SPATIAL DIMENSIONS OF FILARIASIS IN CONTROL UNIT, , : A GIS APPROACH

Thesis submitted to the Bharathidasan University for the award of degree of Doctor of Philosophy in Geography

Submitted by

S. Vadivel Assistant Professor and Part – time Research Scholar,

Research Supervisor Dr.P.H.Anand, M.Sc.,M.Phil.,Ph.D. Associate Professor and Head

Post Graduate and Research Department of Geography, Government Arts College (Autonomous), Kumbakonam – 612 001, Tamil Nadu, India

May - 2012

DECLARATION

I do hereby declare that the thesis entitled “SPATIAL DIMENSIONS

OF FILARIASIS IN KUMBAKONAM CONTROL UNIT, TAMIL NADU, INDIA: A

GIS APPROACH”, which I am submitting for the award of Degree of

Doctor of Philosophy in Geography, to the Bharathidasan University, is the original work carried out by me, in the Post Graduate and Research

Department of Geography, Government Arts College (Autonomous),

Kumbakonam 612 001, Tamil Nadu, India, under the guidance and supervision of Dr. P.H. Anand, Associate Professor and Head, PG and

Research Department of Geography, Government Arts College

(Autonomous), Kumbakonam.

I further declare that this work has not been submitted earlier in this or any other University and does not form the basis for the award of any other degree or diploma.

Kumbakonam S. Vadivel 4th May 2012 Part-time Research Scholar

PG and Research Department of Geography (DST-FIST Recognized) Government Arts College (Autonomous), (Accredited by NAAC // AICTE and Affiliated to Bharathidasan University)) Kumbakonam, 612 001, Tamil Nadu

Dr.P.H.Anand,M.Sc.,M.Phil.,Ph.D. 04-05-2012 Associate Professor and Head,

CERTIFICATE

This is to certify that the thesis entitled “SPATIAL DIMENSIONS OF

FILARIASIS IN KUMBAKONAM CONTROL UNIT, TAMIL NADU, INDIA: A GIS

APPROACH”, submitted by Mr. S. Vadivel, for the award of Doctor of

Philosophy in Geography, in the Bharathidasan University was carried out at the Post Graduate and Research Department of Geography,

Government Arts College (Autonomous), Kumbakonam, 612001 under my guidance and supervision after fulfilling the basic requirements specified by the University.

(P.H. ANAND) Research Advisor

ACKNOWLEDGEMENT

More than 1.3 billion people in 72 countries worldwide are threatened by lymphatic filariasis, commonly known as elephantiasis. Over 120 million people are currently infected, with about 40 million disfigured and incapacitated by the disease.

Lymphatic filariasis can result in an altered lymphatic system and the abnormal enlargement of body parts, causing pain and severe disability. Acute episodes of local inflammation involving the skin, lymph nodes and lymphatic vessels often accompany chronic lymphoedema. To interrupt transmission WHO recommends an annual mass drug administration of single doses of two medicines to all eligible people in endemic areas.

Lymphatic filariasis, commonly known as elephantiasis, is a neglected tropical disease. Infection occurs when filarial parasites are transmitted to humans through mosquitoes. When a mosquito with infective stage larvae bites a person, the parasites are deposited on the person's skin from where they enter the body. The larvae then migrate to the lymphatic vessels where they develop into adult worms in the human lymphatic system. Infection is usually acquired in childhood, but the painful and profoundly disfiguring visible manifestations of the disease occur later in life. Whereas acute episodes of the disease cause temporary disability, lymphatic filariasis leads to permanent disability.

Currently, more than 1.3 billion people in 72 countries are at risk. Approximately

65 per cent of those infected live in the WHO South-East Asia Region, per cent in the

African Region, and the remainder in other tropical areas. Lymphatic filariasis afflicts over 25 million men with genital disease and over 15 million people with lymphoedema. Since the prevalence and intensity of infection are linked to poverty, its elimination can contribute to achieving the United Nations Millennium Development Goals.

World Health Assembly Resolution 50.29 encourages Member States to eliminate lymphatic filariasis as a public-health problem. In response, WHO launched its Global

Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000. The goal of the GPELF is to eliminate lymphatic filariasis as a public-health problem by 2020. The strategy is based on two key components: interrupting transmission through annual large-scale treatment programmes, known as mass drug administration, implemented to cover the entire at-risk population; alleviating the suffering caused by lymphatic filariasis through morbidity management and disability prevention.

The present research is focused upon taking all the parameters concerned are the latest technological development to identify and analyze the problem by using GIS and

GPS technology. The research would help the administration to plan for the future and the scientists to continue in the Filarial related research. For the successful completion of the work several people have extended their assistance and help. I mention few of them here and keep the rest in my mind. At the outset I thank our Principal i/c

Dr. J. Govindadoss, for extending moral and administrative support for the successful completion of this work.

I remember the similar support, which was extended to me by the then Principals, of this college. I thank all the staff members of the Filiarial Contol unit, which is under the control of Director of Public Health and Preventive Medicine, Chennai and

Kumbakonam Filarial Control Unit.

I convey my sincere thanks to Prof. I.C. Kamaraj and Prof. V. Kumaraswamy, former Heads of the Department of Geography, for consistent encouragement and critical suggestions as and when I approach them.

I wish to express my deepest gratitude to Dr. P.H. Anand, Associate Professor and Head, P.G and Research Department of Geography, Government Arts College

(Autonomous), Kumbakonam for his unencumbered, exemplary guidance, indefatigable efforts to steer in the right direction, bountiful scholarly advice, undiminished zeal for extracting fruitful information and for his painstaking efforts and deepest understanding of my needs in this research.

I extend my sincere thanks to Dr. P. Thirumalai, Assistant Professor of

Geography, P.G and Research Department of Geography, government arts college

(Autonomous) Kumbakonam for giving a good shape to this project. I also convey my deep sense of gratitude to my colleagues, Dr. P. Arul, Dr. B. Gobu, Dr. R. Maniyosai,

Thiru. K.K. Jayakumar, Thiru. A. Senthilvelan and Thiru. R. Thulasiraman.

I appreciate the students of M.Sc., Geography, of this college for the assistance during research work.

The present work will be incomplete but for the perfect tolerance, sacrifice, boundless love and ceaseless prayers of my parents, wife Mrs. Anbarasivadivel and childrenV. Sivabalan, V. Sivakrishnan and relatives for providing calm atmosphere during the research work. Last but not the least I am very much thankful to my colleague

Dr. J. Senthil Assistant Professor for his wholehearted support and assistance provided during the GPS data collection.

S. Vadivel CONTENTS

Chapter One

PROBLEM STATEMENT AND PROCEDURES Page #

1.1 Filariasis: Definition and Meaning 1 1.2 History of Lymphatic Filariasis: 2000BC-500AD 3 1.2.1 Discovery of Symptoms: 1588-1592 3 1.2.2 Discovery of Microfilariae: 1863 and 1866 4 1.2.3 Discovery of the Adult Worm: 1876 4 1.2.4 Discovery of the Life Cycle: 1877 4 1.2.5 Discovery of Transmission: 1900 5 1.2.6 Current Discoveries 5 1.3 Identification Methods: Filariasis 5 1.3.1 Infections Agents 6 1.3.2 Mode of Transmission 6 1.3.3 Incubation period 7 1.3.4 Period of communicability 7 1.3.5 Vector Aspects 7 1.3.6 Aedes vectors 8 1.3.7 Mansonia vectors 8 1.3.8 Anopheles vectors 8 1.4 Types of filariasis 9 1.5 Worms that cause filariasis 9 1.6 Lymphatic filarial diseases 10 1.7 Geographical Distribution of Filariasis in Select Countries 11 1.8 Geographical variation in transmission 14 1.9 Filariasis in Asia 16 1.10 Filariasis in India 16 1.11 Filariasis in Tamil Nadu 17 1.12 National Control Strategies in select countries 19 1.13 Review of Literature 22 1.13.1 Socio cultural literature 25 1.14 Impact on infected individuals 27 1.14.1 Current knowledge about LF’s sociocultural burden 27 1.14.2 Impact upon lifestyle and economic opportunities 29 1.15 Impacts on the LF elimination programme 30 1.15.1 Paucity of LF-related sociocultural research 30 1.15.2 Beliefs about disease causality and transmission 31 1.15.3 Community ownership of treatment programmes 32 1.15.4 The value of increasing our sociocultural understanding 33 1.16 Problem Statement 36 1.17 Objectives 36 1.18 Methodology 37

Chapter Two

PROFILE OF THE STUDY AREA

2.1 Introduction 39 2.2 Etymology 40 2.3 History 40 2.4 Geography 42 2.4.1 Topography 44 2.4.2 Drainage 44 2.4.3 Soils 44 2.4.4 Climate 44 2.4.5 Temples 45 2.5 Municipal administration and politics 47 2.6 Economy 47 2.7 Transport and communication 48 2.8 Education 49 2.9 Filariasis: Night Clinic and Administrative Functions 50 2.10 Major Industries 52 2.11 Population Characteristics 52 2.12 Landuse 53

Chapter Three

CREATION OF GIS INFORMATION BASE FOR FILARIASIS PATIENTS

3.1 Introduction 54 3.2 Using GIS for Public Health 57 3.3 The Business of Health Care Geographic 58 3.4 A Wealth of Tools 59 3.5 Tomorrow's Health Care 61 3.6 GIS Information Base filariasis Patients in Kumbakonam: 1998- 2008 63 3.7 Conclusion 66

Chapter Four

DIMENSIONS OF FILARIASIS IN KUMBAKONAM: A FACTOR ANALYTIC METHOD

4.1 Introduction 67 4.2 Filariasis in Kumbakonam 73 4.3 Technique of Analysis 73 4.3.1 The Process of Factor Analysis: Data Matrix 75 4.4 Extracting the factors 77 4.5 Interpretation of the factors 78 4.6 Household level variation in vector infection and mf prevalence 80 4.6.1 Households with mf carriers 80 4.6.2 Households with infected mosquitoes 81 4.6.3 Transmission dynamics 81 4.6.4 No. of mf carriers 81 4.6.5 Antigenaemia prevalence 81 4.7 Filariasis in Kumbakonam: Spatial Dimensions 82 4.7.1 Dimension-I: Quality of Life 88 4.7.2 Dimension-II: Environmental Perception 89 4.7.3 Dimension-III: Stage of Filariasis and Medical Treatment 89 4.7.4 Dimension-IV: Health Care towards the Disease 90 4.7.5 Dimension-V: Psychological Attitudes and Awareness Measures 91 4.8 Conclusion 91

Chapter Five

RECOMMENDATIONS AND CONCLUSION 92

References

Appendices

Publications

LIST OF TABLES

2.1 Growth of Population in Kumbakonam: 1901 - 2011 52 2.2 Different Types of Land use in Kumbakonam 53 3.1 Variable Description and Variable Code 83 3.2 Principle Component Matrix 85 3.3 Rotated Component Matrix 86 3.4 Spatial Dimensions of Filariasis in Kumabakonam: Rotated Factor 87 Structure

LIST OF MAPS After Page # 3.1 GIS Map showing Administrative Units 64 3.2 GIS for the Spatial Distribution of Filarial Cases: 1998 64 3.3 GIS for the Spatial Distribution of Filarial Cases: 1999 64 3.4 GIS for the Spatial Distribution of Filarial Cases: 2000 65 3.5 GIS for the Spatial Distribution of Filarial Cases: 2001 65 3.6 GIS for the Spatial Distribution of Filarial Cases: 2008 65

1 Chapter

Problem Statement and Procedures

1.1 Filariasis: Definition and Meaning

Filariasis is an abnormal enlargement of any part of the body due to obstruction of the lymphatic channels in the area (lymphatic system), usually affecting the arms, legs, or external genitals. In tropical countries the most common cause is filariasis, infestation with certain filaria, small parasitic roundworms of the genera Wuchereria bancrofti or

Brugia malayi that are introduced into the body by many species of mosquitoes. The adult worms live in the lymphatic system, causing local inflammation, fibrosis, and obstruction, and resulting in the characteristic enlargement and thickening of the skin.

The initial damage done by the worms can be greatly worsened by secondary bacterial and fungal infections.

Recovery from filariasis is possible and surgery sometimes helps, but any elephantiasis that develops during the disease cannot be cured. Ivermectin, an antifilarial drug, has been effective with a single dose. Diethylcarbamazine often kills the adult worms or impairs their reproductive capabilities, and the antibiotic doxycycline, which works by killing symbiotic bacteria that live inside the worms, also eliminates adult worms. Albendazole, in combination with others drugs, is being used in a program of mass drug administration undertaken under the auspices of the World Health Organization in an attempt to eliminate filariasis. Begun in 1999 the program treats an entire population in an attempt to eradicate the worm. Control of mosquitoes also is instrumental in holding down the incidence of the disease. Careful hygiene and other measures that prevent and control subsequent bacterial and fungal infections in limbs or genitals in which the lymphatic system has been damaged can reduce disfigurement and suffering. Blocking of the lymph channels and elephantiasis can also result from lymphogranuloma venereum, a sexually transmitted disease.

Filariasis is a general term applied to a group of diseases caused by certain nematode worms known as filaria, which take 3-15 months to mature according to species. The adult live in either the connective tissues by lymphatic or mesentery, where they produce live embryos known as microfilaria. The disease process of fever and inflammation of the lymphatic system in chronic infections leads to debility, disfigurement and disability (Imperato, 1974; Benenson, 1975). Filariasis is a most commonly and widely used term in the world, and in India, for describing the disease process produced by W.bancrofti and to a lesser extent Brugia Malayi. It is a thread like adult worm that lives in the human host for decades. Infected persons are infective only when they have at least 12 microfilaria per 200mm of blood, as only such persons are considered capable of infecting the vectors. Infected humans with microfilaria in their blood serve as the reservoir for the disease (Raghavan, 1969; Hyma, Ramesh and

Gunasekaran, 1989). The usual clinic incubation period from Infective mosquito bite to microfilaria appearing in the peripheral blood is 7-10 months. The shortest period reported is 4 weeks (WHO, 1984; Assessment committee of the NFCP, 1961, 1967,

1971; Imperato, 1974). 1.2 History of Lymphatic Filariasis: 2000BC-500AD

Due to the fact that there is no reliable written record of lymphatic filariasis before the 16th century, ancient historical evidence of lymphatic filariasis cannot be confirmed. Lymphatic filariasis has been known to occur in the Nile region, and ancient artifacts suggest that the disease may have been present as early as 2000BC. A statue of

Pharaoh Mentuhotep II depicts swollen limbs, a characteristic of elephantiasis, which is a symptom of heavy lymphatic filariasis infection. Artifacts from the Nok civilization in

West Africa may show scrotal swelling, another characteristic of elephantiasis. The Nok artifacts date much later than the Egyptian artifacts, from about 500AD.

The first written account of lymphatic filariasis comes from the ancient Greek and

Roman civilizations. In these civilizations, writers were even able to differentiate between the similar symptoms of leprosy and lymphatic filariasis, describing leprosy as

"elephantiasis graecorum" and lymphatic filariasis as "elephantiasis arabum."

1.2.1 Discovery of Symptoms: 1588-1592

The first reliable documentation of lymphatic filariasis symptoms did not occur until an exploration of Goa between 1588 and 1592. During this trip, Jan Huygen

Linschoten wrote that inhabitants were "all born with one of their legs and one foot from the knee downwards as thick as an elephants leg." Although this was the first account of lymphatic filariasis symptoms, more documentation was made in parts of Africa and Asia soon after. In 1849, William Prout became the first to document a condition common to lymphatic filariasis called chyluria. This occurs with the passage of lymph in the urine so it appears milky. Such a description was made in Prout's book entitled On the Nature and

Treatment of Stomach and Renal Diseases. 1.2.2 Discovery of Microfilariae: 1863 and 1866

In 1863, French surgeon Jean-Nicolas Demarquay became the first to record the observation of microfilariae in fluid extracted from a hydrocoele (another common symptom of lymphatic filariasis). Three years later, Otto Henry Wucherer discovered microfilariae in urine in Brazil. However, the connection between these two discoveries was not made until Timothy Lewis noted the occurrence of microfilariae in both blood and urine. Lewis was also the first to make the association between these microfilariae and elephantiasis.

1.2.3 Discovery of the Adult Worm: 1876

Soon after the discovery of microfilariae, the adult worm was documented by

Joseph Bancroft. The observed species was later named after Bancroft, and we now recognize it as W. bancroft.

1.2.4 Discovery of the Life Cycle: 1877

Perhaps the most important discovery related to lymphatic filariasis was that made by Patrick Manson in 1877. Manson was the first to look for an intermediate host for lymphatic filariasis microfilariae. In 1877, he was finally able to pinpoint the microfilariae in mosquitoes. This discovery was later applied to other tropical diseases such as malaria, and was the first discovery of an arthropod as a vector. However,

Manson incorrectly hypothesized that the transmission occurred when the mosquito deposited the filaria in water that then infected humans through ingestion of contaminated water or direct skin penetration.

1.2.5 Discovery of Transmission: 1900

In 1900, George Carmichael Low discovered microfilariae in the proboscis of mosquitoes, and finally pinpointed the true mechanism of transmission. Due to this discovery, we now know that transmission is due to an infective bite from a mosquito vector.

1.2.6 Current Discoveries

As research on lymphatic filariasis continues, more and more discoveries are made in regards to prevalence, treatment options, prevention methods, transmission cycles, and even new species. Clearly, current information on lymphatic filariasis is not complete, and further research is needed.

1.3 Identification Methods: Filariasis

A Bancroftian filariasis is an infection with the nematode worm Wuchereria bancrofti. Man is the only vertebrate host. Early acute manifestations include fever, lymphadenitis, and lymphangities of the extremities, orchitis, epididynitis, funichlitus and abscess. Prolonged and repeated infection with obstruction to lymph flow often leds to hydrococle or to elephantiasis of the limbs; genitalia or breasts or Chyluria. Female worms give rise to embryos, which in the absence of lymphatic obstruction, reach the blood stream.

Life Cycle - The adult worms reside in the lymphatics of the human host. Female

W. bancrofti measure 80–100 × 0.25 mm and the male 40 × 0.1 mm. The adult Brugia spp. has only half of this dimension. Microfilariae are produced from ova in the uterus of the female worm. They are sheathed and measure on average 260 × 8 µm (Figures 84.3,

84.4). Microfilariae are ingested by the vector female mosquito during a blood meal. They escheat in the mosquito stomach, becoming first-stage larvae which penetrate the stomach wall of the mosquito and migrate to the thorax muscles. There they develop through two moults to the infective third-stage larvae (1500 × 20 µm). The development in the mosquito takes a minimum of 10–12 days. Mature infective larvae then migrate to the mouthparts of the mosquito from where they enter the skin of the human host, probably through the puncture site made by the proboscis of the vector when it takes its blood meal. The larvae migrate to the lymphatics and develop to adult worms.

Microfilariae appear in the blood after a minimum of 8 months in W. bancrofti and 3 months in B. malayi. The adult worms may live and produce microfilariae for more than

20 years, but on average the lifespan is shorter. Microfilariae have a lifespan of approximately 1 year. Microfilarial densities may reach 10000 per mL of blood or more, but are usually lower.

1.3.1 Infections Agents

Wuchereria bancrofti and Brugia malayi, and nematode worms and the most important. Man with microfilaria in the blood; in malaysis, occasionally, other mammals are infected with Brugia malayi.

1.3.2 Mode of Transmission

When a mosquito harboring infective larvae bites, W.bancrofti is transmitted to the host. In fact W.bancrofti is transmitted by many species, the most important being culex pipiens, C.fatigans, C.quique fasciatus, Aedes Polynesians and several of

Anopheles, some also vectors of malaria. B.malayi is transmitted by various species of

Mansonia, Anopheles, and Aedes. Microfilaria, picked up by a mosquito while feeding on an infected person, penetrate the stomach wall of the mosquito, lodge in thoracic muscles, develop into infective larvae which migrate to the proboscis and penetrate the new host as the mosquito bites (Beneson, 1975:115)

1.3.3 Incubation period

It is likely that allergic inflammatory manifestations appear as early as three months after infection. But microfilaria does not occur until months later.

1.3.4 Period of communicability

Filariasis is not directly transmitted from human to human. Human may infect mosquito ass long microfilaria are present in the blood. The mosquito is infective from about 10 days after a blood meal until all infective are discharged.

1.3.5 Vector Aspects

Te culex pipiens compels includes C.Pipiens, C.Quinquefasciatus, C.molestud,

C.pallens, C.australiens and C.globocaxitus. Many of these co-exist. C.pipiens has an extensive distribution in temperate latitudes (Holarctic region) and at high attitudes (East and West Africa) and lower latitude (In South Africa, North America, northern Europe and Argentina). It is distribution is increasing with urbanization, and construction activities have created many new, artificial water sources which serve as focal points for the breeding of this opportunistic mosquito (Minjas and Kihamia, 1991).

C.quinque fascitus has colonized tropical and Sub-tropical latitudes. It has been recorded up to 1,800 meters, in four altitudinal Zones in India. Its distributions are also increasing with urbanization and human activity. Many rural pockets which are comparatively free from this mosquito are becoming colonized. Cules fatigans, Prevalent widely in India, breeds usually in collections of dirty of polluted water. It is the most common species that carries the filarial infection. It is the most common species that carries the filarial infection. Common sources are; Latins; Servage; Sullage; Drains; Cess pools and other water collections; Industrial wastes; Domestic wastes; and Artificial containers, inside and outside houses ( Rao, 1981). Other important vectors are Aedes polynesiensis and several Anopheline species.

