf carriers, who have a very low mf count of 1-20/ml of venous blood, could not play a significant role in filariasis transmission.From around 1990, studies on spaced low-dose DEC treatments and various types of combination chemotherapy with DEC and ivermectin increased. Albendazole, a well-known anti-intestinal helminths agent, was later added to the combination. The main findings of these studies with W. bancrofti are: (i) a single dose of DEC at 6 mg/kg reduced mean mf density by ca. 90% 1 year after treatment; (ii) the same dose could damage/kill adult worms; (iii) a single dose of ivermectin at ca. 400 µg/kg was more effective than DEC in reducing mf density during the first year and was similarly or less effective in the second year; (iv) ivermectin probably could not kill adult worms; (v) a single combined dose of albendazole (400 mg) and DEC (6 mg/kg) was effective to reduce mf density by 85 to nearly 100% 12-24 months after treatment; and (vi) ivermectin or albendazole included in the combination chemotherapy produced "beyond-filariasis" benefits: clearance/reduction of intestinal helminths, and, additionally, in the case of ivermectin, skin-dwelling ectoparasites.The Global Programme to Eliminate Lymphatic Filariasis (GPELF) started its worldwide activities in 2000, with the target of elimination by 2020. The basic strategy is to conduct annual single-dose MDAs for 4-6 years. In 2000-2007, a minimum of 570 million individuals were treated in 48 of 83 endemic countries. The drugs used are DEC 6 mg/kg plus albendazole 400 mg in most countries, or ivermectin 200-400 µg/kg plus albendazole 400 mg particularly in onchocerciasis endemic countries in Africa. (MDAs with DEC alone had been used in India.)The GPELF achieved impressive results in terms of parasitological cure/improvement, clinical benefits, social and economic impacts, etc. However, the most impressive result of all was the programme's success in mobilizing hundreds of millions of local people, who not only took drugs but many of them actively supported MDAs as drug distributors and volunteers. Beyond filariasis, the role people can play in supplementing rural health services is now a topic of discussion and a source of hope for a new sustainable system.

Ivermectin, 'wonder drug' from Japan: the human use perspective

Discovered in the late-1970s, the pioneering drug ivermectin, a dihydro derivative of avermectin--originating solely from a single microorganism isolated at the Kitasato Institute, Tokyo, Japan from Japanese soil--has had an immeasurably beneficial impact in improving the lives and welfare of billions of people throughout the world. Originally introduced as a veterinary drug, it kills a wide range of internal and external parasites in commercial livestock and companion animals. It was quickly discovered to be ideal in combating two of the world's most devastating and disfiguring diseases which have plagued the world's poor throughout the tropics for centuries. It is now being used free-of-charge as the sole tool in campaigns to eliminate both diseases globally. It has also been used to successfully overcome several other human diseases and new uses for it are continually being found. This paper looks in depth at the events surrounding ivermectin's passage from being a huge success in Animal Health into its widespread use in humans, a development which has led many to describe it as a "wonder" drug.

Factors influencing drug compliance in the mass drug administration programme against filariasis in the Western province of Sri Lanka

This descriptive, comparative, cross-sectional, randomized community-based study was done to determine factors influencing drug compliance in the mass drug administration (MDA) programme against filariasis in selected urban and rural populations within the Western province of Sri Lanka. The study population was selected using the cluster sampling method. Factors influencing drug compliance were determined by administration of an interviewer-based pre-tested questionnaire eliciting information regarding drug compliance, socio-economic status, educational background, knowledge, attitudes and practices with regard to the 2004 MDA. A total of 2319 people aged between 10 and 90 years (median 40) responded to the questionnaire. The belief that the MDA programme was beneficial was the most important factor affecting drug compliance, as revealed by multivariate analysis of the combined populations (P<0.001). This was so even in the urban population (P<0.001), while the belief regarding the severity (danger) of filariasis was important in the rural population (P=0.013), when the areas were considered individually. Therefore, it is essential for awareness programmes to highlight the dangers (complications) of the disease and to influence the community to perceive the benefits of a filariasis-free community as well as 'beyond filariasis' benefits of having albendazole given in combination in the MDA programme.

