MSF's Drug Administration Campaign to eradicate filariasis in the remote district of Asmat, Papua

Papua is the most easterly and the least developed province of Indonesia. Médecins Sans Frontières began providing primary healthcare in the district of Asmat, on the southwestern coast of the island two years ago. In this remote area, covered by mangroves, tidal swamps and lowland forests, access to healthcare is extremely limited. In early July 2008, a new health campaign was launched to eradicate filariasis, a disabling, mosquito-borne disease. But reaching the population in an area covered by thick tropical forest and accessible only by river presents many logistical challenges.

From the plane, the coast of Asmat looks like a vast sprawling swamp. Rivers of various shades of brown curve and twist, cutting a path through the dense tropical vegetation before flowing into the sea.

In the small hamlets that dot the river banks, the population leads a secluded life. The villagers navigate the waterways using long traditional boats called Kole Kole and have built their bamboo shacks one meter above the ground to counter the constant ebb and flow of the tide. Water is omnipresent and creates a breeding ground for waterborne diseases such as malaria, dengue or filariasis.

"MSF decided to launch this new campaign after realizing during our mobile clinics that filariasis was endemic in the region," explains MSF medical coordinator, Navneet Nebhullar. "The Mass Drug Administration (MDA) of filariasis treatment to the entire population will reduce transmission and eventually eradicate the disease in the area."

Lymphatic filariasis is a parasitic disease caused by microscopically small worms transmitted through the bite of an infected mosquito.  The parasites reproduce and live in the lymph system, which maintains the body's fluid balance and plays a key role in the body's immune system. "Those infected with filariasis don't always present symptoms," stresses Doctor Nebhullar. "But blockage of the lymph system can cause elephantiasis, large swollen legs or breasts or in men huge swollen scrotums, which really impact the patients' quality of life."

MSF initiated the campaign in July and has been working closely with the Ministry of Health, to help them continue the treatment over a period of 5 years.

Although the treatment is easy – only three pills to take every year for five years– the project is ambitious and logistically challenging. There are seven sub-districts to cover in a two and a half month period.

This week, MSF is focusing on the area around Sawa Erma.  Wrapped in their orange waterproof jackets, the teams are loading drugs and gallons of water into speedboats under a torrential rain. "It can be tiring; the weather is unpredictable. Sometimes we face a trip of several hours on the river under a scorching sun and sometimes like today it's pouring rain," explains health promoter Reza Abel, bracing himself for a challenging day.

But he points out the biggest challenge remains reaching the population. Papuans are semi-nomadic and rarely stay in the village for long periods of time. They trek for months in the jungle where they hunt and fish. Sago, a starch extracted from palm trees, provides their basic nutrition, and they also collect and trade sandalwood.

"It can be frustrating. Last week nearly all the villages were almost empty.  We cannot track them down into the jungle so we try to reach the bevak," Abel says.

The bevak are very basic shelters along the river used by one or several families during their long stay in the jungle.

To ensure the campaign reaches the maximum number of people, a health promotion team is sent a few days ahead to meet up with the village chief and arrange the next visit, during which villagers will be given treatment. Health promoters play a critical role in explaining about the disease.

In the village of Asatak, the village chief has rounded up around 200 people in the church, while the teams are preparing the drugs and information charts. The villagers' names are called out in turn and each family comes forward to take their treatment.

MSF has been running mobile clinics for two years around Sawa Erma and is now well known in the area. But as the coverage of filariasis expends, the team is about to move forward into new zones, where the population don't know the medical organization. "It's both exciting and challenging. We will have to gain the population's trust there from scratch," stresses Abel. "The area is even more remote, so we're in for quite a challenge ahead!"

Lymphatic Filariasis

Lymphatic Filariasis is a parasitic disease caused by microscopically small worms (filariae) and transmitted by the bite of an infected mosquito. The parasites reproduce and live in the lymph system, which maintains the body's fluid balance and plays a key role in the body’s immune system.

An adult worm lives between 4-6 years. It mates and releases millions of microfilariae into the blood.

Most people don't have any symptoms. But the improper functioning of the lymph system can lead to swelling in the legs, arms, breasts (lymphodema) or genitalia. These symptoms often appear years after the infection. Men can develop swelling of the scrotum (hydrocele) after the death of an adult worm.

Because of the damage to the lymph system, infected people will have more bacterial infections in the skin and lymph system.  This can cause hardening, thickening and fissuring of the skin (elephantiasis). Although elephantiasis is not curable, many of these bacterial infections can be prevented with appropriate skin hygiene.

WHO estimates that Lymphatic Filariasis puts at risk more than a billion people in more than 80 countries, mainly in tropical regions.  Over 120 million have already been affected and over 40 million of them are seriously incapacitated and disfigured by the disease.

MSF's mass drug administration campaign in Asmat aimed at drastically reducing the number of parasites in the body. In accordance with the WHO recommendations, MSF provides a yearly dose of diethylcarbamazine (DEC) and albendazole that kills the microfilariae circulating in the blood. The drugs  have to be taken every year over a period of 5 years in order to eradicate the disease.

While these drugs do not kill all of the adult worms, they prevent infected people from developing symptoms and from giving the disease to someone else.

Bednets are also distributed in the area and patients suffering from hydrocele are offered surgery, a service made available after MSF rehabilitated the operating theatre, donated surgical equipment and provided training in universal precautions.