1.3.6 Aedes vectors

These are found in countries such as the Philippines, Samoa and French Polynesia where studies (Lu, Valencia, Llagas, Baltazar, and Cahanding, 1983; Carme, Utahia,

Turiara, and Teuru, 1979, for example) have been made on species such as polynesiensis,

A.Samoanus and A.paecilicus. A.polynesiensis is freeholds crabholes water storage drums, discarded automobile tires, cams, bottles, and coconut shells. This species has been found to have a flight range of 400 mm coconut plantations and coastal villages.

A.samoanus on the other hand breeds in leaf axils. A poecilius prefers of breeds in axils of banana trees in the Philippines.

1.3.7 Mansonia vectors

The genus mansonia is divided into two subgenera: Ansonia and mansonioides. It is the subgenus mansouioides that includes the important vectors of lymphatic filariasis caused by B.malyi in the southern and southern Asia. In the past decade, studies on mansonia vectors have been mainly from India, Indonesia, Malaysia and Thailand.

Studies in Sarawak have shown that mansonia mosquitoes are less exophagic than those in peninsula, Malaysia, Sabah and the southern Thailand.

1.3.8 Anopheles vectors

The genus Anopheles is important in the transmission of the periodic W.bancrofti in Africa, southern Asia and the island of New Guinea. It is also a significant vector periodic B.malayi in southern Asia new transmission and distribution records include

A.Gambae from the island I Grande Comoro, and A flavirostris from Sabah. No mosquito other than A.barbirosttis has been identified as a vector of B.Timori WHO. 1992).

C.pallens occurs in China, Japan and the United States of America. C.Molestus is mostly distributed in temperate latitude.

1.4 Types of filariasis

Filarial disease has until recently been synonymous with ‘filarial fever’. Filariasis comprises of several diseases. Most are caused by filarial worms and are transmitted by blood sucking flies. For example, dracunculiasis is a closely related metazoan disease transmitted by water fleas. An onchocerciasis or river blinder which is transmitted by black flies of the genus simulium is probably the most serious of the filarial diseases. It affects more than 40 million people, mainly in Tropical Africa, but also in central and south America. The foci in the eastern Mediterranean Region extend to Yemen and the

Sudan.

The manifestations of on chocerciasis are mainly intense itching and, ultimately in many cases, blindness. The blindness is due to the millions of onchocrca volvulus microfilaria scatted throughout the body, especially in the skin and the eyes. The adult worms lodge themselves in the nodules in the subcutaneous and even in deeper tissues in various parts of the body.

1.5 Worms that cause filariasis

Lymphatic filariasis is the result of infection by parasite nematode worms, both males and females, of the family Filariidae. The males are 15-30 mm long; the females are 30-60 mm long. The female continuously sheds microfilaria about 0.2-0.3 mm long in the lymphatic system which pass subsequently in its blood vessels. Three species are particularly frequent according to Kin Paniker and Vijay Dhanda (1992).

a. Wuchereria bancrofti leads the most severe form of lymphatic

filariasis, affecting limbs, breasts and genitalia and it can induce tropical

pulmonary Eosnophilia.

b. Brugia malayi and brugia timori cause less severe problems and affect

mainly the lower limbs. WHO estimates that there 90 million cases of

lymphatic filariasis in the world, in 76 countries; 905 million people live

areas where they are of risk contacting the disease.

1.6 Lymphatic filarial diseases

Lymphatic filariasis is one of the major public health problems in many developing countries. These diseases affect about 90 million people in Asia, Africa and

South America in addition to an estimated 905 million directly exposed to the rise of infection. These are responsible for considerable disability and disfigurement due to acute ademolymphamngitis and chronic lesions like elephantiasis and hydrocoele .The parasites that cause human lymphatic Filarasis are Wucheraria bancrofti, Brugia malayi (Riji,

1983) and B.timori. Adult worms lodge in lymphatic vessels. The microfilaria circulates in the blood often in a nocturnally periodic pattern, and is transmitted by various genera of mosquitoes.

Lymphatic filariasis is a major health problem in many part of India. The disease is commonly seen among the poorest of the poor and has a very low public health rating in the priorities of most countries where it is prevalent. Unlike Onchoceriasis, lymphatic filariasis can be relatively safely and effectively treated with DEC which ,although mainly microfilariacidal, may in large enough doses be microfilariacidal.In lymphatic filariasis, DEC is however not without side effects which are related to the rapid destruction of large number of microfilaria in patients with high levels of parasilamia.

1.7 Geographical Distribution of Filariasis in Select Countries

Lymphatic filariasis is a major public health problem in tropical countries. Recent estimates suggest that some 120 million persons are infected world-wide; 107 million with Wuchereria bancrofti and 13 million with Brugia malayi. The number of people with physical disabilities due either to lymphoedema and hydrocele or the newly recognised sub-clinical abnormalities of lymphatic and renal function are currently estimated at 43 million, with Bancroftian filariasis accounting for almost 40 million of these cases (Michael 1996).

The International Task Force on disease eradication identified lymphatic filariasis as one of six potentially eradicable diseases since there are now good enough tools to combat the disease (CDC, 1993). The World Health Assembly at its meeting in

May 1997 passed a resolution on the elimination of the disease as a public health problem through mass treatment of affected populations and appropriate management of clinical cases.

In order to initiate any disease control programme based on mass drug distribution, one needs to understand the geographical distribution of the disease in the affected countries in order to know where to target mass treatment. Unfortunately, data on the distribution of lymphatic filariasis are not widely available primarily because the standard procedures for determining which communities are affected are cumbersome, time-consuming, expensive and very intrusive. In areas where the parasite exhibits a nocturnal periodicity, parasitological examinations need to be done at night. This becomes logistically cumbersome to organize, and communities often refuse to co- operate.

Recent epidemiological studies in Ghana suggested that clinical filarial disease is a good proxy measure of the levels of endemicity of filariasis. (Gyapong et al, 1996).

This findings has since been validated in a WHO coordinated multi-country study (WHO

1998a). On the basis of the results, the study participants recommended the use of clinical examinations of a sample of adults as a rapid method to assess the community burden of the disease.

Even with these new rapid assessment methods, it would be very time- consuming and expensive to do filariasis surveys in all potentially endemic communities in order to determine the geographical distribution of lymphatic filariasis. However, given the clustered distribution of filariasis in most parts of the world, it may be possible to develop methods which allow the estimation of the distribution of filariasis on the basis of surveys in a limited spatial sample of communities. Such a method has already proven very valuable for onchocerciasis control in Africa (Ngoumou et al 1994, WHO

1998b).

Filarial Cripples an estimated 130 million people in the developing countries.

There are according to a recent WHO estimated, 119.1 million cases of lymphatic filariasis in the world, in 76 countries and 905 million people live in areas. Where they are at risk of contacting the disease, from the biting Mosquito which transmit the filarial worms that cause serve disability and disfigurement. This amounts to106.2 million of bancroftian filariasis and 12.9 million brugian filariasis (Micheal and Bundy, 1995) the numbers over physical disabilities from their infections is approximately 43 million, with bancraftian filariasis accounting for almost 40 million of these cause in the affected, the limbs well the skin hardness and stretches, producing ulcers in a mild version of the chronic stage of elephantiasis. The swelling is caused by the blockage of vessels in the lymphatic system.

The 1992 report of the WHO expert Committee on filariasis indicates that

Brugian Infection is endemic in 8 Countries in South East Asian region (Bangladesh,

India, Indonesia, Maldives, Myanmar, Nepal, Srilanka and Thailand) While W. Bancroft occurs in 7 countries in the American region (Brazil, Dominican republic Coasta Rica,

Guyana Haiti, Suriname, Trinidadad and Tobago) 4 in the Eastern – Mediterranean region and 17 in the western pacific region (American Samoa, Brunei, Darussalam,

China, Cook Islands, Fiji, French, Polynesia, Malaysia, Nive, Papua, New Guinea,

Philippines, Republic of Korea, Samoa, Tonga and Vietnam), an additional 38 Countries lie within the W.bancrofti endemic areas of sub Saharan Africa (Angola, Benin,

Burkinafaso, Burundi, Cameroon Capeverde, Central Equatorial Guinea, Ethiopia,

Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Kenya, Liberia, Madagascar, Malawi,

Mali, Mauritius, Mozambique, Niger, Ramiro, Saotome and Principe, Senegal,

Seychelles, Sierra Leone, Togo, Uganda, United Republic of Tanzania, Zaire, Zambia and Zimbabwe). India with 45.5 million cases and sub – Saharan with 40 million cases have very similar burdens of W. bancrofti infections. Individually, the two account for 38 percent and 34 percent, respectively of the world burden. By Comparison, hower, There are slightly higher infection and disease rates observed for the sub-Saharan than for India.

1.8 Geographical variation in transmission

The epidemiology of W. bancrofti and B. malayi infections varies in different geographical areas, especially with respect to the prevalence and intensity of infection, the transmission pattern and the clinical manifestations. Differences in vectorial capacity and density are important factors influencing these epidemiological parameters in different endemic areas. Even within the endemic community there can be considerable variation in vector abundance and transmission between different sections and from one household to the next. There are also inherent differences in the parasite; for example, three strains of W. bancrofti and two strains of B. malayi have been recognized on the basis of differences in periodicity of the micro- filariae. In most areas the microfilariae of

W. bancrofti are nocturnally periodic, being adapted to transmission by night-biting

Culex and Anopheles mosquitoes. A diurnal sub periodic form is found in the South

Pacific and in the Andaman and Nicobar Islands (India), whereas a nocturnally subperiodic form is found in Thailand. B. malayi occurs both in a nocturnal periodic and a nocturnal sub periodic form, whereas B. timori is nocturnally periodic. The sub periodic forms are transmitted by vectors that bite mainly during the daytime. It is possible that variation in worm habitat preferences within the host’s lymphatic system may con- tribute to differences in clinical manifestations.

For details of the vector species and their bionomics, see Appendix IV.

Different geographical vector zones have been recognized on the basis of the predominant vector species responsible for transmission in the areas.72 Culex quinquefasciatus is the principal vector of W. bancrofti in urban and semiurban areas of southern and South-east Asia, East Africa and America. Increased pollution of freshwater bodies and the introduction of pit latrines, which favour breeding of this mosquito, have led to increased transmission in many areas. C. quinquefasciatus is an endophilic night- biter. There is no evidence that it is transmitting filariasis in West Africa. In rural areas of

Asia and Africa, Anopheles spp. are the main vectors, with the A. gambiae complex and

A. funestus being the most important vectors in Africa. The main vectors of the

Anopheles spp. bite indoors at night and breed in open, rather clean, water.

In the South Pacific islands the predominant vectors of W. bancrofti belong to day-biting Aedes spp., especially A. polynesiensis. The majority of these mosquitoes bite outdoors and breed in small temporary water collections: tree holes, empty cans and bottles, coconut shells, plant axils and crab holes. In Papua New Guinea night-biting

Anopheles spp. are the principal vectors.

The nocturnally subperiodic form of B. malayi is transmitted by Mansonia mosquitoes in dense swamp forest areas. This form is commonly found also in wild monkeys. Nocturnally periodic B. malayi has been reported only from humans. It is transmitted in open plains and agricultural areas, mainly by Mansonia spp. mosquitoes, although in some areas species of Anopheles and Aedes also play a role. The larvae and pupae of Mansonia mosquitoes obtain their oxygen directly from the cells of certain species of aquatic plants present in clean water-bodies. Survival of the Mansonia spp. is dependent on the association with the plants. Increased pollution has in some places led to a decrease in breeding of Mansonia, with a subsequent drop in transmission of

B. malayi. Mansonia spp. prefers to feed outside and biting usually commences shortly after dusk. A. barbirostris is the only mosquito to date to have been identified as a vector of B. timori. 1.9 Filariasis in Asia

Asia excluding India and China is the region of third highest number of cases with

14.5 million and prevalence of 1.83 percent of bancroftian filariasis. The regional estimates for brugian filariasis suggest that India accounts for 20 percent and china about

32 percent, making up half the global burden. The largest number of cases in both the genera, W. bancroftio an B.malayi , occurs, in the 15-44 age group but the prevalence’s of microfilaraemia and disease are the highest in the age group of 45 – 60 . There is also a male bias for microfilaraemia, 10 percent more in bancroftian and 25 percent more in brugian filariasis chronic disease due to bancroftian also appears to be more prevalent among males than females, largely because of the large number of hydrocoele cases put at 26.79 million. Two third of the known victims of the disease are in India, Indonesia and China, India alone, more than 300 million people are exposed to the threat of filariasis. The efforts at controlling the disease are undermined by the increasing resistance of the parasites to drugs and the mosquito vectors to pesticides. Poor sanitation and urban squalor provide for an ideal ground for filarial mosquitoes.

1.10 Filariasis in India

To give an idea of the extent of burden of bancroftian filariasis in India, the country has 17 million cases of microfilareamia in male (with a prevalence rate of 3.87 percent), 12.46 million in females (Prevalence rate 3.04 percent). Lymphoedema cases are 2.6 million in males (0.6 percent) and 3.98 million in females (0.97 percent).

Hydrocoele on the other afflicts 12.88 males (2.93 percent). These Cases amount to a total of 29.43 million males (6.7 percent) and 16.1 million females (3.92 percent). The extent of burden of being brugian filariasis in India, in the form of microfilaraemia, is 1.105 million cases in males (0.25 percent), and 0.692 million in females (0.17 percent).

Lymphoedema cases number 0.582 million in males (0.13 percent) and 0.282 million in females (0.07 percent). These amount to a total of 1.635 million cases in males (0.37 percent) and 0.949 million in females (0.23 percent).

In India, the National Filaria control Programme (NFCP) is a division of the

National malaria Eradication Programme (NMEP) in the ministry of Health. The Primary

Control Strategies of the NFCP include larviciding and environmental control measures for mosquito reduction in Urban areas, as well as screening urban Population by night blood Surveys and treating with DEC (6 mg/kg/day X 12 days ) Those found either to be microfilaraemic or to have Lymphoedema. Nearly 75 percent of the population is at risk in rural areas all filariasis control efforts are confined urban areas. In India, the following states and union have been identified as endemic to filarial. They are: Andhra Pradesh,

Assam, Bihar, Goa, Gujarat, Karnataka, Kerala, Madhya Pradesh, Maharastra, Orissa,

Tamil Nadu, Uttar Pradesh, West Bengal, Andaman and Nicobar Islands, Daman and

Diu, Lakshadeep and Pondicherry.

1.11 Filariasis in Tamil Nadu

In the State of Tamil Nadu Sample Surveys were conducted in the mid 1970s in

11 out of 15 districts. It was found that a total of 27 million people were exposed to risk out of a total population of 41 million. One million suffered from filariasis and 1.83 million had microfilaria infections (Rao, 1981). Filarias due to W.bancrofti occurred along the coastal zones of Tamil Nadu and in some inland areas. Relatively high microfilaria rates (8.3 to 11.1 percent) were also observed in the early 1955- 59 surveys under the NFCP (Sasa, 1976). The estimated figures for 1985 and 1986 for infection with filaria were 16, 425 and 18, 729 respectively. Data for rural areas were not available for the years 1985 and 1986. In the state, 13 Districts have been identified as endemic to filaria. They are Chennai(Metropolis), Kancheepuram, Thiruvallur, Vellore,

Thiruvannamalai, Thiruchirapalli, Villupuram, Cuddalore, Nagapatinam, ,

Thanjavur, Pudukottai and Kanyakumari.

The First 12 districts are under the control of the Directorate of the Public Health and preventive medicine while Chennai (until recently, Madras) under the Corporation of the metropolis. The National Filaria Control Programme (NFCP) has been, and is being implemented in Tamil Nadu, since 1957. Due to Limited financial resources, however, the fileria Disease control is at present confined to 43 urban areas only. One Survey unit is in operation at Madurai for delimiting the endemic areas in the un-surveyed district and the scheme is funded by the Central Government on 50:50 share of the cost of material and equipment.

Besides these, the state as a unique scheme for encouraging the local bodies to implement anti– filarial and anti – mosquito schemes with grant in aid from the state

Government. Of the 728 local Bodies in Tamil Nadu, 174 are implementing Government approved grant in aid schemes. The public health Department has taken up some special trails for control of rural filariasis; the DEC enriched salt has been distributed in Kiliyur of Villupuram District since 1989, this trail has been very successfully, in reducing filariasis transmission as seen in the micro filarial rate of 15.12 reducing to 0.16 in 1992 and to no rate was reported in 1994.

A follow up of the successful project has been implemented in Kanniyakumari district from October 1995. The Health salt is being distributed through public distribution system (PDS) in endemic villages of this district for the control of the rural filariasis. Now, A DEC monitoring cell has been established in the year 1996. There are other programmes of control as well. A‘ single Day Mass Therapy; for example, has been conducted in august 1996 in Cuddalore district under the NFCP and DEC tablets have been distributed to 2.1 million people to avoid further spread of the disease in the area.

Tamil Nadu is the first state of the Indian Union to implement the new strategy of single day mass therapy. A mass therapy has been implemented in Tanjavur and

Thiruvannamalai Districts during September 1997. In Tanjavur and Nagapatinam

Districts of the Cauvery Delta region in Tamil Nadu, 25 filaria and Malaria clinics have now been established (In 1997) for the diagnosis, treatment and Control of filariasis and malaria, directly under the taluk of the district headquarters Hospitals. There are in facts two district programmes in Operation in the state, namely, the NFCP and the anti – filarial scheme (AFS). The NFCP is being run in a way it takes care of mosquito collection, Dissection of mosquitoes, larvicidal activities, Night Blood Surveys, Blood smear, Examinations, and Treatment with DEC; the AFS on the other hand, is carried out by the municipalities but with night surveys conducted by the NFCP.

1.12 National Control Strategies in select countries

In China, the first National Programme began in 1965 and the results have been remarkable. From a Prevalence of 31 million cases in 196, diligent use of DEC –Fortified salt and mass treatment programme with standard 2 week courses, China has brought the number of filarial cases to an estimated 1.58 million. In all the once – endemic provinces of China today, the prevalence is now less than 1 percent (WHO, 1994). Egypt presents a different picture. There was early success in the control of the bancroftian filariasis through DEC delivery and mosquito/ Environmental Control efforts. But the control programme was relaxed in 1965 and the problem of bancroftian filariasis began to return.

The Peri Cairo rural and semi – urban area of the Nile delta have foci where the prevalence of bancroftian filariasis is greater than 20 percent. The division of the ministry of Health, responsible for the filariasis control oversees control which is based primarily on identifying microfilariaemic individuals in night blood surveys and treating them with standard courses of DEC. There is additionally limited mosquito efforts relying on insecticides and insecticide impregnated bed nets (Harb, Fairs, Gad, Hafez, Rawzy and

Buck, 1993)

In the 1950’s Lymphatic filariasis was a public health priority in French

Polynesia, as 30 Percent of the population was microfilariaemic and 10 percent suffered from hypoedema. Mass chemotherapy with various regimens of DEC was initiated which ultimately became 6mg/kg delivered in single doses twice yearly to the entire population

The mass chemotherapy was therefore reinitiated in1993 by the ministry of Health, with

DEC at 3mg/kg being given every 6 months (Perolat, Guidi, Riviere and Roux 1986).

Indonesia is the only country with all the three species of filarial parasites, and with transmission by five different mosquito genera and a plethora of individual species.

A National Filariasis Control Programme was established in the early 1970,s. There was emphasis on spaced, low –dose DEC with appreciable Community participation and involvement of the primary health care system in the country. The current Strategy is based on mass distribution of low- dose DEC, at 100mg for an adult, 50 mg for a child less than 10 years old , given weekly for 40 weeks by primary health care workers in endemic communities, where microfilaraemia prevalence is more than 1 percent. It was in the early 1960,s that a formal and systematic filariasis control

Programme was started in Malaysia. The current control activities are however in corporated under the vector borne Diseases Control Programme of the Ministry of

Health. With an annual incidence of 3-5 cases microfilariaemia per100,000 population,

17 control teams are dispersed throughout the endemic areas to carry out geographical reconnaissance, night blood surveys treatment of cases with DEC for 6 days, follow – up evaluation and health education (Annual Report of the vector - borne Disease Control

Programme, 1993). A survey in 1960’s put 42 out of 56 surveyed provinces of the

Philippines as endemic to lymphatic Filariasis at present, both bancroftian and brugian filariasis is widespread. The filariasis Control Programme is currently part of the communicable Disease Control Service. Currently, there are 7.5 million People at risk of

W.bancrofti infection along the coastal areas of Srilanka. No new cases of brugian filariasis have been reported after 1968. Until 1987, a million blood films a year were examined for microfilaria; but now only two – thirds of this number is being examined.

The Prevalence of Microfilareamic persons in these areas was 0.36 percent during 1993.

All microfilareamic persons are given DEC at 150 mg twice daily for two weeks, with an additional courses of treatment of one month later.

A filariasis Control Programme was instituted in 1961 in Thailand and it has how been integrated into the basic health services Programme but Supervised by a District filariasis division. Use of Impregnated bed nets and repellents is encouraged. The overall

Objective of the Programme is to the reduced micro filarial carrier rates to at least 0.6 percent in all endemic areas and then to interrupt both transmission and occurrence of

Lymphoedema or elephantiasis (Suvanndabba, 1993). 1.13 Review of Literature

Panicker, Pani Sabesan and Krishnamurthy (1990) have studied the relative utility or door to door surveys, school surveys, community health camps, filariasis clinics and microfilaria detection camps, in the detection of the filariasis in the endemic area for brugian malayi: shertallai taluk in Kerala state, south India. In this study, 67,071 have been examined for microfilaraiamia and 26,929 persons have been examined for the manifestations of filariasis: 1,335 microfilaria carriers and 4,074 clinical cases of filariasis have been detected.