Adverse reactions following mass drug administration during the Programme to Eliminate Lymphatic Filariasis in Orissa State, India

The frequency and severity of adverse reactions are the main reasons for low compliance of mass drug administration (MDA) under the Programme to Eliminate Lymphatic Filariasis (PELF). This paper reports the frequency and types of adverse reactions during two MDAs during January 2002 and September 2004 in the State of Orissa, India. Of the people who consumed the drugs, 15.5% in the 2002 MDA and 16.5% in the 2004 MDA reported one or more adverse reactions. This rate is higher (49.7%) in a group of individuals who were monitored for 6 days from the day of consumption of drugs during the 2002 MDA. However, many of these reactions were mild. No significant difference was found in the frequency of adverse reactions between MDA with diethylcarbamazine (DEC) alone and with DEC and albendazole. Significant gender differences were found in the 2004 MDA but no such differences were found in the 2002 MDA; however, the frequency of adverse reactions increased with age. Of all the adverse reactions, systemic adverse reactions typically associated with microfilarial death were more frequent. The frequency of adverse reactions was higher in microfilaraemics compared with amicrofilaraemic controls. The present study warrants developing an active adverse reaction surveillance system to minimise the impact of adverse reactions on MDA compliance.

Ivermectin: pharmacology and application in dermatology

Ivermectin is a synthetic derivative of the antiparasitic class of compounds known as avermectins. It is a macrolide endectocide with activity against both endoparasites with cutaneous tropism (Strongyloides stercoralis, Ancylostoma braziliense, Cochliomyia hominivorax, Dermatobia hominis, Filaria bancrofti, Wucheria malayi, Onchocerca volvulus, Loa-loa) and ectoparasites such as Sarcoptes scabies, Pediculus humanus, Demodex folliculorum, and Cheyletiella sp. Ivermectin is of great interest in the treatment of patients with different forms of scabies, head lice, demodecidosis, cutaneous larva migrans, cutaneous larva currens, myiasis, and filariasis.

Mass chemotherapy options to control lymphatic filariasis: a systematic review

Understanding the efficacy of microfilaricidal drugs is important in guiding the global programme for the elimination of lymphatic filariasis as a public-health problem. We did a systematic review of the available literature to determine which currently available drug intervention most effectively decreases circulating Wuchereria bancrofti microfilaria in individuals and populations. 57 randomised studies of drug efficacy were identified. Data were combined and compared using weighted mean effect estimates taking into account the longitudinal nature of the data. Combined treatment with diethylcarbamazine plus ivermectin, diethylcarbamazine plus albendazole, and ivermectin plus albendazole resulted in average microfilarial intensity decreases that were 0.7%, 4.6%, and 12.7% of the pre-treatment values, respectively. Drug combinations containing diethylcarbamazine were the most effective against microfilarial prevalence and intensity relative to single drugs or other combinations. The relative efficacies of drug combinations have not been well documented from existing studies and therefore limit the application of evidenced-based recommendations for chemotherapy-based interventions to control lymphatic filariasis. These results provide valuable estimates of drug effect using existing data, but highlight the need for more comprehensive comparative drug studies.

Lethal LPS-independent side effects after microfilaricidal treatment in Acanthocheilonema viteae-infected rodents

Mastomys coucha and jirds infected with Acanthocheilonema viteae, a filarial species free of endosymbiontic bacteria of the genus Wolbachia, suffer lethal side effects after effective microfilaricidal therapy with diethylcarbamazine and levamisole, whereas, M. coucha infected with the Wolbachia-infested species Brugia malayi or Litomosoides carinii tolerate corresponding treatment. Mortality in A. viteae infected, treated animals varied with microfilariae density in the blood. It was up to 100% in highly microfilaraemic M. coucha and jirds, but low or absent in animals with low microfilariae counts. Deaths occurred in most cases 5-24 h after treatment. Characteristic symptoms in animals, which died subsequently were a rapid drop in body temperature by 4-7 degrees C, an increase in hematokrit values by up to 10% and a moderate blood acidosis. Lethal effects in A. viteae infections did not depend on a particular status of hypersensitivity of the animals since desensitization procedures, which protected infected M. coucha against an otherwise lethal intravenous challenge with A. viteae homogenate did not protect against adverse reactions to a subsequent microfilaricidal treatment. The animals were protected from treatment induced death by injection of N-LMMA. Thus the final morbific agent seems NO. The data show that adverse effects after effective microfilaricidal therapy may be caused by microfilariae derived components different from Wolbachia-released LPS.