Case detection and treatment following door to door surveys is the mainstay of filariasis control in china and many Southeast Asian countries including India, anonymous, 1984. It is interesting to note that in china 339 million people have been screened for microfilaria and 4 million have been treated with DEC in a ten years period

(jinjiang; 1986). This has not been possible in the India. It has been found that after 30 years of launching the national filariasis control programme (NFCP) in India, door – to – door surveys were yet to be carried out in 78 or the 290 endemic districts (Sharma,

Biswas, Das and Dwivedi, 1983) and the present programme protected only 5 out of 252 million people in rural areas exposed to the risk of infection (RAO and Sharma, 1986).

The vector control research centre (VCRC) in Pondicherry carried out a five year study (1980 – 1985) in the coastal villages of the region objective was to establish on intersectorial action plan for health by co–ordinating the activities of various

Governmental agencies operating in the village and concerned with local administration , health social welfare education, rural development and fisheries. To encourage the local community, a variety of schemes were introducing by the VCRC. Another early step taken by the programme was to control the most obvious breeding sites of mosquitoes. The local bodies of the Panchayat have paid little attention to water supply and waste water disposal. This resulted in conditions, ripe for the breeding or mosquitoes over waste areas, especially near public taps and wells. The

VCRC is involved in this matter and gained a good name from the community.

The VCRC, with the encouragement of the child development service, gave special training in vector control to anganwadi workers and asked them to pass on this knowledge to women, for whom literacy classes are also provided. With the co – operation of the Department of Education, the Children were taught the public hygiene and simple vector control methods and they reclaimed a mosquito Breeding swap and turned it into play ground They also created a kitchen garden making use of the domestic effluent which normally accumulated in pits that breed mosquitoes.

The VCRC formed a health committee in one village to carry out mosquito larval control into ponds. The ponds were first de weeded, manually. Finger lings of common carp (Cyprinus Carpio) were provided by the VCRC and the members were taught to culture the fast growing, edible fishes. These fishes are used as larvicides for mosquitoes.

In the study by A.F Singh al (19990) Merthiolate was used as a preservative with recommended concentration. This marthiolate saline as control did not cause any skin reaction, whereas the antigen infected simultaneously, on the other arm, elicited positive reaction ratio due to antigen (15 minutes after injection) ranged from 3.0 to 11.31

(median 4.8) which was highly significant (P<0.001), whereas the increase in the whole area due to this mentholated saline ranged from 1.0 to 1.5 (medium 1.0) which was not significant. Hence, merthiolated is a begin preservation and can safely be added to the antigen in the recommended proportion.

Individuals of either sex, aged between 10 and 70 years, where include in the study. These were drawn from filarial (w.bancroftio) endemic (chandraelal, 1973) and filaria non-endemic areas having other helminthes injections. The Registration of micro and a microfilareamic was done on the basis of night blood examination and the antigen was assessed in different groups. The resurgence of lymphatic filariasis in the Nile Delta

(Harb et al, 1993), a study of 325,000 residents of 314 villages in six Governorates of the

Nile Delta area of Egypt, has revealed that the lymphatic filariasis increased from less than 1 percent in 1965 to greater than 20 percent in 1991. In Egypt, surveys of filariasis using combined measurements of the microfilaria rate and of the frequency of clinical manifestations were concluded in many non – randomly selected communities. The results provided a sketch panorama of the distribution of the disease.

Since 1974 a number of small spot surveys have been conducted in several parts of the Nile Delta for filariasis studies. The prevalence and the intensity of microfilaria have increased (Desowitz et al, 1993). The benchmark ecological and entomological analysis (brengues, 1975) indicates bancroftian filariasis found through West Africa from the mangrove swamps of the guinea to the sahelian Borden lands at 16 degrees latitude north. It is the savannah areas that harbor the most filariasis (Hughes and hunter, 1970).

But the disease is not uniformly distributed it is found scattered.

A Typical geographic pattern of spotty occurrence of bancroftial diseases was revealed in the study by lamontellerie (1972). In this survey about 147 villages in a known filarial zone of southwest Burkina Faso. In 12 percent of the villages, there was no filariasis, in another 33 percent, it was below 5 percent prevalence (hypoendemic); 26 percent, 5.0 to 19.9 percent prevalence (meso – endemic); and the remaining 29 percent of the villages suffered more than 20 percent of prevalence (hyperendemicity). Two villages were found with peak infection rates (42 percent and 43 percent), conditions favoured for mosquitoes populations. More recently, coastal lagoons of the wory wast near sassandra was reported hyperendemic buncroftian filariasis (Remy, 1988) and three locations in Barkina Faso.

1.13.1 Socio cultural literature

Lymphatic filariasis (LF), the second most common vector-borne parasitic disease after malaria, is found in over 80 tropical and subtropical countries. WHO estimates that

120 million people are infected with the parasite, with one billion at risk. These figures are certain to be revised upwards because global prevalence mapping has not yet been completed. According to WHO, LF is the second most common cause of long-term disability after mental illness. One-third of people infected with LF live in India, a third live in Africa and the remainder lives in the Americas, the Pacific Islands, Papua New

Guinea and South-East Asia. While not explicitly mentioned in the Millennium

Development Goals, LF and other neglected tropical diseases are recognized in the report on the Commission for Africa as contributing significantly to the overall African disease burden. LF and other helminthic diseases leave infected individuals, particularly women and children, more vulnerable to HIV/AIDS, tuberculosis and malaria.

LF causes a wide spectrum of clinical and subclinical disease. Approximately two-thirds of infected individuals show no overt evidence of disease, but when tested demonstrate some degree of parasite-associated immunosuppression, and many show evidence of renal dysfunction. The remaining third suffer from the chronic manifestations of LF – chronic lymphoedema, elephantiasis and hydrocele. Further, those infected with

LF suffer the debilitating effect of acute filarial attacks that last from five to seven days and may occur two to three times each year. Chronic filarial disease has serious social and economic effects. Those afflicted with elephantiasis and hydrocele are often socially marginalized and poor. Acute attacks and chronic disability cut economic output and increase poverty.

In 1997, a World Health Assembly resolution called for the elimination of LF.

Public health interventions thus far have focused on interrupting the transmission of the parasite through the use of mass drug administration campaigns (MDAs). The MDA programmes deliver community-wide doses of diethylcarbamazine and albendazole, or albendazole and ivermectin, once annually for a period of four to six years. Although substantial progress has been recorded wherever the strategy has been implemented, initial gains have been accompanied by the realization that an intervention that assumes compliance will not alone ensure a permanent solution in many settings. Even in areas where LF prevalence has been reduced to less than 1per cent of the population, elimination remains elusive and in some situations the disease has resurged. We argue that these “upstream” interventions could deliver more effectively “downstream” at community level if the programmes were more firmly grounded in sociocultural awareness during the planning stages.

This paper explores the disparity between the way the disease is defined at the elimination programme planning stages and the way it is defined and perceived in the diverse communities where it is implemented. We describe the impacts of undiagnosed and untreated LF on the lives of potentially active and productive men and women and explore the impact that awareness of local health and sociocultural norms and values can have on improving primary and secondary LF control efforts.

1.14 Impact on infected individuals

Filariasis is caused by nematodes (roundworms) that inhabit the lymphatics and subcutaneous tissues. Three filarial species cause lymphatic filariasis: Wuchereria bancrofti, Brugia malayi, and Brugia timori. Infections are transmitted by mosquito vectors; humans are definitive hosts. Lymphatic filariasis is a major cause of disfigurement and disability in endemic areas, leading to significant economic and psychosocial impact. The epidemiology, pathogenesis, and clinical features of lymphatic filariasis will be reviewed here. The diagnosis, treatment, and prevention of lymphatic filariasis and other filarial infections, including onchocerciasis, loiasis, and mansonellosis, are discussed separately.

1.14.1 Current knowledge about LF’s sociocultural burden

The chronic manifestations of filariasis can have significant, and often very negative, social impacts. The chronic disabling manifestations of this disease, including lymphoedema of the limbs, breasts and external genitalia, have a profoundly detrimental effect on the quality of life of affected individuals. The degree of social disability varies between cultural settings, but the degree of stigmatization appears to be directly correlated with the severity of visible disease. In conservative contexts, affected individuals avoid seeking treatment for fear of drawing attention to their condition.

Failure to treat the disease results in recurrent acute febrile attacks and progressive damage to the lymphatic system. Without access to simple hygiene advice, sufferers are unable to prevent further progression of the outwardly visible complications of LF.

Women bear a double burden in societies where much of their role and identity is dependent upon marriage and the ability to give birth to children. Young unmarried women with LF may be forced to lead a reclusive existence in an attempt to hide their illness or because their limited marriage prospects make them a burden to their families.

In Thailand and in west Africa there is a general perception that children born to a woman affected by LF will be similarly affected. Shame and anxiety related to difficulties in conceiving children are common for LF patients around the world. Young females with LF are considered poor marriage prospects because the disease’s recurrent debilitating acute episodes limit their ability to perform paid and unpaid work. The costs associated with long-term health care as the disease progresses result in perceptions of these women as financial burdens.

Although women may have concerns about marrying men with the physical stigmata of LF, their gender roles and prevailing power structures often leave them in a relatively powerless position. In Haiti, Coreil et al. found that the risk of dysfunction and unhappiness was greater in marriages where the wife had physical manifestations of filariasis. This is supported by data from coastal Ghana.

Gyapong et al. suggest that the physical and psychological burden borne by men has a negative impact on their marriage and employment prospects. The extent of male sexual disability as a result of LF has not been extensively studied, but investigators believe that there is a significant “silent burden”. Gyapong et al. found that hydrocele had a significant impact on young men, particularly at a time when they were struggling to establish their sexual identity and their capacity to be reliable economic providers. Unwillingness to admit to sexual dysfunction may shroud the real extent of this issue.

South American researchers found a wide range of disease-related problems, including marriages without sexual activity, reports of painful intercourse in women whose partners had penile lymphoedema and suicidal thoughts of both male and female partners being attributed to the disease.

1.14.2 Impact upon lifestyle and economic opportunities

Gyapong et al. speculate that the current estimate of 850 000 disability-adjusted life years (DALYs) lost as a result of LF was a gross underestimate. The estimates are based on an assessment of gross clinical manifestations and do not take account of the

“incidence, duration and severity of acute adenolymphangitis”. In particular, the estimate fails to capture the impact of disease on young people who, while not displaying clinical manifestations or physical abnormalities, may be suffering the effects of acute fever attacks. Acute episodes of adenolymphadenitis may result in school absenteeism and poor educational attainment. Chronic disease can also present in childhood and affect children’s quality of life.

As the disease progresses, the individual’s capacity to labour, both productively and reproductively, are increasingly hampered. Coreil et al. note that in the Haitian context, while impairment of mobility impacts upon the ability to garden or sell produce in the market, acute attacks are equally detrimental to individuals’ ability to support themselves and their family.

This finding is echoed by the work of Gyapong et al. and Suma et al. As the disease progresses, the affected individual becomes too severely disabled to contribute to household labour and further burdens the household economy. 1.15 Impacts on the LF elimination programme

The elimination programme is based on a simple two drug, once-yearly treatment of at-risk individuals using safe and effective medicines (albendazole plus either

Mectizan® or diethylcarbamazine [DEC]). The World Health Organization (WHO) recommends a minimum of five rounds to reduce the level of disease below the threshold for sustaining transmission; then mass drug administration (MDA) can be stopped. MDA programmes are already underway in 48 of the 83 LF-endemic countries and a number of other countries are in the process of organising such programmes. Since the programme began, 66 million babies have been born into risk free areas, a number that is expected to increase sharply as even more countries begin LF elimination programmes.

1.15.1 Paucity of LF-related sociocultural research

A comprehensive literature search was undertaken to identify all published sociocultural information available from LF-endemic countries. It was conducted using

PubMed, Ovid and their associated databases. Keywords included: lymphatic filariasis, filariasis, Wuchereria bancrofti, Brugia malayi, Brugia timori, and elephantiasis, hydrocele, sociocultural and socioeconomic.

Published LF literature is dominated by laboratory research and quantitative field measurement of the impact of LF, with a wealth of local prevalence studies of parasite- infected humans and vectors. Several researchers have highlighted the dearth of sociocultural information on local beliefs, perceptions and behaviours towards the disease. The paucity of sociocultural data is a common feature of other neglected tropical diseases. Even with malaria, the neglected parasitic disease with the greatest tradition of socio behavioral research, Williams and Jones observed that this research, while key to successful outcomes, has yet to realize its full potential in contributing to control. Krishna

Kumari et al. and Gyapong et al. have argued that the lack of understanding and documentation of LF’s socioeconomic consequences have led to a gross underestimation of its impact. As the global elimination programme expands, the absence of sociocultural insights and understanding appears to be impeding progress.

The multidisciplinary nature of the social science approach to researching infectious diseases is often poorly understood by disease control programme planners.

Fundamental differences in research paradigms, research strategies and even language make qualitative research approaches and findings difficult to communicate. Williams and Jones observed that changing the status quo can be difficult in a context dominated by research and funding structures that are not geared towards sociocultural approaches.

The United Kingdom-based Institute for Development Studies notes that “Health research

[in the developing context] is often funded by specialised agencies and priorities identified by health sector managers who mostly have medical training.” The very tightly focused health research agenda often overlooks or rejects the development of local sociocultural understanding strategies against LF and other infectious diseases.

1.15.2 Beliefs about disease causality and transmission

Little information has been formally collected about how communities incorporate LF, its origins and impact, into local knowledge systems. The role of mosquitoes in transmitting the parasitic agents of filariasis is poorly appreciated in many endemic communities, and thus it is not surprising that there is little awareness in these areas of the importance of minimizing mosquito contact for preventing infection. In a

Malaysian study, only nine of 108 respondents associated filariasis with mosquitoes, while walking barefoot on dirty ground or consuming contaminated food or drink was commonly implicated as the source of infection. In rural Thailand, while schoolchildren indicated correctly that mosquitoes transmit filariasis and that the disease could be prevented by personal protection against mosquito bites, adults maintained that the disease was inherited or resulted from poor blood circulation, carrying heavy loads, prolonged standing, bathing in or drinking swamp water, personal contact with infected individuals or sorcery. Suma et al. found that many participants in the Indian survey believed that the disease was inherited. In Papua New Guinea and the United Republic of

Tanzania, although most people indicated that mosquitoes spread malaria, few understood that mosquitoes could also spread filariasis (Wynd et al., unpublished observation). Ahorlu et al. found that many villagers in a coastal Ghanian community rejected the mosquito’s role in transmission. In French Polynesia, despite an intensive community education campaign, most people discounted the idea that mosquitoes played any part in disease transmission and attributed LF to the act of immersing an injured ankle in the sea or consuming contaminated food and drink.

In the Philippines correct knowledge of disease transmission was associated with the highest level of formal educational attainment. A study in rural south India found that only 9 per cent of apparently uninfected people and 20 per cent of patients with chronic filarial pathology knew that filariasis was contracted through mosquito bites. Other causes commonly cited were occupation, polluted drinking water and poor nutrition.

1.15.3 Community ownership of treatment programmes

Gyapong et al. found that community-directed MDA programmes achieved much higher levels of coverage than those delivered exclusively through the formal health sector and were especially effective in areas where health facilities were limited.

Rifkinhas argued that community involvement is more effective when viewed as an ongoing process. The explanation for improved coverage in the Ghanaian context appeared to be twofold. First, the community was more likely to “own” the process because it was involved in directing it and, as a result, was more likely to participate and encourage participation by all community members. It is possible that this sense of ownership may override or soften resistance to outside intervention. Secondly, the iterative approach to seeking permission, returning to train local treatment coordinators and ultimately delivering medication resulted in a higher overall level of understanding of the programme’s purpose. Gyapong et al. highlight the need to allow this pilot intervention time to expand into a larger geographical area and to broaden its focus to include other health areas before claiming that the approach has long-term sustainability.

1.15.4 The value of increasing our sociocultural understanding

A quarter of a century ago, Dunn observed that the interactions between sociocultural factors and LF control had largely been ignored, and that few attempts to bridge the gap between biomedical knowledge and indigenous perceptions of disease had been attempted. While there has been some growth of the literature in this area, insights and understandings remain limited. Of the 80 countries known to be endemic for LF, sociocultural information is available for only 11 (Brazil, French Polynesia, Ghana, India,

Kenya, Malaysia, Nigeria, Papua New Guinea, the Philippines, Thailand and the United

Republic of Tanzania).

Disease control programmes in developing countries often fail to fully meet their objectives because the strategies pursued are inappropriate for the community or challenge local perceptions of aetiology, prevention and control. Identification of appropriate and sustainable filariasis treatment and prevention strategies requires a broad understanding of local disease perceptions, including causes, consequences and means of prevention. Since disease perceptions vary geographically, in-depth studies of the social, cultural and economic aspects of disease will need to be context-specific. The involvement of the community should be extended beyond a cursory consultation at the beginning of the process. Community involvement and awareness must underpin and direct the ongoing evolution of filariasis elimination programmes.

Sociocultural research methodologies have been employed by researchers in

Africa, the Caribbean and India. The use of focus groups, key informants and participant appraisal techniques yield quantitative and qualitative data that improve the understanding of local ways of accounting for, explaining and treating the disease.

Equally, they can help to identify those in the community at risk of failing to comply with the treatment regimes, including migrant workers. Social science research illuminates political power structures and stakeholder groups within communities, enabling programmes to include all social groups. It also allows delineation of health service, drug and community factors that influence compliance.

The collection of robust sociocultural data should inform the planning and management of an LF elimination programme. First, an understanding of local descriptions and interpretations of the disease is essential for informing and guiding the development of programmes’ education and communication components. Equally, without the support of local leaders and their participation as proponents and advocates, the achievement of sufficiently high levels of coverage with drug combinations to interrupt disease transmission will be elusive. Secondly, as the long-term morbidity associated with pre-existing disease will continue to persist after transmission is interrupted, sensitive approaches developed in partnership with the community are required to generate the necessary impetus for effectively tackling the burden of chronic disability post-elimination.

Efforts to interrupt transmission and eliminate LF as a public health problem will certainly depend on effective mass chemotherapy campaigns and other public health strategies, including vector control where appropriate. However, to increase the success of elimination strategies, the sociocultural understandings of affected community groups are pivotal in achieving sustainability, local participation and ownership. Early evidence suggests that long-term efforts to eliminate the disease may fall short of elimination in areas where community acquiescence has been replaced by distrust, engendered by misguided communication and vertical programme delivery, or a shift in local power structures. Strategies responsive to community sociocultural understandings will have key roles in reversing this trend and in addressing the disability burden that is currently only superficially understood in affected communities. If disability is detected early and correctly managed, the negative economic and psychosocial consequences may be averted.

To sustain interruption of the LF transmission cycle and prevent this disease’s negative impacts on future generations, sociocultural analysis must be brought into the mainstream of LF elimination efforts. By ensuring that sociocultural perceptions are critical in developing programme strategies and policies, we stand a much greater chance of eliminating LF. 1.16 Problem Statement

The Present problem is the prevalence of filariasis in Kumbakonam temple town which has a long history of its presence. Kumbakonam has a conducive atmosphere and its adverse environmental and ecological conditions favor the growth of filarial worm inside the town as well as its peripheral wards. Kumbakonam is one of the oldest cultural heritage town located in the central parts of Tami Nadu. The town is surrounded by many religious temples with temple tanks. `’ is the major festival which is being held once in twelve years and it is going to be held in 2004. The town does not have proper under ground drainage system and the water is drained in open soak pit and thus allowing mosquitoes to breed. Due to the non-availability of drainage system the drain water is let on nearby vacant sites by which making these sites to soil pollution zones and wet lands. The Temple tanks carry stagnant water pools which also caters the feed for vectors in this region. Kumbakonam is well located in the deltaic regions and the mosquito’s takes shelter in these regions. The presence to Filarial disease is high in this zone when compared to the other 12 Filarial Control Units in Tamil Nadu and it is because of the fact that they infect mainly the occupational character of the people mainly those who are working in the paddy fields and the weaving industry. With this background the present problem has mainly focused to study the Spatial and Behavioral aspects of those who are affected due to the Filarial disease and keep them in the

Geographical Information System (GIS) for further analysis.

1.17 Objectives

It is clear from the above, that Kumbakonam is facing several environmental problems particularly the stagnant water, waste water pollution zones, mosquito breeding sites, marshy environment and so on which is necessary for the mosquitoes can grow continuously and infect the people to the dreaded disease like Filariasis. To study the spatial and behavioural aspects of the affected persons in this region the following objectives are formulated:

a. To study the general environmental conditions that is conducive for the vector growth in this part of rice bowl of Tamil Nadu, b. To study the spatial, environmental and behavioural attitudes about the affected persons in Kumbakonam filarial control unit, c. To create a Geographical Information Base to maintain the data for GIS analysis and for further research, d. To find the most dominating factors that are responsible for the high incidence of Filariasis in this region,

e. To suggest few eradication/ minimization methods of filariasis in this control unit, in the near future. 1.18 Methodology

To study the spatial and behavioural aspects of Filariasis affected persons in

Kumbakonam the reported disease cases were obtained from the Kumbakonam Filarial

Control Unit (KFCU) from 1998 to 2008. The details include, name of the affected person, age of the person, their contact address, disease particulars, year of presence, date of treatment and so on. Kumbakonam base map has been obtained from the

Kumbakonam Municipal Town Planning Department and the map was then digitized.

Based on the addresses of the affected persons obtained from the KFCU were plotted on the maps for all the 272 reported cases for time period 1998-2008. Using the point symbol in the MapInfo software the digitized map was used to plot the reported cases with individual attached data bases. The details of each and every affected person can be obtained by moving the mouse pointer around the points, in the map. This would indicate the spatial distribution pattern of the Filarial disease from the time period 1998-

2008 (five GIS maps). Among the 272 affected cases 100 cases were selected for

Primary survey. The schedule consisting of 68 related questions about the various attitudes of the affected cases towards the Filariasis. Despite the basic information about the respondent the other relevant questions are: perception about the disease and various environmental factors, environmental implications, presence of wet/ waste lands nearby for the growth of vectors, marshy environment, details about the stagnant water and public lavatories, protection from mosquitoes, health personal attention, collection of blood smears, stages of the disease, treatment and psychological attitudes about presence of the disease. Among the 68 questions 32 highly relevant variables from the data matrix were selected for further analysis. Factor analysis is a dimension reduction method was used to group the variables into number of factors for analytical interpretation.

2 Chapter

Profile of the Study Area 2.1 Introduction

Kumbakonam also spelt as Coombaconum in the records of British India, is a town and a special grade municipality in the District in the southeast Indian state of Tamil Nadu. It is located 40 kilometres from Thanjavur and 273 kilometres from

Chennai and is the headquarters of the of . The town is bounded by two rivers, the River to the north and Arasalar River to the south. According to the 2001 census, Kumbakonam has a population of 140,021 and has a strong Hindu majority; but it also has sizeable Muslim and Christian populations.

Kumbakonam dates back to the Sangam period and was ruled by the Early

Cholas, Pallavas, Medieval Cholas, Later Cholas, Pandyas, the Vijayanagar Empire,

Madurai Nayaks, Thanjavur Nayaks and the Thanjavur Marathas. It rose to be a prominent city between the 7th and 9th centuries AD, when it served as a capital of the

Medieval Cholas. The town reached the zenith of its prosperity during the British Raj when it was a prominent centre of European education and Hindu culture and it acquired the cultural name, the "Cambridge of South India". In 1866, Kumbakonam was officially constituted as a municipality, which today comprises 45 wards, making it the second largest municipality in Thanjavur District, koodathin konam (i.e,angle of the (POT) origin city) Kumbakonam, Kodathin Vasal Kodavasal(I.E., Entrance Of The Pot), between Kumbakonam and Kodavasal Center of the Pot (Madyaman) is "Thirucherai".

Kumbakonam is known as the "temple town" due to the prevalence of a number of temples here and is noted for its Mahamaham festival which attracts people from all over the globe. The main products produced are brass, bronze, copper and lead vessels, silk and cotton cloths, pottery, sugar, indigo and rice.

2.2 Etymology

The name "Kumbakonam", roughly translated in English as the "POT"s angle", is believed to be an allusion to the mythical pot, the Sanskrit kumbha of the Hindu god

Brahma, which according to Hindu legend, contained the seed of all living beings on earth. The kumbha is believed to have been displaced by a pralaya or deluge and ultimately came to rest at the spot where the town of Kumbakonam now stands. This event is now commemorated in the Mahamaham festival held every 12 years.

Kumbakonam is also known as Baskarashetramand Kumbamfrom time immemorial and as Kudanthai in ancient times. Kumbakonam is also spelt as Coombaconum in the records of British India. Kumbakonam was also formerly known by the Tamil name of

Kudamukku. Kumbakonam is also identified with the Sangam age settlement of

Kudavayil. Winslow, in his 1862 Tamil-English dictionary, associates negative connotations with Kumbakonam. However, Winslow later apologized for his erroneous claim.

2.3 History

The region around Kumbakonam was inhabited as early as the Sangam Age (3rd century BC to 3rd century AD). The present-day Kumbakonam is believed to be the site of the ancient town of Kudavayil where the Early Chola king Karikala held his court. Some scholars identify Kumbakonam as the site of the fabled prison of Kudavayir-kottam where the Chera king Kanaikkal Irumporai was imprisoned by the Early Chola king

Kocengannan. Kumbakonam is identified with the town of Malaikūrram which had served as the Chola capital as early as the 7th century and with the town of Solamaligai which had also served as a Chola capital. According to the Sinnamanur plates,

Kumbakonam was the site of a battle between the Pallava king Sri Vallabha and the then

Pandya king in 859 and between the Pandya king Srimara Pandya and a confederacy of the Cholas and Gangas.

Kumbakonam came into limelight during the rule of the Medieval Cholas who ruled from the 9th century AD to the 12th century AD. The town of Pazhaiyaarai, 8 kilometres from Kumbakonam was the capital of the Chola Empire in the 9th century.

Following the decline of the Chola kingdom, Kumbakonam was conquered by the

Pandyas in 1290. Following the demise of the Pandya kingdom in the 14th century,

Kumbakonam was conquered by the Vijayanagar Empire. Krishnadevaraya, the emperor of Vijayanagara visited the town in 1524 and is believed to have bathed in the famous

Mahamaham tank during the Mahamaham festival. Kumbakonam was ruled by the

Madurai Nayaks and the Thanjavur Nayaks from 1535 to 1673 when it fell to the

Marathas. Each of these foreign dynasties had a considerable impact on the demographics and culture of the region. When the Vijayanagar Empire fell in 1565, there was a mass influx of poets, musicians and cultural artists from the kingdom.

According to the chronicles of the Hindu monastic institution, the Kanchi matha, the matha was temporarily transferred to Kumbakonam in the 1780s following an invasion of Kanchipuram by Hyder Ali of Mysore. When Tipu Sultan invaded the east coast of South India in 1784, Kumbakonam bore the brunt of his invasion. The produce fell sharply and the economy collapsed. Kumbakonam did not recover from the calamity till the beginning of the 19th century.

Kumbakonam was eventually ceded to the British East India Company in 1799 by the Thanjavur Maratha ruler Serfoji II and reached the zenith of its prosperity in the late

19th and early 20th century when it emerged as an important center of Brahminism,

Hindu religion and European education in the Madras Presidency. The opening of the

Suez Canal in 1869 fostered trade contacts with the United Kingdom. In 1877, railway lines were completed linking Kumbakonam with the ports of Madras, Tuticorin and

Nagapattinam. The Tanjore district court was established in Kumbakonam in 1806 and functioned from 1806 to 1863.

Kumbakonam continued to grow even after India's independence though it fell behind the nearby town of Thanjavur in terms of population and administrative importance. The population growth rate began to fall sharply after 1981. This decline has been attributed to limited land area and lack of industrial potential. On July 16, 2004, a devastating fire in the Sri Krishna school killed more than 80 children.

2.4 Geography

Kumbakonam is located at 10.97°N 79.42°E. It is situated 273 km south of

Chennai, 96 km east of , and about 40 km north-east of Thanjavur. It lies in the region called the "Old delta" which comprises the north-western taluks of

Thanjavur District that have been naturally irrigated by the waters of the Cauvery and its tributaries for centuries in contrast to the "New Delta" comprising the southern taluks that were brought under irrigation by the construction of the Grand Anicut canal and the Vadavar canal in 1934. It has an average elevation of 26 metres (85 ft). The town is bounded by two rivers, the Kaveri River on the north and Arasalar River on the south.

Although the Cauvery delta is usually hot, the climate of Kumbakonam and other surrounding towns is generally healthy and moderate. Kumbakonam is cooler than

Chennai, the capital of Tamil Nadu. The maximum temperature in summer is about 40 degrees Celsius while the minimum temperature is about 20 degrees Celsius.

Kumbakonam receives an annual rainfall of 114.78 centimetres every year. The region is covered with mainly alluvial or black soil which is conducive for rice cultivation. Other crops grown in Kumbakonam include mulberry, cereals and sugarcane.

The flora of the Cauvery Delta mostly comprises palm trees. The town of

Kumbakonam is surrounded by extensive paddy fields. Methods of irrigation were considerably improved following the opening of the in 1934. The fauna of the Cauvery Delta is limited to cattle and goats. The town is situated at the western flank of the Kumbakonam-Shiyali ridge which runs along the Kollidam riverbasin separating the Ariyalur-Pondicherry depression from the depression. This granular ridge projects further eastwards penetrating the Pondicherry depression and forms a hard layer of cretaceous rock underneath the sedimentary top soil.

Residential areas make up 32.09 percent of the town's total area while commercial enterprises and industrial units make up 2.75 and 1.21 percent respectively. The non- urban portion of the town constitutes about 44.72 percent of the total area. Kumbakonam has a total of 45 slums with a population of 49,117. The town has around 141 kilometres of roads, 544 municipal roads making up 122.29 kilometres. There are also around 18.71 kilometres of state highways running through Kumbakonam. Over 87 per cent of the municipal roads are paved. The town gets its water supply mainly through the

Valayapettai headworks across the river Cauvery and the Kudithangi headworks across the river Kollidam.

2.4.1 Topography

The Town from a continuous stretch of level land with a few ups and downs made by the deposition of the rivers. The town is located at about 27 metres above mean sea level. The flow of water in the rivers of cavery and its distributory Arassalar has been highly Seasonal.

2.4.2 Drainage

In Kumbakonam town the drainage system is ‘open drainage system’ and hence drainage water is drained into Cauvery River and Arasalar River with in the city. The drainage cannals are illmaintained and out modded and this leads to the city environmental pollution. The river cauvery passes through the northern town and is flowing east and west. On the south the river Arasalar passes at the east to west Direction of the town.

2.4.3 Soils

The soils of the Kumbakonam are mostly alluvial deposits. The soils are classified into major soil groups according to the soil survey techniques namely entisiols (alluvial soil). The Entisiols (alluvial soil) are recent deposit of Alliuval soil with moderate to rapid permeability. The soils are suitable for rice and other irrigated dry crops.

2.4.4 Climate

The Kumbakonam town experiences a moderate climate throughout the year. The mean annual temperature is 32.2o C. There is a steady rise in Temperature from January to May. The highest temperature is 38.1o C observed in May and April. April, May and

June are the hottest months of the year. Although summer is hot. Occasional rainfall results in water stagnation in the wet field from august the temperature gradually lower to minimum of 28.20o C in January. Climate association with topography played on important factor in the dust Pollution. The town receives most its rainfall during northeast monsoon, the annual average of rainfall is 12,600 mm. The maximum rainfall received by the town is from October to December.

2.4.5 Temples

Kumbakonam is known for its temples and mathas. There are around 188 Hindu temples within the municipal limits of Kumbakonam. Apart from these, there are several temples around the town thereby giving the town the sobriquets temple town and City of temples. The most important temples present in Kumbakonam are the Sarangapani temple, the Kumbeswara temple and the Ramaswamy temple.

The Sarangapani temple was constructed by Nayak Kings in the 15th century and has twelve storeys high. The Ramaswamy temple, which has scenes from the Hindu epic

Ramayana depicted on its walls, was constructed by the Nayak ruler Raghunatha Nayak in the 16th century. Its principal idol of Lord Rama is made from a single piece of saligrama. The Kumbeswara temple is considered to be the oldest Saivite shrine in the town. It was constructed by the Medieval Cholas in the 7th century AD.[citation needed]

This is the main temple of the town and as per the local mythology, is closely connected with the Mahamaham tank where pilgrims from all parts of India bathe once every 12 years during the Mahamaham festival. The temple of Nagesvara has a separate shrine for the Sun god Surya who is believed to have worshipped the Hindu God Shiva at this place. Kumbakonam has one of the few temples dedicated to the Hindu god Brahma.

Kumbakonam also has a number of Hindu monastic institutions or mathas. The

Sri Sankara matha of Kanchipuram was moved to Kumbakonam during the reign of

Pratap Singh and remained in Kumbakonam until the 1960s. There are also two Vellalar mathas in the nearby towns of Dharmapuram and Thiruppanandal and a Raghavendra matha in Kumbakonam. There is also a branch of the Vaishnavite Ahobila mutt in

Kumbakonam.

The Thirupureswarar temple of Patteeswaram, the Oppliyappan Sannadhi, the

Swamimalai Murugan temple and the Airavateswarar temple at are located in the vicinity of Kumbakonam.

Kumbakonam has a strong Hindu majority; but it also has sizeable Muslim and

Christian populations. Among Hindus, Kallars, Thondaimandala Mudaliars, Brahminsand

Dalitsare the numerically dominant Tamil-speaking groups. are more numerous and affluent in Kumbakonam than in other parts of Tamil Nadu. There are also large populations of Moopanars, Vanniyars, Konars and Nadars. Amongst Muslims, the Sunnis are dominant. However, there is also a significant Shia minority. Most of the Muslims are

Marakkayars or Labbays. The majority of Muslims in Kumbakonam are involved in commerce or maritime trade. Kumbakonam also has a large population of Protestant

Christians largely due to the efforts of the German missionary Christian Friedrich

Schwarz. The Catholics in Kumbakonam are mainly affiliated to the Roman Catholic

Diocese of Kumbakonam which was separated from the Archdiocese of Pondicherry in

1899. The population of Kumbakonam is predominantly Tamil-speaking. The commonly used dialects is the . There are significant minorities speaking Thanjavur Marathi, Telugu, Kannada and Saurashtrian as their mother tongue.

2.5 Municipal administration and politics

The functions of the municipality are devolved into six departments: General,

Engineering, Revenue, Public Health, Town planning and the Computer Wing. All these departments are under the control of a Municipal Commissioner who is the supreme executive head. The legislative powers are vested in a body of 45 members, one each from each of the 45 wards. The legislative body is headed by an elected Chairperson and is assisted by a Deputy Chairperson.

2.6 Economy

The important products of Kumbakonam include brass, bronze, copper and lead vessels, silk and cotton cloths, sugar, indigo and pottery. Kumbakonam is considered to be the chief commercial centre for the Thanjavur region. As of 1991, around 30per cent of the population was engaged in economic activity. Rice production is an important activity in Kumbakonam. Of 194 industrial units in Kumbakonam, 57 are rice and flour mills. Kumbakonam is also a leading producer of betel leaves and nuts; the betel leaves produced in Kumbakonam are ranked amongst the best in the world in terms of quality.

The A. R. R. Agencies, a leading manufacturer has its factory in Kumbakonam. The main administrative offices of T. S. R. & Co., a cosmetic company, are also based in

Kumbakonam. Kumbakonam is also famous for its metal works. The Tamil Nadu

Handicraft Development Corporation had been established in the nearby town of

Swamimalai in order to train bronze artisans. Kumbakonam is an important silk-weaving centre and more than 5,000 families were employed either directly or indirectly in silk weaving. Silk weaved in Kumbakonam is regarded as one of the finest in the subcontinent. They are largely used in the manufacture of Thirubuvanam silk sarees.

Kumbakonam was also an important salt-manufacturing area during British rule. In recent times, Kumbakonam has emerged as an important manufacturer of fertilizers.

Apart from its manufactures, tourism is also a major source of income for the town. The Hindu temples and colonial-era buildings have been recognised for their tourism potential. The 12th-century Airaveswarar temple in the town of Darasuram near

Kumbakonam is an UNESCO World Heritage Site. Kumbakonam is also frequented visited by art collectors interested in handloom cloth and other curios.

2.7 Transport and communication

Kumbakonam is well-connected by road and rail with the rest of India. The nearest international airport is at Tiruchirapalli, which is 94 km from Kumbakonam. The nearest seaport is located at Nagapattinam whch is about 50 km away. There are regular government and private bus services to Chennai, Thanjavur, Tiruchirapalli,

Chidambaram, Nagapattinam, Coimbatore, Madurai, Pondicherry, and Tirunelveli. The

Karnataka State Road Transport Corporation (KSRTC) operates daily services from

Bangalore to Kumbakonam. On March 1, 1972, the Cholan Roadways Corporation was established by the Government of Tamil Nadu with its headquarters in Kumbakonam in order to improve transportation facilities in the districts of central Tamil Nadu. The organisation acquired the fleets of buses earlier owned by private operators - Sri

Ramavilas Service, Raman and Raman Limited and Sathi Vilas. On July 1, 1997, the organization was renamed Tamil Nadu State Transport Corporation, Kumbakonam and presently forms first division of the Tamil Nadu State Transport Corporation. The corporation runs a reconditioning unit and a tyre re-threading unit in Kumbakonam. Kumbakonam is connected by rail with most important towns and cities in South India.

The Mysore-Kumbakonam Express which was extended upto connects

Kumbakonam with Mysore. The train also halts at Bangalore on its way to Mysore and back. The Tiruchirapalli-Kumbakonam passenger train connects Kumbakonam with

Tiruchirapalli while the passenger train runs regular services between

Kumbakonam and Chidambaram.

The traditional modes of transportation are bullock carts. It is recorded that as late as the 1950s, landlords and rich farmers travelled mostly by bullock carts with the exception of rare long journeys, which they undertook by buses or motor vehicles.

Kumbakonam has an efficient local bus transportation system. The mofussil bus stand is located in the south-east of Kumbakonam and is situated just opposite to the Arignar

Anna Bus Stand where the long-distance buses are stationed. There are occasional ferries that transport people and goods across the Cauvery. Till the beginning of the 20th century, students of the Government Arts College used to cross the Cauvery on coracle ferries in order to attend college. Since the construction of a bridge in 1944, the practice of transporting men and goods by coracles has greatly diminished.

2.8 Education

Kumbakonam emerged as an important centre of education in the late 19th century and was known as the "Cambridge of South India". The Government Arts

College, established in Kumbakonam in 1854, is one of the oldest educational institutions in the Madras Presidency. It began as a provincial school on October 19, 1854, before being upgraded to a government college in 1867. It was affiliated to the Madras

University in 1877. One of the early principals of the college was William Archer Porter, a Cambridge Wrangler, who, along with T. Gopala Rao, was instrumental in its elevation to a government college. He is also credited with framing the college's acclaimed educational policy. In 1881, it became a full-fledged college and high school courses.

Notable faculty members included U. V. Swaminatha Iyer while the Indian mathematician Srinivasa Ramanujan who studied from 1904 until 1906 when he dropped out, was one of its noted pupils. The Government Arts College for Women was started in

1963 and had a total strength of 2,597 pupils in February 2006. The college offers various undergraduate courses and one post-graduate course and is affiliated to the Bharathidasan

University. Other colleges in Kumbakonam include Idhya Colleges of Arts and Sciences,

Annai College of Arts and Sciences,Government College Of Fine Arts and Arasu

Engineering College. The Shanmugha Arts, Science, Technology & Research Academy has a satellite campus based in Kumbakonam where arts and sciences are taught.

The Native High School, founded in 1876, and the Town Higher Secondary

School, one of whose students was Srinivasa Ramanujan, were some of the oldest schools in the Madras Presidency. At present, there are of 36 government and private schools in

Kumbakonam.

2.9 Filariasis: Night Clinic and Administrative Functions

There are two subunits and two night clinics in operation in the study area of

Kumbakonam Town, under the control unit are Kumbakonam which is in Thanjavur

District. In Kumbakonam control unit, there is 13 administrative staff (1 superindent, 2

Assistant, 1 Junior Assistant, 1 Typist, 2 Drivers, 5 Office Assistant, 1 Night Watchman).

In the technical using of the control unit, there is one endomoligical Assistant and for

Laboratory Assistant. The Laboratory Assistant is engaged in Blood semear Examinations. Under the Control of the Filaria Officer at Kumbakonam Control Unit, there are 10 sub units and 9 night clinic. The breading places in the study area are category as follows: pucca drainage, katche drainage, pacca chspit, katche chspit, septic tank, disused well, used well, overhead tank, cesspool and other water containers. These breading centers are monitored by the NFCP personnel. The NFCP personnel spray larvicides like M.L.OILS, Baytex, Temiphos and Pyroxene, whichever is available in the market for the eradication of mosquitoes.

The night clinics that operate in the delta region of Kumbakonam (two codes; O and P) have main functions are Blood Smear Collection (for lab Test) and Slides

Examination (positive microfilaria detection). Each night clinic carries out 1,500 blood smear tests a months and treatment with statement with standard DEC. The Fileria and

Malaria clinics, attached to the Kumbakonam Government Hospitals provide lymphoedema treatment. They are also implementing the programs of control units and night clinics, their main functions are

a. Interferential therapy;

b. Heat Therapy;

c. Penumatic compression Therapy and

d. Supply of Lymphoedem tablets to avoid swelling;

The sub units operate between 6 to 11 am (collection of Mosquitoes, and

Ministrative works) and 2.30 pm to 5.30 pm (antilarvae spray). The night Clinics operate in the day between 2 to 5pm (Blood smear Tests) and 9 to 1 pm (Blood smear

Collection).

2.10 Major Industries

Kumbakonam is also one of the leading market centers in Thanjavur district. It is a prosperous center for metallurgic works. The town is noted for weaving, brass utensils and handicrafts.

2.11 Population Characteristics

In 1901, the details of population of Kumbakonam are known authentically there were only 59,673 persons in 1901. It had increased gradually to more then 100,000 in sixty years. The population decreased from 64,647 in 1911 to 60,700 in 1921. This may be due to extensive famine and war conditions that prevailed. In all other decades there was an increasing trend in population growth. According to 2000 census, the total population of Kumbakonam was 141,814 of which 70,544 are females and 71,270 are males. The population distribution in ward wise is mostly even except some central parts of the town.

Table: 2.1 Growth of Population in Kumbakonam: 1871 - 2011

Year Population ±per cent 1871 44,444 --- 1881 50,098 +12.7 1891 54,307 + 8.4 1901 59,673 + 9.9 1911 64,697 +8.3 1921 60,700 -6.1 1931 62,317 +2.7 1941 67,008 +7.5 1951 91,643 +36.8 1961 92,581 +1.0 1971 113,130 +22.2 1981 132,832 +17.4 1991 139,483 +5.0 2001 141,812 +0.4 2011 167,098 +58.2 Source: Municipal office records The growth of population during various decennial periods, Population of the town during 1961 was 92,581 among them 46,029 were male and 46,552 were females.