[Ivermectin]

Ivermectin is a semi-synthetic derivative of a macrocyclic lactone. It causes paralysis in many nematodes and arthropodes because of its effect on ion-channels in cell membranes. Ivermectin was first used in veterinary medicine. In man, it was shown to be microfilaricid against Onchocerca volvulus. Most of the adverse reactions following treatment were mild, without the systemic and ocular side effects usually complicating diethylcarbamazine therapy. In endemic areas after repeated administration of ivermectin, a dramatic reduction in dermal microfilarial load was observed, resulting in a decrease in transmission. There was a significant decrease in the prevalence of anterior segment lesions in the eyes and acute onchocercal skin disease. Moreover, ivermectin also exhibited microfilaricidal activity against Wuchereria bancrofti and Brugia malayi. Annual mass treatment with a single dose of diethylcarbamazine alone, or associated with ivermectin, was initiated in endemic areas for lymphatic filariasis. The preliminary results showed a decrease in the reservoir of microfilariae and rate of transmission, a reduction in the frequency of clinical lymphatic abnormalities due to bancroftan filariasis. In Loa loa infections ivermectin decreases microfilaremia, but serious adverse events such as encephalopathy can be induced in patients with high rate of microfilaremia. Ivermectin appears to be the drug of choice in Strongyloides stercoralis infections, a single dose is highly effective with less frequent side effects than thiabendazole. Oral ivermectin is an alternative to topical scabicides, it appears as effective as local treatment for common scabies, but there are few comparative studies. The best indications for ivermectin in this ectoparasitic infection could be the outbreak in institutions and crusty scabies, but in association with topical treatment. The precise position of this agent in the treatment of scabies remains to be specified. Ivermectin is also affective in the treatment of ascariasis and cutaneous larva migrans. It could also be a promising treatment for head lice.

Coverage, compliance and some operational issues of mass drug administration during the programme to eliminate lymphatic filariasis in Orissa, India

This paper reports the coverage, compliance and other operational issues of mass drug administration (MDA) of diethylcarbamazine and albendazole under a programme to eliminate lymphatic filariasis (LF) in Orissa state of India. Both quantitative and qualitative methods were used to collect data from 90 villages and nine urban areas of four districts of Orissa, India. In Orissa, 67% of people older than 2 years had received the drugs during MDA and 42% had consumed them. About 25% of people had not taken the tablets although they received them. Urban areas recorded lower rates than rural areas. The paper discusses some policy/health system-, community- and drug-related issues that influenced coverage and compliance of MDA. It is essential to improve compliance in future rounds of MDA to achieve targets of control and eventual elimination of LF in a reasonable time frame.

Safety, tolerability, efficacy and plasma concentrations of diethylcarbamazine and albendazole co-administration in a field study in an area endemic for lymphatic filariasis in India

Filariasis control programmes are moving towards a strategy of repeated single-dose mass treatment of endemic populations. Using a combination, such as albendazole (ALB) to diethylcarbamazine (DEC) gives both macrofilaricidal and anti-helmintic activity. However, the safety of the combination versus DEC alone should be established in field studies in large populations prior to incorporation into national programmes. The present study compared the safety, tolerability, and efficacy of single doses of DEC 6 mg/kg + ALB placebo with DEC 6 mg/kg + ALB 400 mg in populations living in two filariasis endemic villages in the district of Wardha in western India. The study was double blind, parallel group, and randomized. Safety and tolerability study were studied in males and females older than 5 years. Safety was assessed by monitoring if adverse events (AEs) over 5 days affected daily acivities. Subjects in the 2 treatment groups experienced insignificantly different effects on daily activities and the combination was shown to be safe. Efficacy was evaluated by microfilaraemia (Mf), immunochromatographic test (ICT) and ultrasonography (USG) at 0, 3, 6, and 12 months of follow up. The efficacy study enrolled 103 male patients (aged 18-50 years) in microfilariae positive, clinical disease and asymptomatic, amicrofilaremic groups. There was no significant difference in efficacy between groups at 12 months. Within the Mf positive group, significant differences were seen in microfilaraemia (P < 0.001) with both treatments, and in USG (P < 0.001 and P < 0.004 respectively), at 12 months. The present field study has shown the combination of DEC + ALB to be as safe as the single drug DEC and thus the combination can be put in use in the national filariasis control programmes. Both drugs were adequately absorbed. The study at present does not provide evidence for the greater efficacy of the combination at 12 months follow up. While the safety of the combination has been ascertained, the incorporation or otherwise of ALB into national programmes for greater efficacy must await results of studies with longer follow up.