In 1961 to 1971 the growth is very high compared to the proceeding years and in 1961 the population was 92,581 and it had increased to 1, 13,130 in 1971 and also in 1981 which is nearly 20,000 for the two consecutive decades. But in the case from 1981 to

1991 the increase was only about 7,000 and during the period from 1991 to 2001 it was very less. It is evident that during the earlier periods the growth was abnormal and it has gradually decreased over the present decade. It may be due to the awareness among the people about the population control measures and also due to the out migration.

2.12 Landuse

Land use refers to utilization of land under different categories. The land use of

Kumbakonam town can be divided into major groups and they are residential, commercial, industrial, transportation, public and semi-public, education, recreational, open spaces and cultural lands, among the different land use

Table: 2.2 Different Types of Land use in Kumbakonam

Percentage to Area in Sq Km Total Residential 7.98 63.5 Commercial 0.82 6.6 Industrial 0.37 2.9 Public and semi-public 0.57 4.5 Transportation 2.04 16.2 Education 0.55 4.4 Recreation 0.07 0.5 Agricultural 0.18 1.4 Total 12.58 100.0 Source: Municipal office records

3 Chapter

Creation of GIS Information Base for Filariasis Patients

3.1 Introduction

Lymphatic filariasis (LF), the second most common vector-borne parasitic disease after malaria, is found in 81 tropical and subtropical countries. World Health

Organisation (WHO) estimates that 120 million people are infected with this parasite and

1.3 billion (i.e. >20per cent of the global population) are living at risk of infection. It is estimated that 40 million people are suffering from the long term complications of the disease. One-third of people infected with LF live in India, one third live in Africa and the remainder lives in the Americas, the Pacific Islands, Papua New Guinea and South-

East Asia. The Global Programme for Elimination of Lymphatic Filariasis (GPELF) began its campaign to interrupt transmission of the parasite using a strategy of annual mass drug administration (MDA) to those at risk and to control or prevent LF-related disability through morbidity management programs in which 12 million people have been treated since 2000. The latest WHO figures shows that around 381 million people received filariasis treatment in 2005 alone in 42 countries. In India LF is endemic in 18 states and the Union Territories. Approximately 420 million people reside in endemic areas and 48.11 million are infected. Mortality is uncommon, whereas morbidity associated with this infection can be considerable and lifelong. Because of these factors,

LF escapes the attention of planners and governments. Rural and urban areas in India suffer with lack of adequate antifilarial measures and it is estimated only 11per cent of the endemic population is protected by the National Filaria Control Programme (NFCP),

Government of India.

LF causes a wide spectrum of clinical manifestations in the infected populace.

Most of the population suffers with symptoms of LF such as chronic lymphoedema, elephantiasis and hydrocele. Those infected with LF further bear the debilitating effect of acute filarial attacks that last from five to seven days and may occur two to three times each year. Chronic filarial disease has serious social and economic effects. Those afflicted with elephantiasis and hydrocele are often socially marginalized and poor. Acute attacks and chronic disability cut economic output and increase poverty. This is evident from the observation that 94per cent of the countries with the lowest human development index (HDI) are endemic for LF. The chronic manifestations of filariasis can have significant, and often very negative, social impact. LF has traditionally been considered to be a disease associated with poverty, inadequate sanitation and underdevelopment.

Sociodemographic factors such as ethnic group, parent's education and occupation, use of protective measures, and living standard of the family are suggested to be important risk factors for epidemics of vector borne disease. From filarial endemic countries there is little published evidence of an association between LF and country-level poverty. In

Philippines, there is an apparent association between LF endemicity and poverty at provincial level. In the majority of control strategies, the target population of disease transmission and control are overlooked. In filariasis, poor knowledge and indigenous, traditional belief systems contribute to high-risk and inappropriate illness prevention and treatment.

Lymphatic filariasis (LF), caused by Wuchereria bancrofti and transmitted by the

Southern house mosquito Culex quinquefasciatus, accounts for 95per cent of the total LF cases in India. To asses the LF disease and its biased factors, a pilot scale study was carried out in Karimnagar district of Andhra Pradesh. The villages of this district have been recognised as endemic for filariasis and MDA programs are still going on. There are no such reports available on impact of socio-economic factors on LF in Andhra Pradesh.

Hence, the aim of this study is to assess the relationship between socioeconomic status and occurrence of LF in these villages of Karimnagar district of Andhra Pradesh.

The tremendous potential of GIS to benefit the health care industry is just now beginning to be realized. Both public and private sectors are developing innovative ways to harness the data integration and spatial visualization power of GIS. The types of companies and organizations adopting GIS span the health care spectrum--from public health departments and public health policy and research organizations to hospitals, medical centers, and health insurance organizations.

Esri has over 5,000 health care clients worldwide who are using the resource integration capabilities of GIS to create analytical and descriptive solutions. GIS plays a critical role in determining where and when to intervene, improving the quality of care, increasing accessibility of service, finding more cost-effective delivery modes, and preserving patient confidentiality while satisfying the needs of the research community for data accessibility.

3.2 Using GIS for Public Health

In 1854, an English physician, John Snow, provided the classic example of how mapping can be used in epidemiological research. He identified the water source responsible for an outbreak of cholera in London by mapping the locations of those afflicted. GIS has continued to be used in public health for epidemiological studies. By tracking the sources of diseases and the movements of contagions, agencies can respond more effectively to outbreaks of disease by identifying at-risk populations and targeting intervention.

Public health uses of GIS include tracking child immunizations, conducting health policy research, and establishing service areas and districts. GIS provides a way to move data from the project level so that it can be used by the entire organization. Clinical and administrative information can be disseminated in a visual and geographic manner that is readily understood using Esri Internet Map Server (IMS) technology. This health data can be easily accessed using an Intranet or the Internet

Balancing individual privacy with data accessibility has become more challenging for public health agencies. "Spatially Enabling Vital Health Care Data" features an article that describes the South Carolina Department of Health and Environmental Control's program for managing georeferenced health records. The department aggregated health record data at the census tract level so that the privacy of individual patients was preserved while allowing easy access to data through the use of an ArcView GIS query tool.

Quick access to medical records is crucial to effective treatment. A new program that will make electronic medical records available for all armed services members, their dependents, and retirees has placed the Department of Defense at the forefront of GIS application development for health care. The department will pursue a patient-centric GIS approach that focuses on the development of information around the patient, in contrast to the approach used by the computerized medical record industry that builds information around each episode or encounter a patient has with the health care system.

3.3 The Business of Health Care Geographic

While health care professionals in the public health sector were early adopters of

GIS and continue to find new and innovative uses for this technology, the use of GIS in the private health sector has grown substantially in the last decade. Private sector use now encompasses applications in marketing and business management as well as those concerned with patient care. These applications take into consideration the unique constraints under which the health care industry must operate.

Health care providers can no longer afford to indulge in the "build it and they will come" fallacy. Health care is a repeat business. Though many hospitals and medical centers have operated under Reilly's law of retail gravity more square footage equals a larger trade area to draw from they have begun to realize that to be competitive they need to be located conveniently to their customer base.

Site analysis operates a little differently for hospitals and medical centers. Unlike other types of businesses, hospital locations continue to be dictated by Certificate of Need

(CON) programs in many states. This eliminates relocation as a method for improving the market from which hospitals draw patients and leaves health care providers with two methods of encouraging growth. Both require effective site analysis.

Providers can find new markets by increasing the range of services they offer based on an analysis of patient needs, both present and future, in their market area. This allows growth without requiring relocation.

Another stationary strategy involves identifying and cultivating a hospital's most profitable services. This strategy includes studying competitors to learn about the services they offer and populations they serve and to gauge how profitable they are.

Using GIS for demographic analysis to estimate the demand for various types of services can benefit individual physicians. Physician specialties are more effectively marketed by locating offices near pools of potential patients. This type of analysis can be extended for application by health care providers.

How consumers access the services of managed health care providers is controlled by geographic location. Matching physician locations to where employees live or work assures that primary care physicians are available throughout the network and that the types of specialties required by specific populations are located reasonably close to these populations. Employers favor providers with networks that minimize the distance employees must travel to obtain care.

"Mapping Health Care Networks" tells how Esri business partner GeoHealth

Incorporated of Redlands, California, has developed an ArcView GIS application that helps managed care providers balance the location, type, and patient workload of physicians in their network.

3.4 A Wealth of Tools

Managing patient care environments within hospitals and medical centers has become an increasingly complex task. Caregivers require critical information that is readily available in a visually streamlined format. Loma Linda University Medical Center, one of the world's premier medical research centers, uses a GIS-based system called the Patient Location and Care Environment System (PLACES) to let caregivers see the physical bed location of each patient and to retrieve demographic and clinical information.

PLACE uses an ArcView GIS application to view computer-aided design/computer-aided manufacturing (CAD/CAM) floor drawings that show room and bed locations for each floor and are tied to daily census information. When the system is complete, physicians will be able to log on to an Intranet to retrieve the location and other relevant information on their patients. Patient admission will also be improved because admitting personnel will be able to quickly identify available beds. The use of mapping to improve health care services doesn't stop at the building level.

BodyViewer, an ArcView GIS extension developed by GeoHealth Incorporated, allows users in the health care industry to analyze, visualize, and map more than 14,000 of the International Classification of Diseases, Ninth Revision (ICD-9) codes that are used throughout the health care industry to index every known ailment, treatment, and procedure. BodyViewer logically aggregates these ICD-9 codes and displays them graphically as organs and organ systems. The user can build a map showing where these aggregated ICD-9 codes occur geographically.

Business management and marketing practices for private sector health care companies have been enhanced through the use of various GIS software packages from

Esri. ArcView Business Analyst provides the data and ease of use that make product line planning more effective by geographically linking operational data to patient and provider location data. Areas that are underserved can be pinpointed. Marketing strategies and promotions can be more effectively targeted to the populations that would benefit from them through the use of ArcView Business Analyst.

Health care organizations can use GIS to improve management practices. Many health organizations employ sales personnel. BusinessMAP PRO provides a fast and easy way to balance sales territories, track prospects, and perform limited market analysis.

Using ArcView GIS, medical supplies and equipment can be visually located and inventoried. Linking the physical location and condition of equipment or supplies in a large facility or distributed medical campus is a powerful new management tool.

GIS can enhance customer service for a health care provider. Using, dynamic maps that show the location of services are readily available over the Web. ArcLogistics

Route improves how, health services are delivered at home by scheduling and optimizing routes between patients.

3.5 Tomorrow's Health Care

GIS has helped the health care industry manage resources and personnel in of the same ways it has helped other consumer service enterprises. Use of GIS for business function--marketing, sales, and facility and materials management will continue to grow.

However, in the increasingly information-intensive environment of tomorrow's health care, the role of GIS will have greater importance due to its abilities to integrate a wide range of data sources, from legacy systems to image data, and to make complex data more quickly and easily understood.

Application of remote sensing (RS) and geographical information systems (GIS) for Epidemiology and control of lymphatic filariasis (EM 9902 AFR) was developed to produce filariasis distribution maps for Tamil Nadu, Karnataka, Kerala and Pondicherry, and to identify the environmental risk factors in relation to occurrence of disease and (iii) to develop tools for decision making, for the control of filariasis, Karnatakaand

Pondicherry was created in the first year (2000) of the study.

All the possible risk factors that are likely to influence the occurrence of lymphatic filariasis (either directly or indirectly) were listed under three major categories viz., physiographic, climatic and demographic. Initially, correlation of such environmental variables as altitude, water vapour, rainfall, relative humidity and saturation deficit that are likely to have a direct bearing on the filarial endemicity was examined. The other variable (‘dummy indicators’) like vegetation and land use / land cover (soil types, built up structures etc.,) and demographic were dealt with subsequently.

Bivariate (‘Pearson’ correlation) analysis explained a positive association of filariasis endemicity (point data available in Tamil Nadu) with temperature (r = 0.41, p <

0.05) and rainfall (r = 0.44, p < 0.05). Though there is no direct association between filariasis endemicity and humidity, a significant association with saturation deficit (r =

0.53, p < 0.01) was observed. The filariasis endemicity was found to have a negative correlation with altitude ( r = - 0.44, p < 0.05) Multivariate (Multiple linear regression - stepwise) analysis revealed that among the seven possible risk variables (as stated above) included in the analysis, only three (altitude, rainfall and saturation deficit) emerged as significant variables contributing to 64 per cent of the variation in the endemicity rate.

The predictive value of the regression model is low, suggesting that the other variables like vector breeding potential (land use / land cover etc.), socio-economic characteristics etc. of the area may also be facilitating the situation conducive for the disease occurrence.

The RS image files have been calibrated to produce Normalized Differences Vegetation Index (NDVI). The NDVI was also used to determine the land use / land cover pattern.

The cultivable (moisture) and low vegetation zone with composite NDVI values ranging between 145 and 158 were the areas found to be associated with filariasis prevalence.

The appropriate classification (‘range finding’) for predicting the potential risk of filariasis is being explored in relation to space and time. The areas are to be classified ultimately into potentially endemic and non-endemic in terms of environmental variables. This needs to be validated following a ground truth survey. The outcome of this survey will form an important base in the map union function, which will facilitate the creation of mapping tools for decision-making. To achieve this, a sample survey has been planned in selected geo- coded points in the study area. Once the study area is classified and the real time point data generated, prediction may be possible with the use of environmental variables and demographic profiles.

3.6 GIS Information Base filariasis Patients in Kumbakonam: 1998-2008

To create different GIS data base files and also to study the spatial distribution of filariasis in Kumbakonam the data has been gathered from the Kumbakonam Filarial

Control unit (KFCU) from 1998 to 2008. According to the KFCU there are 272 filarial cases were reported for the above five years. The individual reported cases are as follows: 1998 (30 cases), 1999 (3 cases), 2000 (164 cases), 2001 (57 cases) and 2008 (18 cases). The data shows that the reported filarial cases are not uniform. The collected information has been plotted on to a base map of Kumbakonam and each and every point has been traced from the address of the affected persons for the above five years. These maps were first digitized and then the points were also transferred to the respective location after properly identifying the addresses and street names. The details provided by the KFCU about the patients were also attached with the sequential data base files and this would indicate the details of the affected persons. The details include the patient ID, name of the patient, address with door number and street name, sex category, age, disease particulars, and how long the person is having the disease and date of treatment. The data base can be updated with additional information if required. The data base is given in the

Appendix.

Map 3.1 shows the administrative units of Kumbakonam. According to the 2001 census the population of the town is 141,814, spread over in the 45 wards. Map 3.2 is designed to show the GIS for the spatial distribution of Filarial cases reported in 1998 with attached data base file of the individual cases. There are 30 reported cases during this period. The spatial distribution shows that the disease has widespread prevalence in the peripheral wards except one case at the centre of the ward. The reason for low reported cases are that the people were not willing to/ afraid of giving blood smear for tests and identification whether the sample person is affected/ probability to be affected.

According to Map 3.3 there are only three cases reported and the locations are in

the western periphery of the town. The data base in the map, for example indicate that the patient ID is 109; name of the patient is: Kamala; Address: 99, Mukkannar st; Sex: F;

Age: 33; Disease particular: Whether the disease is present either in the left or right leg;

Year: How long you are affected and reported; Date of treatment began: 8-10-1999.

Like wise each and every case data can be studied from the GIS base files. The low reported cases in this year is due to the fact that the unwillingness of the people who are

living in Kumbakonam to give blood smear for sample analysis and hence the sample

Map 3.1

GIS Map showing Administrative Units

Map 3.2 GIS for the Spatial Distribution of Filarial Cases: 1998

Map 3.3 GIS for the Spatial Distribution of Filarial Cases: 1999

selection was very low. The Health personal who takes the blood during night hours did not get co-operation from the sample population and this could be the probable reason.

Map 3.4 shows the distribution cases for the year 2000. The number of reported cases is 164 which is very high when compared to the previous years. The main reason behind this is that there was no awareness about the filariasis disease among the people of

Kumbakonam and that could be several controlling factors. According to the Health

Department the staff strength has been increased considerably to visit each and every sample population household and teach them about the disease. They have also taught them about the surrounding they live and if the disease has grown and how this would affect the external system and so on. The awareness that was created by the health personal there has been a widespread response from the sample population and they themselves voluntarily come forward to give blood samples and due to this co-operation even in a single house they have identified two or more number of affected persons due to filarial worm. Map 3.4 shows except few wards all others have reported cases and it is particularly widespread prevalence in the southern parts of Kumbakonam.

Map 3.5 shows the distribution cases for the year 2001. According to the KFCU the number of reported cases is: 57 cases. The spatial pattern of disease indicates that it has widespread prevalence in the western parts of Kumbakonam. The disease has been brought under control for this year when compared to the previous year.

Map 3.6 depicts the filarial distribution case for the year 2008 and the number of reported cases is: 18. They are spatially distributed in the southern parts of

Kumbakonam. The considerable decrease in the number of cases when compared to the

Map 3.4

GIS for the Spatial Distribution of Filarial Cases: 2000

Map 3.5 GIS for the Spatial Distribution of Filarial Cases: 2001

Map 3.6 GIS for the Spatial Distribution of Filarial Cases: 2008

two previous years are mainly due to the fact that the health department has actively engaged in creating awareness among the sample population and involved in preventive measures like distributing the medicines at their door steps. They keep on watching the patients as well as their environment. Due to the environmental and disease ecological awareness there has been a considerable as well as remarkable decrease in the town.

3.7 Conclusion

Filariasis is a dreaded disease, which affects the lymphatic system. The reaction could be disfiguring of external organs particularly the legs and legs. The main cause of the disease, which has widespread prevalence in the town could be improper environmental conditions of the oldest heritage town. The disease could be prevented only by way of creating awareness among the people and not merely providing medicines and it is like prevention is better than cure.

4 Chapter

Dimensions of Filariasis in Kumbakonam: A Factor Analytic Method 4.1 Introduction

Filariasis has been identified as one of the six diseases, which are targeted for elimination. The World Health Organization (WHO) has called for targeting lymphatic filariasis (LF) elimination by the year 2020 (Ottesen, 2000). The main focus of intervention to interrupt transmission is to adopt administering a mass annual single dose

(6 mg/kg of body weight) of diethylcarbamazine (DEC) with albendazole (400 mg).

Although substantial progress has been made wherever the strategy has been successfully implemented to enhance compliance and to reduce infection levels in mosquitoes

(Richards et al. 2005), in certain areas where LF infection prevalence has been reduced to less than 1per cent, either the elimination remains mysterious or the disease has resurged

(Esterre et al. 2001; Sunish et al. 2002). This may be due to the intervention failure at the bottom level because of neglect of socio-cultural factors during the planning stages. In view of this, developing a model to understand the role and impact of socio-economic determinants, knowledge and practices on LF will be of potential value to identify the probable causes and their effect on the occurrence of filarial disease. This information will assist health planners and policy makers in devising appropriate and sustainable control strategies to eliminate LF.

From a preliminary study with a small sample, it was observed that the proportion of filarial cases in the lower income group was 0.43. Accordingly, in order to have an OR of filarial disease of at least two in the lower income group as compared to the higher income group, the sample size was found to be 264, i.e., 132 cases and 132 controls. An inclusion criterion for the case was that an individual affected with either lymphoedema or hydrocele and he/she should be in position to respond independently. For controls the inclusion criteria were that he/she should be non- infected for LF and should be in a position to respond independently. Accordingly, respondents covered were of three types, viz., persons with lymphoedema; hydrocele, which are the major clinical manifestations of LF (Surendran et al. 1996) in the study area and non-infected individuals. Thus, a minimum sample size in each group of lymphoedema and hydrocele was fixed to be 135.

Considering the total sample size of lymphoedema and hydrocele cases, the sample size of the non-infected individuals was fixed to be 270. The sample size was inflated by

40per cent to substitute for non- responsiveness and absenteeism during data collection.

For cases, the address details of patients diagnosed with major clinical manifestations

(lymphoedema or hydrocele), attending filariasis clinics from 1992 to 1997 at Vector

Control Research Centre, State Filaria Control Unit and Government General Hospital,

Pondicherry were listed and numbered serially and this cohort of patients formed the study population of the affected individuals. From the sample blood survey data

(Manoharan et al. 1997) obtained in 1992, address details of ‘non-infected’ individuals for W. bancrofti infection were also listed and numbered serially and formed the study population for control. Respondents with minimum age of 15 years were included in the study. The required number of individuals from the respective study population was selected at random using EpiStatver 2000 software program. Each selected individual was located in his/her house and the nature and purpose of the study were explained to each respondent verbally. The respondent was assured that his/her identification as well as information would be kept confidential and the information provided by him/her shall be used for research purpose only. An attempt was made to determine the knowledge level on disease transmission, diagnosis, treatment and prevention, mosquito breeding and control and personal protection measures against mosquito bites.

In many countries, lack of funds and inadequate use of existing cost-effective tools to fight infectious diseases are compounded by a failure to take account of the health impact of other sectors.

All too often, the key determinants of health – as well as the solutions – lie outside the direct control of the health sector. They are rooted in areas such as sanitation and water supply, environmental and climate change, education, agriculture, trade, tourism, transport, industrial development and housing. Yet many countries lack the capacity to measure the impact of other sectors on health. Unless these issues are addressed, it can be difficult to prevent or even control some infectious diseases.

The link between environmental quality and health, for example, is critical. Over

10per cent of all preventable ill-health today is due to poor environmental quality – conditions such as bad housing, overcrowding, indoor air pollution, poor sanitation and unsafe water. Bad housing and poor environmental conditions have the greatest impact on acute respiratory infections and diarrhoeal diseases. And children are worst affected – accounting for as much as two-thirds of all preventable ill-health due to environmental conditions.