Cloning and biochemical characterization of blisterase, a subtilisin-like convertase from the filarial parasite, Onchocerca volvulus

Blisterase is a subtilisin-like proprotein convertase of nematodes. The enzyme is named after the blistered cuticle found in Caenorhabditis elegans with the bli-4 e937 mutation. The critical role of the enzyme in cuticle production makes it a potential drug target for parasitic nematodes. We have cloned and expressed blisterase from the parasitic nematode Onchocerca volvulus, a major cause of blindness in Africa. The catalytic domain of the protease exhibits 84% identity with the corresponding domain of its closest homologue, C. elegans blisterase. O. volvulus blisterase expressed in insect cells has maximal activity in 1 mm calcium at neutral pH. The protease is inhibited by EDTA, the suicide substrate decanoyl-RVKR-chloromethylketone, alpha1-antitrypsin Portland and by its own propeptide. Substrate assays with fluorescent peptides show that O. volvulus blisterase requires a P4 arginine and a basic amino acid at P1 for cleavage. The kcat of blisterase on the peptide substrate, t-butyloxycarbonyl-RVRR-4-methylcoumaryl-7-amide was determined to be 0.018 s-1. In vitro cleavage studies with the nematode polyprotein antigen demonstrated that blisterase cleaved at tetrabasic (RRKR) but not at dibasic (KR) sites. This report describes the first biochemical characterization of the nematode specific protease, blisterase.

Ivermectin and filariasis

Ivermectin, a parasiticide that long ago proved its worth in veterinary medicine, became one of the most effective tools for control programs against human filarial diseases in the 1980s. It is provided at no cost, is effective against microfilariae (blocking their transmission) and can be administered annually as a single oral dose with virtually no side-effects: these considerations led the WHO to officially declare eradicable two endemic filarial diseases (among the major endemic diseases worldwide), onchocerciasis and lymphatic filariasis.

Mass treatment to eliminate filariasis in Papua New Guinea

BACKGROUND

The global initiative to eradicate bancroftian filariasis currently relies on mass treatment with four to six annual doses of antifilarial drugs. The goal is to reduce the reservoir of microfilariae in the blood to a level that is insufficient to maintain transmission by the mosquito vector.

METHODS

In nearly 2500 residents of Papua New Guinea, we prospectively assessed the effects of four annual treatments with a single dose of diethylcarbamazine plus ivermectin or diethylcarbamazine alone on the incidence of microfilariae-positive infections, the severity of lymphatic disease, and the rate of transmission of Wuchereria bancrofti by mosquitoes. Random assignment to treatment regimens was carried out according to the village of residence, and villages were categorized as having moderate or high rates of transmission.

RESULTS

The four annual treatments with either drug regimen were taken by 77 to 86 percent of the members of the population who were at least five years old; treatments were well tolerated. The proportion with microfilariae-positive infections decreased by 86 to 98 percent, with a greater reduction in areas with a moderate rate of transmission than in those with a high rate. The respective aggregate frequencies of hydrocele and leg lymphedema were 15 percent and 5 percent before the trial began, and 5 percent (P<0.001) and 4 percent (P=0.04) after five years. Hydrocele and leg lymphedema were eliminated in 87 percent and 69 percent, respectively, of those who had these conditions at the outset. The rate of transmission by mosquitoes decreased substantially, and new microfilariae-positive infections in children were almost completely prevented over the five-year study period.

CONCLUSIONS

Annual mass treatment with drugs such as diethylcarbamazine can virtually eliminate the reservoir of microfilariae and greatly reduce the frequency of clinical lymphatic abnormalities due to bancroftian filariasis. Eradication may be possible in areas with moderate rates of transmission, but longer periods of treatment or additional control measures may be necessary in areas with high rates of transmission.

Lymphatic filariasis: new insights into an old disease

Lymphatic filariasis has afflicted people in the tropical areas of the world for thousands of years but even up to comparatively recent times it has been poorly understood and its importance under recognised. In the last 2 decades or so there has been a flurry of activity in filariasis research, which has provided new insights into the global problem of filariasis, the pathogenesis of filarial disease, diagnosis and control.

Drug treatment of tropical parasitic infections: recent achievements and developments

Drug development offers potential solutions to a number of tropical health diseases, although the expense of pharmaceutical research and lack of return on investment has limited the production of new agents. The greatest successes have been through the development of single dose therapy and mass treatment control programmes for a number of diseases. We review some of the current treatment regimens for malaria, intestinal helminth infection, onchocerciasis, filariasis and schistosomiasis, and their use in clinical practice. Geographical spread and emergence of drug resistant parasites have hindered the control of malaria, the most important global parasitic infection. Artemisinin compounds have proved effective antimalarial agents producing rapid reduction of parasite load and can be used in combination treatment regimens to combat multidrug resistance. Intestinal helminth infections are widespread, giving rise to nutritional deficiencies and impaired childhood cognitive development. Pregnant women in developing countries are at increased risk of morbidity. Treatment with a single dose benzimidazole such as albendazole or mebendazole has beneficial effects on morbidity and rates of transmission. Diethylcarbamazine has been used in the treatment of onchocerciasis and human filariasis. A complicated escalating dose regimen over several weeks is associated with systemic and allergic reactions and may require corticosteroid cover. Simplified regimens for mass population treatment with ivermectin have proved useful and been used in combination with single dose albendazole and diethylcarbamazine. The African Programme for Onchocerciasis Control in West and Central Africa has been one of the most successful mass control programmes virtually eliminating new infections by a combination of chemotherapy, education and vector control. Schistosomiasis is of increasing importance as a result of the creation of new snail habitats by agricultural and economic development. Praziquantel has become the most widely available and effective chemotherapy for schistosomiasis. There have been a number of reports of persistent schistosome egg shedding after treatment posing concerns about the emergence of drug resistance. Eflornithine has been successfully used in patients with human trypanosomiasis failing melarsoprol therapy however expense and availability have limited its potential. Mass control treatment programmes have targeted schoolchildren, adolescents and pregnant women. The integration of schistosomiasis, onchocerciasis, filariasis and helminth control programmes has been considered as a cost-effective method of delivering treatment. It is likely that future control will be based on this optimisation and integration of existing regimens, rather than the development of new agents.

Tolerability and efficacy of single-dose diethyl carbamazine (DEC) or ivermectin in the clearance of Wuchereria bancrofti microfilaraemia in Pondicherry, south India

In a double blind design the tolerability and efficacy of single-dose DEC (6 mg/kg/body weight) or ivermectin (400 microg/kg/body weight) was studied in 30 asymptomatic W. bancrofti parasite carriers each. Although both drugs were tolerated well, the adverse reaction score (DEC 0.5; ivermectin 1.5) and overall incidence (DEC 65.0%; ivermectin 93.3%) were significantly higher in the ivermectin group. Major adverse reactions were fever, headache and myalgia, all of which peaked on the second day post-therapy. Efficacy was measured in terms of proportion of cases clearing parasitaemia and reduction in mean parasite density compared to pre-therapy levels. Although at the end of one year the ivermectin group showed a significantly higher efficacy (34.8%, 97.0%) compared to DEC (8.3%, 83.8%), at the end of the second year there was no significant difference in efficacy between the drugs (73.7%, 99.5% for ivermectin; 47.8%, 98.9% for DEC). The tolerability and efficacy of the two drugs were not significantly different between gender, age and weight classes of patients.

Eosinophilia and helminthic infections

Among microbial agents, helminths are the most common cause of eosinophilia. An approach to the evaluation of a patient with eosinophilia is outlined, with particular emphasis on clues in the history, examination and routine laboratory data that can help with the diagnosis. Multiple helminthic infections have been associated with eosinophilia, and the characteristic modes of spread, clinical manifestations, diagnostic tests and therapeutic considerations of these infections are discussed.

Epidemiology and immunopathology of bancroftian filariasis

Human lymphatic filariasis affects 120 million people worldwide. Although the disease is considered to be potentially erradicable by the World Health Organization, comprehensive studies on epidemiological aspects as well as mechanisms of pathology development are still premature. The following review summarizes currently available data on these topics and ends by discussing the latest control strategies.

Randomised community-based trial of annual single-dose diethylcarbamazine with or without ivermectin against Wuchereria bancrofti infection in human beings and mosquitoes

BACKGROUND

WHO has targeted lymphatic filariasis for elimination. Studies of vector-parasite relations of Wuchereria bancrofti suggest that a reduction in the microfilarial reservoir by mass chemotherapy may interrupt transmission and thereby eliminate infection. However, no field data exist on the impact of chemotherapy alone on vector efficiency and transmission intensity of W bancrofti. We compared the impact of an annual community-wide single-dose treatment with diethylcarbamazine alone or with ivermectin on rate and intensity of microfilaraemia, and transmission intensity in an area of Papua New Guinea endemic for intense W bancrofti transmission.