In developing countries, about 700 million people – mainly women and children in poor rural areas – inhale harmful smoke from burning wood and other fuels. They are increasingly at risk from acute respiratory infections, especially pneumonia. Over a billion people lack access to safe drinking water – increasing their vulnerability to diarrhoeal and parasitic diseases. In Africa, Asia and Latin America, at least 600 million urban dwellers live in unhealthy homes or neighbourhoods. Almost 800 million people worldwide lack access to health services.

Elsewhere, changes in land and water use can also have a major impact on the incidence and pattern of disease. Deforestation, agricultural development, dams and irrigation schemes can trigger outbreaks of parasitic or other infectious diseases through favouring the spread of malarial mosquitos or freshwater snails that spread schistosomiasis. Most at risk are the over half a billion poor people who live in ecologically fragile regions. Other diseases affected by environmental change include lymphatic filariasis, dengue fever, leishmaniasis, Chagas disease and bacterial meningitis.

Meanwhile, an increase in global warming could have a similar impact on the spread of tropical diseases. A temperature rise of only 1-2o C over the next 50 years could extend the range of malarial mosquitos further north – increasing the proportion of the world's population at risk of malaria and other mosquito-borne diseases such as dengue and lymphatic filariasis.

Poverty and malnutrition are other key factors that affect health. Malnutrition is particularly lethal in combination with infectious diseases such as pneumonia, malaria, measles and diarrhoeal diseases – the major killer diseases affecting children. It is an underlying factor in over half of all child deaths. In 1997, an estimated 160 million children were moderately or severely malnourished. More than one in four of the world's population were estimated to be living in poverty – over a billion of them with incomes of less than $1 a day. Even in industrialized countries, 100 million people live below the poverty line.

The critical need for collaboration between health and other sectors has been highlighted most recently by efforts to prevent HIV/AIDS. A few governments have attempted to reduce individual vulnerability to HIV/AIDS through a cross-sectoral approach. The aim is to influence infrastructure development plans, laws, education, labour policies and the exercise of human rights, for example, in an effort to create an environment that makes it easier for people to avoid HIV/AIDS. This can involve providing incentives to enable girls to finish secondary education, boosting job and educational opportunities for women to break the cycle of economic and sexual dependency, and ending the criminalization of marginalized groups such as sex workers and injecting drug users. It can also involve carrying out impact assessments for development projects to foresee ways in which schemes could fuel the epidemic – through accelerating the pace of urbanization, for example, or splitting up families through creating the need for a migrant labour force.

In Thailand, where prostitution remains illegal, the government's pragmatic approach to slowing down the epidemic has brought a significant decline in infections – especially among the young. The multispectral approach included work with brothel owners to urge 100per cent condom use in brothels, the launch of mass media campaigns to encourage respect for women and discourage men from visiting sex workers, improved educational and vocational opportunities for women to keep them out of the sex industry and improved access to care, as well as economic and social support for people living with HIV/AIDS.

In addition to the need for increased collaboration between the different public sectors which impact on health, there is a need to build partnerships with the private sector. The recent launch of the New Medicines for Malaria Venture – a joint initiative by the public and private sectors to develop new antimalarial drugs – is an example of efforts to harness greater public and private sector collaboration in developing new products for use in developing countries. Another example is the donation of drugs by industry free-of-charge to help eliminate infectious diseases with a high disease burden in developing countries. These include donations of drugs by pharmaceutical manufacturers

SmithKline Beecham and Merck for the treatment of lymphatic filariasis and river blindness, and Pfizer for trachoma. In addition vaccine manufacturers have occasionally donated vaccines during outbreaks of disease, such as meningitis, for polio eradication, and for vaccine trials in developing countries.

WHO's efforts to eradicate or eliminate diseases are a collaborative effort by global partnerships. WHO has forged strategic alliances with governments, ministries of health in developing countries, international development banks, foundations, the private sector, civil society, non-governmental and international organizations and other UN agencies.

Global efforts to eradicate polio, for example, have demonstrated what can be achieved through private sector collaboration. Rotary International, a private sector service organization, has raised $500 million to fund vast quantities of vaccine for mass immunization campaigns and to help equip a refrigerated cold chain for vaccine transport. Rotary has used its global network of over 28 000 clubs in 155 countries to enlist volunteers to carry out social mobilization campaigns, provide organizational skills for immunization campaigns, and administer polio vaccine drops to children.

4.2 Filariasis in Kumbakonam

Kumbakonam is one of the Special Grade Municipal towns in Tamil Nadu since

1988. It is the second largest town in Thanjavur District having a taluk head quarters with a population of 139264 according to the 2010 census. Kumbakonam is also termed as “Temple City” because of the presence of more temples when compared to other towns in TamilNadu. ‘Maham’ is one of the major Hindu festivals which are being celebrated once in twelve years held in the month of ‘Masi’ (February-March) which is equivalent to the “Kumbamela” in the North India. There is however problems and we should keep them in our mind as well. The most important of these is the half-hearted participation of the community and the ‘resigned’ attitude of the individuals afflicted with the disease. And there are other problems, too. No proper drainage system is in place, in any of the territorial jurisdiction. All the waste waters stagnate on the main roads and thoroughfares. Sometimes, the waste water is from the residential areas. The people must be made to know that the environmental management is not solely dependent on the personnel of the health department.

4.3 Technique of Analysis Factor analysis is a generic term that we use to describe a number of methods designed to analyze interrelationships within a set of variables or objects [resulting in] the construction of a few hypothetical variables (or objects), called factors, that are supposed to contain the essential information in a larger set of observed variables or objects that reduces the overall complexity of the data by taking advantage of inherent interdependencies [and so] a small number of factors will usually account for approximately the same amount of information as do the much larger set of original observations. Cureton and D'Agostino (1983) described factor analysis as "a collection of procedures for analyzing the relations among a set of random variables observed or counted or measured for each individual of a group". The purpose, they said, "is to account for the intercorrelations among n variables, by postulating a set of common factors, considerably fewer in number than the number, n, of these variables". Bryman and Cramer (1990) broadly defined factor analysis as "a number of related statistical techniques which help us to determine them [the characteristics which go together]”.

Gorsuch (1983) reminded the reader that "all scientists are united in a common goal: they seek to summarize data so that the empirical relationships can be grasped by the human mind”. The purpose of factor analysis, he said, "is to summarize the interrelationships among the variables in a concise but accurate manner as an aid in conceptualization". These definitions most likely make a great deal of sense to those

"left-brained" individuals who understand complex things fairly easily. Kerlinger (1979) gave both a left-brained and a right-brained definition of factor analysis.

For the left-brainers: "Factor analysis is an analytic method for determining the number and nature of the variables that underlie larger numbers of variables or measures". And for the right-brainers he noted: "It [factor analysis] tells the researcher, in effect, what tests or measures belong together--which ones virtually measure the same thing, in other words, and how much they do so”. He further commented on factor analysis in terms of curiosity and parsimony. He noted, "Scientists are curious. They want to know what's there and why. They want to know what is behind things. And they want to do this in as parsimonious a fashion as possible. They do not want an elaborate explanation when it is not needed.” He sounds like a very right-brained individual! Each definition of factor analysis has common elements. Each refers in some way to the correlations among variables as reflected by the use of the words interrelationships, intercorrelations and relations. Further, each definition makes clear the notion of reducing the number of variables into a smaller set of factors. In short, factor analysis helps to explain things by reducing large amounts of information into a manageable form and size. Now that is an explanation that right-brained individuals (and of course, lefties, too), can comprehend!

4.3.1 The Process of Factor Analysis: Data matrix

The first step in an exploratory factor analysis is to display the data in a data matrix. A data matrix is "any array of numbers with one or more rows and one or more columns" (Reymont & Joreskog, 1993). This appears to be quite straightforward (much to the surprise and relief of the right-brained). Ah, but not so fast. In an effort to complicate matters, there are issues of a vector (a matrix that has only one row) and a scalar (which has both one row and one column), as well as a variety of matrices identified by Gorsuch (1983) in developing factor analytic concepts. (The right-brained among you are possibly noticing a constriction of air passages at the number of possible options, but not to worry. This is merely an introductory paper on the topic of factor analysis). Correlation Matrices. In order to determine the factors underlying the variables, a "variable reduction scheme" (Gorsuch, 1983) is used which shows how the variables cluster together; i.e., the variables are correlated with one another. These correlations are represented in a matrix of association. A statistical measure of association such as the Pearson r is used to indicate the magnitude of the correlations. A correlation (or variance-covariance) matrix represents the relationships among the set of variables in the study. In this correlation (or variance-covariance) matrix of variables, the values located on the diagonal will be 1.0. This is because each of the variables will correlate perfectly with itself. The off-diagonal elements are the co-variances between all variable pairs. (Remember, right-brainers, this simply means the correlations between the variables.) Because the number of correlations in the matrix reflects the number of variables used in a study, it is possible that a single correlation matrix may have thousands of entries. Factor analysis, explained Hetzel (1995), "attempts to simplify the correlation matrix by accounting for a large number of relationships with a smaller number of explanatory constructs [i.e., factors]". He further stated that these hypothetical factors are determined by examining additional data matrices, specifically the factor pattern matrix and the factor structure matrix.

In much of the literature on factor analysis, the term "factor loading" is used instead of the more accurate terms, factor pattern coefficients and factor structure coefficients, which are the elements comprising the factor pattern and factor structure matrices. The exact nature of these coefficients and corresponding matrices is beyond the scope of this paper. The important element is that factor pattern coefficients represent the relationship of a specific variable to a specific factor without the influence of other variables (Stevens, 1992). The factor structure coefficients can be thought of as being identical to structure coefficients in other types of Correlation analyses. These coefficients show the correlations of the variables with the factors (Hetzel, 1995). It is with the results of these additional matrices, and through the careful interpretation of the data, that the factors are extracted and interpretations made.

4.4 Extracting the factors

We are reminded by Cattell (1978) that "factor analysis is, in principle, nothing more than asking what the common elements are when one knows the correlation". It is at this point, when we have calculated the correlations between the variables and factors that we can begin to determine the number of factors underlying the variables. The chief concern, at this stage, according to Kim and Meuller (1978) is whether a smaller number of factors can account for the co-variation among the original, larger set of variables.

Gorsuch (1983) indicated that there are numerous methods that can be used in deciding how many factors to retain. Again, these methods are too detailed for the current paper, but in general, regardless of the method used, he suggested that "one would want to account for at least 70per cent of the total variance".

The critical point in deciding how many factors to retain is that this decision requires the researcher to carefully consider the data and to use his or her judgment. As with many other statistical concepts, a number of decision rules are available to help guide the researcher with the decision as to the specific number of factors to retain. This topic was summarized by Hetzel (1995): Regardless of the rules eventually used, when considering the number of factors to retain, it is important for the researcher to remember the advantages and limitations of the various decision rules and to make a subsequent decision in a thoughtful and well-reasoned manner, based on the nature of the analysis.

4.5 Interpretation of the factors

Following the initial extraction of factors, an interpretation of these factors is necessary. Kim and Meuller (1978) pointed out: It is important to emphasize that factor analysis does not tell the researcher what substantive labels or meaning to attach to the factors. This decision must be made by the researcher. Factor analysis is purely a statistical technique indicating, which, and to what degree, variables relate to an underlying and undefined factor. The substantive meaning given to a factor is typically based on the researcher's careful examination of what the high loading variables measure.

Put another way, the researcher must ask what these variables have in common.)

It should be noted that the factors must be called something other than the name of a particular observed variable. The reason for this is that factors are latent aggregates of observed variables and the factor name should represent the aggregate and not be confused with a specific measured variable. At this point in the analysis, the minimum number of factors that can account for the observed correlations have been identified and named. To obtain a more easily interpretable solution regarding the factors, the researcher can engage in a process known as rotation. This is most easily done by computer and again, is too complicated a matter for this paper. The results of rotation, however, indicate "the simplest solution among a potentially infinite number of solutions that are equally compatible with the observed correlations" (Kim & Mueller, 1978). The process of exploratory factor analysis results in the smallest and most compatible number of underlying factors from a larger set of initial variables on a test or instrument. The process can be summarized as follows: (a) the researcher collects observed scores (raw data) on an instrument without having a preconceived notion as to the number of underlying factors, (b) presents this information in data matrices, (c) correlates the variables, and (d) identifies the factors underlying the variables.

The impact of transmission heterogeneities to immune- epidemiology of lymphatic filariasis: The objective of the study is to examine the variations in exposure to mosquito biting at individual and household level and relate them to prevalence of infection in human population. The study has been carried out in a village with a population of 2083 in Villupuram district in Tamil Nadu, endemic for Wuchereria bancrofti transmitted by Culex quinquefasciatus. The prevalence of chronic lymphatic filariasis wass 15.2 per cent in the village.

A total of 139 randomly selected households have been included in the study.

These households have been monitored for a year to quantify the transmission intensity, prevalence of microfilaraemia and antigenaemia and also incidence of acute disease.

Exposure to infection was assessed by fingerprinting the blood meal of vector mosquitoes and parallel human blood samples in respective households, using a 9-locus radioactive

STR system based PCR for amplification. W. bancrofti infection in human subjects was determined by membrane-filtration of microfilariae from blood. Humoral immune response, in terms of filarial specific IgG1, IgG3, IgG4 and IgE antibody levels, and circulating filarial antigen levels among members of the selected households, were investigated on two time points. The results of the study are summarized below. Out of 276 blood meal PCR fingerprints, 73 per cent of mosquitoes resting in a house had fed on people within that household, whereas 27 per cent of them had fed on people outside the house, which implies that a considerable number of mosquitoes move between households. Additionally, 13 per cent of mosquitoes had multiple feeds on different individuals in the household, with the rate of multiple feeding depending on the density of humans in the household. Further, younger age classes (5-30 years) were bitten by vectors more frequently than the older age classes.

4.6 Household level variation in vector infection and mf prevalence

134 households have matched data for entomology and parasitology. Out of 134 households, 31 (23 per cent) households were free from infected mosquitoes and mf carriers. The remaining 103 (103/134=76.8per cent) households have either mf carriers and/or infected mosquitoes. 37 households (37/134=27.6 per cent) have both mf carriers and infected mosquitoes. 12 (12/134=8.95 per cent) households have only mf carriers, with no infected mosquitoes. 54 out of 134 (40 per cent) households have only infected mosquitoes, with no mf carriers. Only 16 out of 134 (=11.9 per cent) households were found with infective mosquitoes, an evidence for active transmission.

4.6.1 Households with mf carriers

49 out of 134 (36.5 per cent) households have mf carriers. The number of mf carriers per household ranged from 1 to 3 (Fig. 4.10). 37 of these 49 households (=75.5 per cent) have infected mosquitoes. 12 of these 49 households (12/49=24.5per cent) have no infected mosquitoes. Out of 85 households with no mf carriers, 54 (63.5 per cent) were with infected mosquitoes. Infective mosquitoes were found in only 8 of the 49

(=16.3 per cent) households with mf carriers. The average number of mf carriers per household is 0.49 (range: 1-3). The over all mf rate is 13.8 per cent (66/479*100). When considered only those households with a sample size of =>5 each were considered, a maximum prevalence of 42.8 per cent (3/7) was observed in one household.

4.6.2 Households with infected mosquitoes

91 out of 134 (67.9 per cent) of the households are with infected mosquitoes. 37 of these 91 (=40.6 per cent) households were found with mf carriers. 43 out of 134 households (=32.1 per cent) are free from infected mosquitoes. However, 12 of these 43 households (27.9 per cent) are with mf carriers. Out of 16 households with infective mosquitoes, only 8 (=50 per cent) households have mf carriers.

4.6.3 Transmission dynamics

The per-man hour resting density ranged from 0 in five households to 57. Only one household has a density of 93, in which 2 out of 5 people sampled were found to be positive for mf. The infection rate ranged from 0per cent to 42.9 per cent and infectivity rate from 0per cent to 9.1 per cent

4.6.4 No. of mf carriers

(Only those households from where minimum of 20 mosquitoes were dissected were considered). The transmission intensity index ranged from 0 to 19.5 in one house, where also 2 out of 5 sampled persons were found positive for mf.

4.6.5 Antigenaemia prevalence

The prevalence of the circulating filarial antigenaemia (CFA) was 27.7per cent in the study population (n=465). A one year follow up of 73 individuals with CFA showed that 52 (71.2 per cent) remained positive for CFA and 21 (28.8 per cent) turned negative. 12.8per cent of the CFA negative individuals (n=188) turned positive during the one year period. The antigenaemia prevalence and intensity was maximum in 21-30 year age class and minimum in 41-50 year age class and it tended to increase in >50 year age classes.

4.7 Filariasis in Kumbakonam: Spatial Dimensions

To study the Spatial Dimensions of people in Kumbakonam town among the 272 cases 100 samples (nearly 40 per cent of the sample) have been considered to find the various factors that are responsible for the prevalence of the disease. A questionnaire schedule was prepared with 68 relevant questions to gather information about the people’s perception about their environment and disease. The questions include apart from the basic information about the respondent, age of the person, sex category and the level of education the additional and major information such as: environmental perception about the disease, stagnant water areas nearby, presence of marshy environment, existing drainage facilities either drain or open pits, waste water stagnant pools b\nearby, lavatory and intact septic tank facility, usage of mosquito bite prevention methods, health personal attention towards the anti-mosquito spray, collection of blood samples and co-operation with the health personal, stages of the disease and place of occurrence, medical treatment after the disease presence, side effects during oral medicine, presence of disease through whom, psychological attitudes about the neighbours, relatives and friends with the filarial disease persons and how the patient feels once the disease has affected. The questionnaire schedule is given in the Appendix.

The data for the above variables were gathered from the affected respondents tracking with the addresses obtained from the KFCU. The survey was conducted for one month and after the survey the schedule was converted into a geographical data matrix.

The data was studied carefully and among the 68 variables the most important and justifiable variable of 32 (Table 3.1) have been selected for the 100 samples. Now the data matrix is in the form of 32 * 100. The data was then fed into the computer and the

Factor analysis method was performed by using SPSS package version 10. The results of the factor analysis are given in the tables 3.2 and 3.3. The results of the rotated factor structure and the eigenvalues, percentage of contribution, cumulative contribution and the communality are given in table 3.4.

Table 3.1 Variable Description and Variable Code Variable Code Variable Description X1 AOR Age of the Responded X2 LOE Level of Education X3 PFD Perception about the Filarial disease X4 EID Environmental implication about the disease X5 PAD Perception about dirty X6 PWS Perception about Waste water stagnation X7 PMM Perception about Mosquito menace X8 PVC Perception about vegetation cover X9 PAD Perception about options of drainage X10 ADF Availability of drainage facility X11 ASP Availability of waste water in stagnant pools X12 ALF Availability of Lavatory facility X13 AST Availability of septic tank X14 UMC Usage of Mosquito Coils X15 UON Usage of Odomos during night X16 UGB Usage of good night and banish mates X17 HPA Health personal attention towards antimosquito spray X18 CBS Collection of blood semears at night X19 CFW Co-operation with of field workers during collection of blood semears X20 SOD The stage of the disease X21 COT Consumption of tablets regularly after disease presence X22 NDT Number of doses and time periods X23 SHE Side effects- Headache during the tablet conception X24 SEJ Side effects routine job per how many days X25 PEC Preventive efforts to curtail disease X26 PDP Presence of disease through public health department X27 PSD Presence of disease surfaced while distributing tablets X28 TFM Treatment of your family members X29 TYN Treatment of your neighbors X30 TYR Treatment of your relatives X31 PAB Psychological attitude-Bitter X32 PAF Psychological attitude-Fate

Factor analysis is used to uncover the latent structure (dimensions) of a set of variables. It reduces attribute space from a larger number of variables to a smaller number of factors and as such is a "non-dependent" procedure (that is, it does not assume a dependent variable is specified). Factor analysis could be used for any of the following purposes: To reduce a large number of variables to a smaller number of factors for modeling purposes, where the large number of variables precludes modeling all the measures individually. As such, factor analysis is integrated in structural equation modeling (SEM), helping create the latent variables modeled by SEM. However, factor analysis can be and is often used on a stand-alone basis for similar purposes. To select a subset of variables from a larger set, based on which original variables have the highest correlations with the principal component factors. To create a set of factors to be treated as uncorrelated variables as one approach to handling multicollinearity in such procedures as multiple regression. To validate a scale or index by demonstrating that its constituent items load on the same factor, and to drop proposed scale items which cross- load on more than one factor.