METHODS

We carried out clinical and parasitological surveys in 14 communities in matched pairs. People aged 5 years or older in seven communities received randomly assigned diethylcarbamazine 6 mg/kg and people in the other seven communities received diethylcarbamazine 6 mg/kg plus ivermectin 400 micrograms/kg. We made physical examinations for hydroceles and leg oedema and investigated microfilarial densities by membrane filtration before and after treatment. We selected five communities for monthly entomological surveys between September, 1993, and September, 1995. Mosquitoes were collected in these communities by the all-night landing catch method and were individually dissected to identify rates of infection and infectiveness.

FINDINGS

2219 (87.6%) of 2534 eligible people received treatment. Microfilarial rate and density had decreased 1 year after treatment in all 14 communities; this decrease was significantly higher in communities given combined therapy than in those given diethylcarbamazine alone (mean decreases 57.5% and 30.6%, respectively; p = 0.0013). Greater decreases were also seen in community-specific microfilarial intensity with combined therapy (mean reductions 91.1% and 69.8%, respectively; p = 0.0047). The rate of leg oedema was not altered, but the frequency of advanced hydroceles decreased by 47% with combined therapy and 56% with diethylcarbamazine alone. 26,641 Anopheles punctulatus mosquitoes were caught during 499 person-nights of landing catches. Exposure to infective third-stage larvae decreased in all monitored five communities. Annual transmission potential decreased by between 75.7% and 98.8% in combined-therapy communities and between 75.6% and 79.4% in communities given diethylcarbamazine alone. Transmission was almost interrupted in two communities treated with combined therapy.

INTERPRETATION

Annual single-dose community-wide treatment with diethylcarbamazine alone or with ivermectin is effective for the control of lymphatic filariasis in highly endemic areas, but combination therapy brings about greater decreases in rates and intensity of microfilaraemia.

Randomised placebo-controlled comparison of ivermectin and albendazole alone and in combination for Wuchereria bancrofti microfilaraemia in Haitian children

BACKGROUND

Lymphatic filariasis and intestinal helminth infections are important disorders in tropical areas. Periodic treatment with albendazole is now used in many school-based intestinal helminth-control programmes. However, few such programmes exist for lymphatic filariasis, despite evidence that single-dose treatment with ivermectin can greatly reduce the concentration of Wuchereria bancrofti microfilariae in the blood for months to years. We aimed to assess the potential for school-based control of lymphatic filariasis by investigating the efficacy and tolerability or combined ivermectin and albendazole in Haitian schoolchildren.

METHODS

In January, 1996, we collected 832 20 microL capillary blood samples for inclusion in a randomised controlled study from children aged 5-11 years, and examined them by microscopy for W bancrofti microfilariae. Infected children were randomly assigned treatment with placebo (n = 29), a single 200-400 micrograms/kg dose of ivermectin (mean, 273 micrograms/kg, n = 28), 400 mg albendazole (n = 29), or a combination of 200-400 micrograms/kg ivermectin and 400 mg albendazole (n = 24). Children with high concentrations of microfilariae in the blood were admitted to hospital and adverse reactions were monitored for 3-5 days, otherwise children were examined at school or during a visit to their home. 4 months after treatment, we examined blood samples again for microfilariae.

FINDINGS

113 microfilaraemic children were enrolled (mean age 7.8 years). 4 months after treatment, the proportion of children who remained positive for microfilariae was significantly lower in the ivermectin plus albendazole group (four [17%]), but there were no significant changes in the other three groups (20 [69%] placebo, 22 [76%] albendazole alone, 17 [61%] ivermectin alone remained positive; p = 0.004). Geometric mean microfilarial concentration decreased from 9.3 to 5.3 per 20 microL blood among children who received placebo; from 15.5 to 1.5 per 20 microL blood among those who received ivermectin only (p = 0.032); from 14.1 to 5.1 per 20 microL blood among those who received albendazole alone; and from 13.7 to 0.3 per 20 microL blood among those who received both ivermectin and albendazole (p = 0.0001). Systemic adverse reactions did not differ significantly between children who received ivermectin alone and those who were treated with ivermectin and albendazole [corrected].

INTERPRETATION

For children with W bancrofti microfilaraemia, combined treatment with ivermectin and albendazole was more effective than treatment with ivermectin only, with no measurable increase in severity of adverse reactions.

Successful use of ivermectin in the treatment of endemic scabies in a nursing home

Ivermectin, an antiparasitic agent, was successfully used as a sole agent to combat endemic scabies in a closed 33-bed ward of a rural nursing home. Previous topical therapies, including multiple applications of permethrin, gamma-benzene hexachloride, benzyl benzoate and precipitated sulfur in white soft paraffin, had failed. Several patients exhibited hyperkeratotic crusted scabies with head and neck involvement and all residents except one recently arrived resident had evidence of active infestation. All residents were treated with 200 micrograms/kg of ivermectin and this dose was repeated 2 weeks later in all subjects. Four weeks after the first dose of ivermectin there was no evidence of active scabies and all rashes were totally resolved by 6 weeks. The action of ivermectin, its safety and its indications are discussed.

[Diethylcarbamazine in the treatment of Bancroft's filariasis]

The authors presented a detailed review about the treatment of bancroftian filariasis with diethylcarbamazine. The interesting aspects about the drug discovery and the basic concepts about its pharmacology were reported in a summarised form. On the other hand, emphasis was made about the speculation done by several authors about the intriguing findings regarding its efficacy reported in the literature. Latter, it was brought the new advances about the disease, as for example, the visualization by ultrasound of living Wuchereria bancrofti adult worm on its natural host--the human being. This made possible the comprehension of several paradoxical issues reported, focusing the treatment of infection using diethylcarbamazine. So far, because of the lack of ideal drug with micro and macrofilaricidal properties, together with the new understand about the disease and the new parameters for monitoring the efficacy of the drug, diethylcarbamazine has back its importance conquered at the begin of its discovery, almost fifth years ago.

Ivermectin for the chemotherapy of bancroftian filariasis: a meta-analysis of the effect of single treatment

The efficacy and safety of ivermectin in the treatment of filariasis due to Wuchereria bancrofti was assessed by a meta-analysis of the results from 15 published clinical trials. Seven hundred and forty-eight microfilaraemic patients were enrolled in 7 dose-finding and 8 comparative studies. Administered as a single dose, ivermectin induced nearly complete clearance of microfilariae from the blood from the first day to 30 days post-treatment, followed by gradual recurrence of microfilaraemia and increase in its intensity. Higher doses of ivermectin showed greater clearance effects and maintained lower microfilaraemia levels for a longer time. The adverse reactions caused by the drug were flu-like, transient, generally mild and well tolerated by patients. The frequency and intensity of adverse reactions were strongly associated with pretreatment microfilaria counts in the blood, but independent of dose. The findings of the meta-analysis suggest that ivermectin given at a single annual dose of 200 micrograms/kg body weight or higher, whether or not in combination with DEC, has great potential for therapeutic strategies to control bancroftian filariasis.

Ultrasound diagnosis of filarial funiculoepididymitis

Genital presentation of filarial disease is not uncommon in endemic areas of the world. Acute, febrile illness involving the epididymis and spermatic cord (funiculoepididymitis) is one of many such presentations. With an internationally mobile society, physicians today, even in nonendemic areas, may encounter patients with filarial infestations. We report the first case of presumptive diagnosis of this disease using scrotal ultrasound.

Ultrasonographic assessment of the adulticidal efficacy of repeat high-dose ivermectin in bancroftian filariasis

Since diethylcarbamazine, the drug recommended for treatment of lymphatic filariasis, seems only partially effective against the adult worm, intense interest persists in identifying a macrofilaricidal drug for this infection. To evaluate directly in vivo the macrofilaricidal activity of repeat high-dose ivermectin, 15 men who had living adult Wuchereria bancrofti detected in the scrotal area by ultrasound were treated with 400 micrograms/kg of ivermectin at 2-week intervals for 6 months (total dose, 4.8 mg/kg). Serial ultrasound examinations were performed before, during, and for 6 months after treatment. Profound suppression of microfilaraemia followed the first dose of ivermectin, but movements characteristic of the adult worm on ultrasound remained unchanged both in location and pattern. Even when given in total doses of 4.8 mg/kg, ivermectin appears to have no observable activity against adult W. bancrofti, although its ability to suppress microfilaraemia makes it potentially useful for the control of lymphatic filariasis.