Table: 3.2 Principle Component Matrix Variable Code Component

1 2 3 4 5 6 7 8 9

X29 TYN .878 -.228 .190 -.212 0.050 0.066 .102 .179 -0.063

X30 TYR .876 -.221 .182 -.194 0.055 0.088 0.064 .139 -0.064

X28 TFM .808 -.151 .223 -.419 -.108 0.002 0.057 .109 -0.021

X20 SOD .506 0.006 -.432 0.037 0.099 .191 -.267 0.066 -0.027

X23 SHE -.401 -.130 .331 -0.050 .303 -.101 -0.015 -.155 0.077

X12 ALF .241 .860 -0.002 0.002 .149 -.239 0.035 0.063 -0.044

X13 AST .232 .857 0.010 -0.042 .126 -.264 -0.010 0.026 -.085

X7 PMM -0.026 .377 0.055 -0.074 0.055 .211 .231 .197 0.023

X21 COT -0.053 -.174 .699 .142 -.155 -.299 -.142 .205 -.164

X22 NDT -0.035 0.036 .601 0.084 .251 -.295 -0.020 .309 0.039

X24 SEJ -.209 -.126 .489 -0.035 .156 -.102 0.069 -.357 -.223

X32 PAF -.329 -.119 -.434 -0.078 -0.075 -.349 .427 .186 .258

X19 CFW -0.024 -.135 .398 .117 -.164 0.031 0.071 -0.065 .237

X27 PSD .257 -.198 -.182 .580 .421 .131 .314 .196 -0.059

X26 PDP .224 -.278 -0.038 .564 .478 0.046 .310 0.070 -.150

X25 PEC .105 -.116 0.038 .477 -.239 .368 0.0001 -0.065 0.077

X3 PFD .387 .262 .254 .472 -.353 -0.095 .186 -.164 .203

X18 CBS 0.006 -0.039 .238 -.375 .296 .118 .132 -.173 .364

X2 LOE 0.075 -0.069 -0.021 -.238 .517 -0.043 -.419 .-0.046 .226

X17 HPA .101 -0.087 .222 .125 -.395 .330 0.038 -.142 .224

X10 ADF -.298 0.075 .188 .227 -.163 .477 .108 .333 .250

X6 PWS -.159 -0.008 .263 .208 0.038 .419 0.037 -0.027 -.130

X14 UMC -.238 .198 0.086 -.196 .217 .379 -0.026 .353 -0.001

X8 PVC 0.013 0.014 0.0009 -.339 0.049 .240 .611 -.237 -0.012

X9 PAD -0.001 -.296 -.118 .242 .158 -0.015 -.429 .237 0.090

X11 ASP -0.061 -.350 -0.039 -.206 -0.075 -0.097 .136 -394 -0.032

X31 PAB -0.054 .201 .191 .172 .350 .371 -.253 -.380 -.146

X15 UON .273 0.088 .146 .134 .201 -.233 .188 -.333 -.144 X16 UGB .275 .184 .285 -.154 161 -0.072 .111 .307 .147

X5 PAD 0.046 .291 -0.037 -.100 .423 -266 .134 .134 .527

X4 EID .283 .402 0.094 .297 .160 .140 0.009 -.221 .482

X1 AOR -.370 0.032 0.076 -0.069 .119 -0.008 .279 .237 -.482

Source: Factor Analysis using SPSS package Table: 3.3 Rotated Component Matrix Variables Code Component

1 2 3 4 5 6 7 8 9

X29 TYN .958 0.006 -0.017 .161 0.062 -0.074 -0.001 0.046 0.035

X30 TYR .939 0.002 -0.040 .154 0.075 -0.090 0.046 0.052 0.019

X28 TFM .938 0.024 -.0009 -.127 0.068 -.101 -0.051 0.049 .108

X12 ALF 0.029 .937 -0.026 -0.046 0.011 -0.017 0.021 -0.012 0.059

X13 AST 0.026 .927 -0.012 -.112 -0.019 -0.061 0.048 -0.025 0.052

X11 ASP -0.019 -.371 0.014 -.112 -0.024 -.362 -0.031 0.062 .269

X21 COT .151 -0.074 .754 -0.088 .102 -0.026 0.045 -.211 -.264

X22 NDT .109 .194 .697 .103 -0.0007 .133 -0.028 .148 -.178

X20 SOD .353 0.059 -.589 0.038 0.028 -0.062 0.055 -0.086 -.275

X24 SEJ -.110 -.140 .517 -0.027 -0.052 -.230 .323 0.044 .233

X23 SHA -.298 -.152 .426 -0.013 -0.079 -0.044 .143 .321 0.086

X27 PSD 0.078 -0.008 -.104 -885 0.028 0.042 -0.029 -0.022 -0.079

X26 PDP 0.073 -0.066 0.067 .878 -0.008 -0.096 0.077 -0.004 -0.039

X3 PFD .123 .284 0.089 .126 .727 -.126 -0.004 -.278 0.030

X4 EID -0.019 .392 -.142 .167 .576 0.042 .185 .309 0.024

X17 HPA 0.098 -.243 0.039 -.119 .511 .164 .134 -.137 0.097

X1 AOR -.171 0.015 .279 .131 -.494 .183 -0.016 -.278 .220

X19 CFW 0.025 -.179 .303 -0.040 .186 0.076 0.019 -0.028 0.044

X25 PEC -0.082 -0.009 .150 .169 .372 -.310 -.194 -.240 -.263

X10 ADF -.208 -.124 -0.009 0.084 -.248 .680 0.004 -0.096 0.002

X14 UMC -0.046 0.089 0.012 -0.034 -.263 .580 .133 .143 0.053

X15 UON 0.041 .225 0.083 .268 0.011 -.473 0.046 0.004 .163

X7 PMM 0.073 .308 -0.022 0.035 -0.030 .366 0.012 -0.033 .241

X16 UGP -0.090 .114 .326 -.239 0.029 .363 -.227 -0.022 0.073

X32 PAF -.326 -0.083 -.102 0.084 -.109 -0.019 -.744 0.050 .169

X31 PAB -.168 0.096 -0.013 .100 0.021 -0.004 .725 .156 0.019

X6 PWS -.101 -.143 .120 .150 0.079 .291 .389 -.126 0.093

X2 LOE 0.084 0.035 -0.043 -0.057 .197 -0.083 .162 .640 -.266

X5 PAD -0.014 -.120 .135 .220 0.0007 -0.022 -.412 .630 0.093

X18 CBS 0.092 0.004 .109 -.116 0.075 0.033 0.066 .558 .339 X8 PVC 0.089 -0.077 -0.079 0.053 -0.038 0.044 -0.029 0.071 .757

X9 PAD -0.012 -.201 -0.054 .159 -0.062 0.043 0.009 .135 -.584

Source: Factor Analysis using SPSS package

Table 3.4 Spatial Dimensions of Filariasis in Kumabakonam: Rotated Factor Structure Variables Code F1 F2 F3 F4 F5 Comm Dimension I: Environmental Quality of life Open/No drainage facility X10 0.740 0.956 Water stagnant areas nearby X11 0.944 0.928 Septic tank intact/ availability X12 0.920 0.925 Marshy environment/ more X8 0.886 0.883 vegetation cover Dimension II: Perception about the Environment Environmental perception X4 0.963 0.885 about the disease Perception about mosquito X7 0.837 0.801 menace Perception about open drainage X9 0.625 0.704 pits Usage of mosquito bite X16 0.581 0.701 protection methods Dimension III: Stages of Filariasis and Medical Treatment Types of disease and stages X20 0.682 0.809 Tablet consumption and doses X22 0.655 0.666 Types of side effects and X23 0.634 0.606 number of days Satisfaction about the treatment X24 0.619 0.618 by MO’s. Dimension IV: Health care Towards the Disease Towards anti-mosquito spray X17 0.518 0.728 regularly Collection of blood smears X18 -0.452 0.599 regularly Provision of Tablets regularly X21 0.692 0.566 Co-operation with the field X19 0.425 0.529 worker Dimension V: Psychological Attitudes and Awareness Treatment by family members X28 0.745 0.567 Treatment by neighbors and X29 0.763 0.486 relatives Personal Psychology X31 0.565 0.458 Preventive efforts to curtail the X25 0.431 0.456 disease

Eigen values 3.712 2.633 2.321 2.159 1.919 Percent of variance explained 11.601 8.229 7.253 6.746 5.996 Cumulative percentage of 11.601 19.830 27.083 33.829 39.826 40.000 variance Source: Factor Analysis using SPSS package

The dimensions, based on the variables loading on them and on the strength of the loadings themselves, have been designated as follows:

Dimension-I Quality of Life

Dimension-II Environmental Perception

Dimension-III Stages of Filariasis and Medical

Treatment

Dimension-IV Health Care Towards the Disease

Dimension-V Psychological Attitude and Awareness

Measures

4.7.1 Dimension-I: Quality of Life

The four variables loading significantly on the factor are: open/ or no drainage facility (loading 0.740), water stagnant areas nearby (0.944), septic tank intact/ availability (0.920), and marshy environment/ more vegetation cover (0.886). All the variables are positively loaded and very significantly as well. The dimensions appear to be implying that these four major variables play a significant role in creating a conducive atmosphere for the vectors to grow either in the stagnant water areas or in the marshy environment. The adverse environmental conditions are clearly co-ordinates with the above variable, which transmits the filarial worm into the human body which ultimately affect them in this region. The Eigen values of the main factor dimension are 3.712 and the variance explained is 11.061 per cent. All the variables have high communality unique variations as well.

4.7.2 Dimension-II: Environmental Perception

The second dimension is the perception about the environment of the people in this region and all the variables are positively loaded. The main variables in this category are environmental perception about the disease (0.963), perception about mosquito menace (0.837), perception about open drainage pits (0.625) and usage of mosquito bite protection methods (0.581). Environmental perception is a major factor in any urban setting and several studies indicate that if the people’s perception about their surrounding is good they lead a healthy environment. In the present context in the study area the perception about the living environment contributes major underlying variable positively.

From the majority of the affected persons, they do not have any idea about the presence of disease and some of them think that the bulging of leg or hand is due to some other problem and not due to lymphatic filariasis. Similarly they patients do not agree with the point that it is due to drainage water and stagnant water, which forms mosquito breeding grounds. This dimension has an Eigen value of 2.633 and the variance explained is in the order of 8.229 per cent.

4.7.3 Dimension-III: Stage of Filariasis and Medical Treatment

Stages of filariasis and Medical treatment forms the third dimension with the major underlying variables are: types of disease and stage (0.682), tablet consumption and doses (0.655), types of side effects and number of days (0.634) and satisfaction about the treatment by medical officers (0.619). There are three stages of filariasis: early stage, mature and old stage. Due to lack of awareness about the people they approach the medical officers of the Filarial Control Unit only they attain either the mature stage or the very late stage. Some time the recent co-operation by the people of this region for the regular blood smear tests the disease is being identified at the early stages. They immediately have given the prescribed medicines with number of doses. Some time the medicines would react the patients and the alternate solutions are being given. This dimension has an Eigne value of 2.321 with the percentage variance of 7.253.

4.7.4 Dimension-IV: Health Care towards the Disease

The fourth dimension is the Health care towards the disease. There are four variables loaded in this factor and they are: Towards anti-mosquito spray regularly

(0.518), collection of blood smears regularly (-0.452), provision of tablets regularly

(0.692) and co-operation with the field worker (0.425). Recent years the peoples were given proper knowledge about the filarial disease and its ecological factors that allows the mosquito to grow and interaction with the people by the KFCU. People in this region constantly watching the anti-mosquito liquids being sprayed with regular intervals. The number of incidence has been increased during 2000 which was purely identified by the health officers after properly testing the blood smears. This means in the previous years the people were not co-operative and hence they were hiding the disease. The tables are being distributed regularly for the positive cases of filariasis patients and even in single house there are two or more number of afflicted persons were identified. The co- operation with the field worker is highly positive and it is due to the increase in awareness about the disease and to take all preventive measures individually. This fourth dimension has an eigne value of 2.155 with a contribution of 6.746 percentages.

4.7.5 Dimension-V: Psychological Attitudes and Awareness Measures

The final factor is the Psychological attitudes and awareness measures that are being taken/ under consideration. The variables loaded in this category are: treatment by family members (0.745), treatment by neighbours and relatives (0.763), personal psychology (0.565) and preventive efforts to curtail the disease (0.431). Psychological attitudes about the affected persons with enlarged legs and hands are one of the major underlying phenomenons that have to be considered seriously. The reason is that how they feel once the disease is affected and how they move with the enlarged organs and how the others who are nearby, friends and relatives and their attitudes about the affected persons and so on. Naturally the people in the surrounding particularly in the affected zone would take care of their environment to curtail this type of adverse disease. As per this study the psychological attitudes of the people have been changing towards their environment and taking all the control and preventive measures. This factor has an Eigen value of 1.919 with a percentage contribution of 5.996.

4.8 Conclusion

The Results of Factor Analysis yielded five spatial dimensions, namely, Quality of Life, Environmental Perception, Stages of Filariasis and Medical Treatment of the patients/ afflicted, Health Care Towards the Disease and Psychological Attitudes and

Awareness Measures, from the samples gathered from the affected persons in the study area.

5 Chapter

Recommendations and Conclusion

Elimination and eradication of human disease has been the subject of numerous conferences, symposia, workshops, planning sessions, and public health initiatives for more than a century. Although the malaria, yellow fever, and yaws eradication programmes of earlier years were unsuccessful, they contributed greatly to a better understanding of the biological, social, political, and economic complexities of achieving the ultimate goal in disease control. Smallpox has now been eradicated and programmes are currently under way to eradicate poliomyelitis and guinea-worm disease. In 1993, the

International Task Force for Disease Eradication evaluated over 80 potential infectious disease candidates and concluded that six were eradicable. In 1997, the World Health

Assembly passed a resolution calling for the "elimination of lymphatic filariasis as a public health problem".

The favorable attributes and potential benefits of eradication programmes are a well-defined scope with a clear objective and endpoint, and the duration is limited.

Successful eradication programmes produce sustainable improvement in health and provide a high benefit-cost ratio. Eradication programmes are attractive to potential funding sources because they establish high standards of performance for surveillance, logistics, and administrative support; develop well-trained and highly motivated health staff; assist in the development of health services infrastructure including, for example, mobilization of endemic communities; and provide equity in coverage for all affected areas, including urban, rural, and even remote rural areas. They also offer opportunities for other health benefits (e.g. for dracunculiasis eradication: health education and improved water supply), improved coordination among partners and countries, and dialogue across frontiers during war. Decisions on initiating a global disease eradication campaign should also take into consideration the ideal sequencing of potentially concurrent campaigns. Eradication programmes consume major human and financial resources. Careful consideration must be given to whether two or more eradication programmes are to be conducted simultaneously or sequentially, or if the target disease is confined to a limited geographical area.

Disease elimination and eradication programmes can be distinguished from ongoing health or disease control programmes by the urgency of the elimination and eradication programmes and the requirement for targeted surveillance, rapid response capability, high standards of performance, and a dedicated focal point at the national level. Eradication and ongoing programmes constitute potentially complementary approaches to public health. There are areas of potential overlap, conflict and synergy that must be recognized and addressed. In many cases the problem is not that eradication activities function too well but that primary health care activities do not function well enough. Efforts are needed to identify and characterize those factors responsible for improved functioning of eradication campaigns, and then apply them to primary health.

Evaluation of the effectiveness of advocacy measures for sustained compliance with DEC mass treatment for the elimination of lymphatic filariasis in Tamil

Nadu, south India (EM 9901 AFR) the strategy recommended for elimination of LF consists of (i) annual single dose mass treatment with anti-filarial drugs to interrupt transmission and (ii) morbidity management to alleviate suffering in chronic patients. The state government of Tamil Nadu launched annual DEC mass treatment programme in 12 districts in the year 1997-98. Evaluation of programme in some districts in Tamil Nadu and information from other parts of the country suggest that the extent of distribution of drug and peoples’ compliance with treatment is limited by certain operational problems and lack of enthusiasm among people to participate in the programme. In the first few rounds of MDA, drug distribution rates were in the range of 65per cent to 80per cent and treatment compliance rate ranged from 50per cent to 65per cent. It is hypothesized that the treatment compliance rate should be above 80per cent to facilitate elimination of LF.

Based on these results it was concluded that an advocacy campaign is necessary to improve the drug distribution and treatment compliance rates. Therefore a study has been undertaken to understand the factors that influence drug distribution and treatment compliance, facilitate development of advocacy material by the state government, monitor and evaluate the effectiveness of the advocacy campaign. The study was jointly carried out by VCRC and the Department of Public Health and Preventive Medicine

(DPH), Government of Tamil Nadu.

The study consists of two phases – first phase envisages collection of baseline information and development of advocacy strategy and second phase implementation and evaluation of advocacy strategy. While VCRC played a major role in the base line information collection and evaluation of the strategy, the DPH was primarily responsible for the development and implementation of advocacy strategy. The annual mass treatment programme was implemented in 12 districts in the year 2001. Until 2001, in all the districts only DEC was distributed. The base-line (pre-advocacy) information has been collected in Cuddalore and Villupuram districts in Tamil Nadu.

The phase I study focused on understanding the factors that influences drug distribution and treatment compliance and the people’s knowledge of filariasis through qualitative research methods and assessment of pre-advocacy drug distribution and treatment compliance rates through quantitative questionnaire survey. 2.05 per cent households in Cuddalore district and 2.52 per cent households in Villupuram district had one or more of their members affected with elephantiasis. The respective figures for hydrocele were 10.71per cent and 13.76 per cent. However, a majority of respondents consider elephantiasis and hydrocele as different disease entities. While hydrocele was recognized as a common health problem in all villages, respondents in 32 per cent of the villages only said that their communities were affected by elephantiasis. About 34per cent of the respondents believe that elephantiasis can be spread from one person to another and the same proportion attributed elephantiasis to mosquito bite.

Other important perceived causes of elephantiasis were drinking water from local ponds, accumulation of bad fluid in the legs and poor hygiene around the houses.

Only 9 per cent believe that hydrocele can be spread from person to another and injury and heredity were the perceived causes of hydrocele. While 28 per cent believed that elephantiasis can be cured, 72 per cent thought it can be prevented. The most important way of prevention was said to be taking medicine. 86per cent of the respondents said that hydrocele can be cured and 72 per cent suggested surgery is the best option for that.

About 45 per cent believe that the elephantiasis disease can be eradicated from their communities. However, the private practitioners, health workers and PHC medical officers felt that annual mass treatment alone may not be able to eliminate lymphatic filariasis. They emphasized very much that improvement in sanitation and vector control measures are also necessary to achieve elimination of LF. Community members also believe that the government’s effort to control filariasis will be successful, as seen with other diseases such as polio, and feel that people should extend support to these programmes.

About 85 per cent of the people were aware of drug distribution in their communities for elimination of elephantiasis and 73 per cent believed that the drug protects them against the disease. The drug distribution rate was 72 per cent (range 49 per cent to 89 per cent in different villages and urban wards) in Cuddalore district, it was 71 per cent (range 0 per cent to 94 per cent) in Villupuram district. However, many people who received the drug failed to consume and therefore the final compliance rate with treatment was much lower than the distribution rate. The treatment compliance rate was

34 per cent (range 16 per cent to 73 per cent) in Cuddalore district and 32 per cent (range

0per cent to 58 per cent) in Villupuram district. A number of respondents felt that many people received tablets but did not bother to consume the tablets either because they were not told about the importance of the programme or did not feel that consumption of the drug is necessary. Some expressed that the programme should have been implemented in a better way as it has been done in Polio and Guinea worm eradication programmes. Some medical officers cited that the funds provided for the programme are not adequate.

While 55 per cent of the households possess radio, and 30 per cent of the rural households and more than 80 per cent of the urban households were having television.

About 45 per cent of the respondents read news paper. Television and health workers were the important source of health messages. The details on development, implementation and evaluation of the effectiveness of advocacy campaign are being studied.

Control

In communities endemic for lymphatic filariasis, the disfiguring and debilitating clinical manifestations result in much suffering and have severe socioeconomic and psychological consequences for those affected. The objective of control is to reduce trans- mission and morbidity, thereby eliminating lymphatic filariasis as a public health problem. Successful programmes for the control of lymphatic filariasis must be based on a thorough understanding of the distribution and dynamics of the disease in the targeted population. The diverse characteristics of communities in endemic foci, as well as differences in vector, parasite and disease parameters, emphasize the importance of having multiple measures and approaches for control.

The main method used in the control of lymphatic filariasis is mass chemotherapy. It may be supplemented by mosquito control. Morbidity control through patient management (hygiene, antimicrobial treatment, physiotherapy) and establishment of self-help groups is recommended. To achieve success in a control programme it is necessary for the community to be actively involved. Community leaders and motivated persons should be identified and approached for the purpose of obtaining their cooperation. Adequate health education should be given regarding the nature of the disease and on the methods used for its control.

Before starting a control programme, knowledge of the geographical delimitation of the disease is essential. Rapid assessment procedures are based on examination of specific age-sex groups in selected populations to determine the prevalence of easily recognizable signs such as hydrocele or circulating antigenaemia

Geographical information system (GIS) has been utilized for large- scale mapping of the disease. All areas with indigenously acquired infections are considered to be endemic.

Criteria for distinguishing different levels of endemicity have so far not been established.

Mathematical models of lymphatic filariasis transmission, infection and disease within the endemic community have been developed. It is envisaged that such models can be used to predict the outcome of control based on different measures, and thus can provide guidance towards the most cost effective control strategies in specific settings.

Elimination

Lymphatic filariasis (also called elephantiasis) is one of the diseases being controlled through integrated programmes it is also treated with ivermectin but it has already been successfully eliminated from China, Korea and ten African countries.

Elimination means stopping transmission in a particular territory.

Elimination of lymphatic filariasis in certain countries has been possible because ivermectin is so effective, but there are other factors working in our favour, according to

Bockarie: “The drug is very good, tools for diagnosis are very good. There is no natural reservoir for the parasite, so if you can eliminate it from humans, it is gone. If you reduce the parasite load in the community to less than 1 in 1000, transmission is impossible.” Like onchocerciasis, lymphatic filariasis is caused by thread like nematode worms, although the worms that cause lymphatic filariasis are transmitted by mosquitoes rather than blackflies. Infection leads to thickening of the skin and other tissues, and massive swelling, particularly of the legs and male genitals. Of course, there are still many people with lymphatic filariasis in the countries where transmission has been successfully interrupted it will take many more years for the signs of the disease to disappear.

Since OCP ended, strategies for onchocerciasis have also moved more towards elimination in certain countries. These were prompted, says Bockarie, by the recent upsurge in interest in NTDs generally. “We have the resources to monitor and evaluate progress and there is a bigger workforce available which means we can put in place protocols for effective monitoring.”

Although onchocerciasis and lymphatic filariasis are treated with the same drug, it will not be simple to eliminate both diseases in all countries. “One of the biggest challenges is co-infection,” says Bockarie. “We can control onchocerciasis and lymphatic filariasis with existing tools but only in certain settings.”