Filariasis in the Kaiyamba Chiefdom, Moyamba District Sierra Leone: an epidemiological and clinical study

In a cross-sectional epidemiological and clinical study of human filariasis, 630 individuals were examined for Onchocerca volvulus, Wuchereria bancrofti and Mansonella perstans infections in five communities in the Kaiyamba Chiefdom, Moyamba District, Sierra Leone. The overall prevalence of O. volvulus infection in males 144(39.1%) and females 94(35.9%) was not significantly different and the sex prevalence rate between communities was also not significant (G = 3, d.f. = 4, P > 0.05). Prevalence of O. volvulus was significantly lower (G = 42.331, d.f. = 5, P < 0.001) in the 5-9 age group (13.3%) compared to the 40-49 age group (61.9%). Sixty-four (10.2%) and 38(6.0%) of individuals examined were positive for W. bancrofti and M. perstans infections respectively and prevalence of both infections in the five communities was not significant. Mixed infections with the all three filaria parasites were recorded in 10(3.2%) of the individuals. One hundred and sixty-four (71.3%) clinical cases due to W. bancrofti were inflammatory in nature; 36.5% were chronic, of which, 26.6% were hydroceles and 9.4% involved elephantiasis of both the scrotum and the lower legs. All 19(3.0%) of M. perstans-related clinical cases were inflammatory. Ninety-three(63.3%) of O. volvulus positive individuals that presented symptoms were inflammatory in nature, 14(9.5%) had ocular symptoms and 57(38.8%) had subcutaneous nodules. These data indicate that infections due to O. volvulus, W. bancrofti and M. perstans may be of public health importance in Sierra Leone.

Advantages of an annual single dose of ivermectin 400 micrograms/kg plus diethylcarbamazine for community treatment of bancroftian filariasis

In 1994 and 1995, 2 supervised single dose treatments for bancroftian filariasis were given to all inhabitants ( > 3500) aged > or = 3 years on a Polynesian island. This island is divided into 4 political zones. Each zone was treated with a different dosage of the combination ivermectin (IVR) and diethylcarbamazine (DEC) as follows: (1) IVR 400 micrograms/kg plus DEC 6mg/kg, (2) IVR 400 micrograms/kg alone, (3) DEC 6 mg/kg alone (4) IVR 400 micrograms/kg plus DEC 3 mg/kg. 1717 inhabitants (aged > or = 20 years) had venous blood sampled when treated. The reductions in microfilaraemia prevalence rates one year after treatment were, respectively, 32%, 11%, 14% and 32%. The reductions in microfilaraemia levels one year after treatment were, respectively, 96%, 80%, 82% and 95%. Stool specimens from 82 children aged 6 years were examined for intestinal nematodes just before and just after treatment. IVR 400 micrograms/kg significantly reduced the prevalence and intensity of trichiuriasis. The combination IVR + DEC is a powerful tool for the control of lymphatic filariasis. Further studies are required to determine the appropriate presentation of DEC (salt and/or tablets), the frequency of treatment, and the duration of the control programme necessary to eradicate this disease.

Direct assessment of the adulticidal efficacy of a single dose of ivermectin in bancroftian filariasis

Although the potent microfilaricidal activity of ivermectin is well established, its efficacy against adult Wuchereria bancrofti is unknown. We used longitudinal ultrasound examinations for periods of 3-9 months to assess directly the macrofilaricidal effect of a single 400 micrograms/kg dose of ivermectin in 15 men from Recife, Brazil who were infected with W. bancrofti. Before treatment, microfilarial densities ranged from 3 to 3098 microfilariae per mL of blood, and movements characteristic of the living adult worm (the 'filaria dance sign') were observed by ultrasound examination of the scrotal lymphatic vessels in all 15 men. Following treatment, microfilarial density was markedly reduced in all men, but the filaria dance sign remained unchanged in both location and pattern. Eight months after treatment, a dilated lymphatic vessel was surgically removed from one patient at the site of the filaria dance sign, and 3 intact adult worms were released. When given as a single 400 micrograms/kg dose, ivermectin had no observable effect on adult W. bancrofti. Therefore, prolonged suppression of microfilaraemia following treatment with ivermectin cannot be explained by a macrofilaricidal effect of the drug. Ultrasound is a valuable new tool for directly and rapidly assessing the macrofilaricidal efficacy of antifilarial drugs in lymphatic filariasis.