One problem is another parasite called Loa loa, which is also sensitive to ivermectin. Unfortunately, in patients with large numbers of Loa loa parasites in their bodies, treatment with ivermectin can cause serious, potentially fatal, effects when dead

Loa loa worms enter the bloodstream. So ivermectin cannot be used to treat onchocerciasis or lymphatic filariasis where Loa loa infections are also prevalent. This does not mean, however, that we have to give up.

“Different strategies are being developed,” says Bockarie, “such as more refined, higher resolution mapping.” Knowing precisely where the diseases are endemic is vital to using resources in the most efficient and effective way. The standard approach for onchocerciasis and lymphatic filariasis has been to go to a district and sample the people.

If more than 1 per cent is infected, the whole district is classed as endemic and is eligible for treatment. This does not work in areas with Loa loa mapping has to be done at the village level if the status of all three infections is to be accurately determined and the right strategy implemented.

In areas with co-infection of Loa loa, the drug albendazole can be used first to reduce the levels of Loa loa infection in order to dampen the adverse effects of treatment with ivermectin that follows. Of course, as with the early days of OCP, control and elimination efforts do not have to focus on drugs. Other approaches include using antibiotics to kill Wolbachia, a bacterium that lives in lymphatic filariasis and onchocerciasis parasites but not in Loa loa. The parasites are dependent on Wolbachia, so killing the bacterium kills the parasites. However, there are other issues with using antibiotics: treatment is over one or two weeks rather than in a single annual dose as with the antiparasitic drugs, which makes it harder to ensure people get the full course of treatment. Targeting the insects that transmit the parasites – the flies that carry Loa loa, or the mosquitoes that transmit the worms that cause lymphatic filariasis is called vector control, and it is an approach that Bockarie has been championing for years: “What pushed me into public health and advocacy,” he explains, “was that vector control was being ignored. The lymphatic filariasis control programme had two main objectives: drugs to reduce infection in humans, and reduce or manage morbidity. Vector control was missing. When the lymphatic filariasis programme was developing, there was no space to talk about mosquitoes.”

Bockarie’s early training was in medical entomology the use of scientific knowledge about insects to understand and address human disease. He began studying malaria but mosquitoes that transmit malaria also transmit lymphatic filariasis and other

NTDs, although this sometimes seems to get overlooked: “In the last two to three years, we’ve seen the impact of [insecticide treated] bed nets on malaria,” he says. “But we know bed nets would impact on lymphatic filariasis as much as, if not more than, malaria what’s happening in lymphatic filariasis?”

While the integrated efforts to control and eliminate various NTDs are growing, it seems there is a need to integrate them further with efforts against the big three infectious diseases – malaria, tuberculosis and HIV/AIDS – as well.

Eradication

Eradication can be simply defined as global elimination. It was achieved in the

20th century with smallpox and we may be close to eradicating a second disease in the form of dracunculiasis, or Guinea worm disease. How? “Stop people drinking infected water,” says Bockarie. “It’ll completely eradicate it, get rid of the parasite completely.” It sounds simple, although as dracunculiasis is another neglected tropical disease, simple doesn’t necessarily mean easy, but the WHO has set a firm target in its NTDs roadmap to eradicate dracunculiasis by 2015.

Professor David Molyneux, acting chair of the UK Coalition against NTDs and one of the scientists who introduced the term ‘neglected tropical diseases’, has described progress on dracunculiasis so far as remarkable: “The total number of cases has declined from well over three million in the late 1980s to only 1060 reported in 2011.

The end is in sight. What is remarkable is that this has been done without a drug or a vaccine. Applying basic public health principles health education, case containment, surveillance, water filtration and enhanced access to safe water has been critical.

“Success is in sight but as always, the cost remains as we travel down the final mile and need to identify the last infected villages and isolate final cases.”

The Carter Center has been a particularly strong advocate for action against dracunculiasis over the past 25 years and will play a role along with a number of funders including the UK Department for International Development and the Gates

Foundation in achieving the 2015 eradication target. Another NTD called yaws is set for eradication by 2020 but for the other NTDs, control and national or regional elimination strategies remain crucial.

In the present study an attempt has been made to create a Geographical

Information Base (GIB) for the filariasis disease cases from 1998 – 2008 with the attached data bases. The maps designed for five years clearly indicate the presence of filarial disease and also we can infer that how the awareness among the people of

Kumbakonam has been increased towards the disease by which in a single family more than two cases were identified.

The locational data base can be updated after gathering the relevant other information and with the GIB, Geographical analysis can be performed. The existing pattern of the disease clearly shows that from 1998 to the present the infected cases were surfaced and being treated. According to the health personal, the Government has planned to eradicate the disease before 2020. From the factor analysis for the 32 variables were grouped into five major factors namely: Environmental quality of life,

Perception about the Environment, Stages of Filariasis and Medical Treatment, Health care Towards the Disease, and Psychological Attitudes and Awareness contributed nearly

40 per cent. According to the primary survey analysis, to eliminate the disease the above five areas have to be concentrated spatially.

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FILARIASIS IN KUMBAKONAM: CREATION OF GEOGRAPHICAL INFORMATION BASE (GIB) AND SPATIAL DIMENTIONS

A. personal Details on the Respondent:

1 Name (Optional) 2 Age In years : 3 Sex Male/Female 4 Education In completed years 5 Occupation Agriculture: Weaving : Government Job: Private institution: Public institution: Own businesses: 6 Address Door no: Street name: Place name: 7 Family size Male adults: Female adults: Male children: Female children: 8 Control units Kumbakonam 9 Name of the sub units 10 Name of the night Clinic

B. Details on Epidemiology and Diseases:

11 How long have you been suffering In years: from the disease (Filariasis)? 12 How did you to know about this On his/her own disease 13 Do you known the reason behind the Yes/no disease 14 Do you know that your environment Yes/no is the reason for it? 15 Do you know that it is caused by the Yes/no mosquitoes?

16. Your perceptions about your own environment: a Dirty b Waste water is stagnant c Mosquito menace d Much vegetation/plants e No storm drains/drainage f People defecate/Urinate on road sides

17. Facilities/Amenities at home: a Drainage available b Waste water is stagnant pools c Lavatory d Septic tank e Well f Washing plat form around wall g Separate wash place for clothes and vessels h Big vessels/utensils for storing drinking water 18. There mosquito menace in the night: yes/no

19. The man to prevent mosquito menace at night: a Bed nets b Smoking c Mosquito coils d Odomos e Good night/banish mates 20. Does it affect/has it affected any other of your family members? : Yes/no

C. Control and prevention Filariasis:

21. does the health personal spray anti-mosquito larval sprays around your house: Yes/no

22. What do the health workers do? a Give information about disease b Take blood smears at nights c Distribute tablets regularly d Capture mosquitoes for laboratory analysis e Announce results of laboratory analysis

23. Did you corporate with field workers for collecting blood smears: yes/no

24. Is your disease in early stages? : Yes/no

25. Or is it in later, mature stages? : Yes/no

26. Do you take tablets regularly? : Yes/no

27. If yes, how many tablets? : In numbers

28. If no, give reasons

29. If you have taken tablets, what are the side effects? a Headache b Fever c Nausea d Vomiting

30. Do the side effects affect your daily job routine: yes/no?

31. How many days: in number

32. To prevent disease and avoid side effects of treatment? a Surgical operation b Any other preventive efforts

33. Do you know about the national Filariasis Control Programme (NFCP)? : Yes/no

34. If yes, how did you come to know? a Through public health department b Through advertisement c While census was being taken d While health workers distributing tablets

35. Because you have / are afflicted by disease (answer: compassionately / insultingly or bitterly) a How do your family members treat you? b How do your friends treat you? c How do your neighbors treat you? d How do your relatives treat you? 36. How do you fell about it, psychologically? a Bitter / Hateful b It is fate. c Can be avoided

37. The efforts you take to prevent it from spreading/ infecting others (List one by one)

1. 2. 3. 4.

APPENDIX - II

Spatial Distribution of Filarial Cases: 1998

ID Name Address Sex Age Place of Year Date_ occurrence ** Treat 40 Balamurugan 3x Karuppur road M 40 LL & 15 5/1/1998 S/o Palanivel RL 39 Ramesakumar Karuppur road M 18 RL 4 5/1/1998 S/o Narayanan 50 Vinoth 24, Chennai road M 10 LL 8 5/8/1998 S/o Arokiyaraj 20 Manjula 16-c, Suruttai pattai F 27 RL 7 30/9/1998 W/o Shanmugam Melakottiyur

14 Mariyamal 4-5, Mudukku street F 50 RL & 8 8/6/1998 W/o Chandrakasan LL 13 S. Kannan 10, Krishnan koil M 55 RL 3 8/6/1998 S/o Srinivasan West street. 12 Rajeshknna 4, South street M 18 LL 8 8/6/1998 C/o Rajendran . Melakottiyur 7 Selambarasan 41, Swamimalai M 9 LL 8 18/6/1998 C/oAmbalavanan Main road 8 Swaminathan 13-A, Swamimalai M 65 RL 5 18/6/1998 S/o Rathinam Main road 6 Venkatraman 44, Swaminalai M 20 LL 10 18/6/1998 S/o Lakshmanan Main road 4 Selvam Moopa koil west street M 39 RL 5 11/6/1998 S/o Karumpairam 1 Jagaghalaprathaban 26 Moopakoil west street M 35 RL 4 11/6/1998 96 Balakrishnan 29,A, Sudamani Colony M 22 RL 4 5/10/1998 C/o Srinivasan 88 Malika 22, Pettaiyadavar Street F 23 LL 5 5/7/1998 W/o Durairaj 89 Ganesan 22, Pettai north M 41 RL 7 8/10/1998 S/oVennyappan 107 Jayalaxmi 2, Mukkannar Street F 24 LL 5 29/4/1998 W/o Subramanian 108 Jaybal 99, Mukkannr Street M 35 RL 7 27/10/1998 S/o Saminathan 225 Parvathy Kattunayakkan Street F 30 RL 6 5/10/1998 W/o Raj 260 Umma 19, Mariyaman Koil F 16 LL 8 15/12/1998 W/o Gurusamy Street 261 Mohan 28, Mari Amman koil F 30 RH 6 28/7/1998 S/o Moorthy Street 259 Hayarnesabeevi 13-9, Thaikal Street F 42 RL & 10 21/9/1998 D/oAbdulhamid LL 37 Kamala 1/A, Brameshpuram F 28 LL 4 23/7/1998 W/o Rathinavel Valinadapu 67 Kannan 7, Srinivasa M 23 RL 8 28/1/1998 S/o Kaliyamoorthi Nandavanam 44 Sellammal M.M.R Nagar F 45 RL 5 29/7/1998 W/o Vellayutham Perumandi Main Road 43 Keerteega 16, Perumandi Main F 8 RL 6 28/7/1998 D/o Murugan Road, North Street. 45 Kalyamoorthy 11-F Perumandi Main M 52 LL 8 29/7/1998 S/o Marimuthu Road 42 Balu 1, Perumandi Main M 34 LL 28 28/7/1998 S/o Kumbalingam Road, Sudukkadu Steet. 41 Gopal 12, Perumandi Main M 52 RL 4 28/7/1998 S/o Vaithilingam Road, First Street 155 R. Banchamoorthy WECP Kumbakonam M 35 RH 4 27/10/1998 S/o Raman 153 Alamelu Kamakodinagar Santhu F 35 LL 7 29/7/1998 W/o Subaiyan ** Presence of disease for the period specified Source: Filarial Control Unit, Kumbakonam

Spatial Distribution of Filarial Cases: 1999

ID Name Address Sex Age Place of Year Date occurrence ** _treat 99 Kanimozhi Mallukachetti St F 13 LL 5 6/10/99 D/o V. Perumal 97 Sokkalingam 5. Nellukadai St M 37 RH 7 28/10/99 S/o Sambasivam 109 Kamala W/o 99, Mukkannar St F 33 LL 6 8/10/99 Jayabal ** Presence of disease for the period specified Source: Filarial Control Unit, Kumbakonam

Spatial Distribution of Filarial Cases: 2000

ID Name Address Sex Age Place of Year Date occurrence ** Treat 100 Subramanian 64, Malluka chetti M 38 RH & LL 10 10/2/2000 s/o Ayyadurai street 111 Radhakrishnan 1, chetti new street M 59 RL 15 9/2/2000 112 Gowri 28,Chetti new street F 45 RL 15 9/2/2000 w/o Rengachari 114 Geetha 41, Chetti new street F 45 LL & RL 8 11/2/2000 w/oLakshmanan 115 Giyaudeen A.r.r. road, 130, chetti M 50 LL 15 12/2/2000 new street 113 Rajamannar 39, Chetti new street M 75 LL 10 11/2/2000 s/o Balakrishnan 116 Laxmiammal A.r.r road chetti new F 65 LL 20 15/2/2000 c/o thulasiraman street 118 Annapurani Chetti new street F 56 LL 25 14/2/2000 c/o Loganathan 117 Vasumathi 138, A.r.r road Chetti F 53 RL 5 14/2/2000 w/o Chakrabani new street 125 Baskar 9, Palaniyappa colony M 35 LL 7 20/1/2000 s/o Samy 177 Krishnamurthy 22/23, Thuvarankurichi M 63 RL 12 8/2/2000 s/o Ramasamy new street 175 K. Sethuraman 40, Thuvarang kuruchi M 53 LL 8 8/2/2000 s/o k. Subaiyan street 176 Rukmani 25-f, Thuvarang F 60 RL&LL 25 8/2/2000 kuruchi middle street 174 Krishnamurthy 38, Thuvarang kuruchi M 61 RL&LL 10 27/1/2000 s/o Ramasamy Ayer street 189 Kanagavalli Amman koil street F 43 RL 10 8/3/2000 w/o Paramanantham 197 Amsavalli 2/920, Mullai nagar F 70 LL 10 27/7/2000 w/o Kathiresan 198 Sundarambal 2/998, Mullai nagar F 55 LL 10 27/7/2000 188 Lelismary 17,Singarathoppu F 50 RL 15 6/3/2000 w/o Susai 190 Arokyasamy 41, Sengankanni F 17 RL 5 28/6/2000 d/o Thamburaj 195 Muthukrushnan 171,Vivekananthanagar M 76 LH 6 21/7/2000 193 Samboornam 155, Vivekanantha F 65 L;L 10 21/7/2000 w/o Gobalakrushnan nagar 192 Pangajam 29, Vivekananda nagar F 44 LL 3 19/7/2000 w/o Ramaiyan 194 Kamala 169, Vivekanantha F 40 LL 15 21/7/2000 w/o Paramasivam nagar 179 Rajeswari 636,Ottai south street F 55 RH 6 7/11/2000 180 Poonkothai 614,Ottai south street F 40 RL 8 8/11/2000 w/o Duraisamy 181 Maruthai 614,Ottai south street M 30 RL 10 9/11/2000 182 Panchauarnam 674,Ottai south street F 35 LL 20 20/2/2000 w/o Thangaraj 184 Sakthivel 45,Kothan ottai street M 29 RL 3 2/3/2000 186 Srinivasan 6,Kothan ottai street M 82 LL 5 6/3/2000 187 Jothi 3,Kothan ottai street F 40 RL 8 2/3/2000 w/o Swaminathan 183 Anchamal 2, Kothan ottai street F 51 RL&LL 10 23/2/2000 w/o Ramachandran 199 Sornnamal 52,Thoppu street F 65 RL 15 18/3/2000 w/o Ramamurthy 201 Vasudevan 46, M 50 RL&LL 20 23/3/2000 s/o Palaiya Ramachandrapuram 202 Lakshmanan 46, M 30 LL 20 25/3/2000 s/o Thangamuthu Ramachandrapuram 204 Padma 13, Sowrastra middle F 66 RL&LL 20 10/4/2000 w/o Balakrushnan street 208 S.p. Vijaya 22,Sowrastra middle F 61 RL 5 12/4/2000 street 207 Sonnammal 51, Sowrastra middle F 65 LL 12 12/4/2000 c/o J.R.Venkatraman street 206 Ramamani 13, Sowrastra middle F 58 LL 15 10/4/2000 c/o Sethuraman street 205 Saraswathi 27,Sowrastra F 40 RL&LL 10 30/3/2000 w/o Govindan 222 Jayalaxmi 63/64 Yadhava street F 45 RH 12 6/6/2000 c/o Kamaraj 220 Renuka 20/13 North erthkara F 41 RL 20 12/5/2000 w/o Jothiraman street 223 Vasanthi 58/27 Kumaran street F 40 LL 5 6/6/2000 w/o Kirushnamurthy 221 Pattammal 35/23 Maruthuva street F 60 LL 20 15/5/2000 w/o Palanisamy 219 Govindasamy 19,South Erthukara M 65 LL 3 3/5/2000 s/o Srinivasan street 226 Alamelu ammal 57/23 Kaduvetti street F 70 LL 10 23/5/2000 227 Banumathi 73/14 Indragandi salai F 42 LL 10 5/7/2000 w/o Sathiya 231 Vachala 10, Manai street F 35 LL 7 26/5/2000 c/o Prabu 230 Krishna Ayer 18,14 Manai street M 71 RL&LL 12 24/1/2000 228 Sarangapani 14, Manai street M 65 LL 20 24/1/2000 s/o Kuppusamy 233 Vengatraman 18/38 Manai street M 55 RL 14 11/7/2000 232 Vasantha 22/23 Manai street F 40 RL&LL 5 5/7/2000 264 Amul 36, Arasallar M 70 LL 10 31/8/2000 w/o Santhanam vazhinadappu 263 Laxmi 59, Arasallar F 65 RL 20 29/8/2000 w/o Krishnasami vazhinadappu 266 Amirtham 29g, Mariyamman koil F 50 RL 6 10/5/2000 w/o Sadayappan street 262 Mohan 28, Mariyamman koil F 30 RH 6 28/7/2000 s/o Moorthy street 265 Umahabeba Mariyamman koil M 50 RL&LL 8 4/9/2000 w/o Mohamed street 258 Ganambal 15, South valluvar F 48 RL 15 24/11/2000 w/o Subramaniyan street 267 Dhanalakshmi 33/14b, Veerapandiyan F 40 LL 10 23/9/2000 w/o Palanivel street 271 Saroja 7, Needamangalam F 56 LL 7 18/8/2000 w/o Sowndarajan main road 272 Marimuthu 30, Ambethkar street M 67 LL 20 19/8/2000

270 Segathambal 87, Needamangalam F 44 LL 2 10/8/2000 w/o Thenyappan main road 269 Kamala 33/6-B Karaikal main F 45 LL 3 9/8/2000 w/o Sampantham road 157 Kaliyamoorthy 18/7,Thilakar mela M 61 LL 12 11/2/2000 street 158 Cathedra 16/3, Whitaker mela F 48 LL 5 12/1/2000 street 159 Meenakshiyammal 23-a, Thilakar mela F 60 RL 10 20/1/2000 c/o Susila street 160 G. Chanthira 18/c, Thilakar mela F 48 LL 10 20/1/2000 w/o Krishna moorthy street 156 Kunchupillai 18, Thilakar mela street M 75 LL 22 11/1/2000 256 Yasotha 18/54-A, Kamarajar F 50 LL 25 6/11/2000 salai 257 Swaminathan 196 Prabu cycle M 50 LL 20 24/11/2000 company 255 Sowndaravalli S.b.m.c street F 65 LL 20 8/9/2000 164 Jenifar 16-a, Pathimapuram F 14 RL 6 14/12/2000 new bus stand 165 S. Esthar 7, Pathimapuram new F 50 LL 10 14/12/2000 bus stand 151 Ahamadhunachiya 2-f, Mothilal street F 60 LL 10 24/6/2000 w/o Ebrakin 152 Vangmanirao Krishnappanakan north M 70 LL &RH 10 24/6/2000 s/o Ramaiya rao street 149 Kartik s/o 18-n, Mothi lal street M 17 LL & RL 4 12/6/2000 Kaliyamoorthy 150 Nalini 18-m, Mothilal street F 42 RL & LL 10 12/6/2000 c/o Janakarajan 57 G.D. Shagunthala 79/36, Periyar colony F 44 LL 20 5/1/2000 59 Nallammal 10, Kuyavan street F 70 RL & RH 7 12/9/2000 w/o Arunachalam 60 Subbammal 1-a, Kuyavan street F 60 RL 15 12/9/2000 w/o Sokkaiya 38 Jagaparali kms Nagar M 40 LL 5 9/6/2000 w/o Karimravuthar 17 Sellanal 18, Earakaram Val F 37 LL 37 28/6/2000 w/o Ganesan nadappu 31 Ambiga 40, Asath colony F 50 RL 3 19/3/2000 w/o Krishnamoorthy 32 Rukkumani 45, Puthupettai M 60 LL 20 10/3/2000 d/o Manikkam 26 R. Veeramani Chekkadi st. M 20 LL 41 13/7/2000 s/o Rmachandran Melacaueri 25 Chinnapilai 19/20, Cheakkadi st. F 18 RL & LL 18 12/7/2000 w/o Mottiyapathar Melacauveri 24 Naduncheliyan 61, Kaliyamman koil M 27 LL 27 3/7/2000 s/o Chenniyan st. Melacauveri

23 Saravanan Kelarkudi st. M 30 RL 5 3/7/2000 s/o Thirunawgrasu Melacauvari 22 Devi 19/45, Cheakadi st. F 32 LL 6 3/7/2000 w/o A. Moorthy Melacauvari 27 Murugesan 12-a, Korikkaithotam M 50 LL 9 21/8/2000 s/o Govindan Melacauveri 21 Hajamaydeen 5. Main road muslim st. M 65 RL 2 16/8/2000 s/o Bhair mohamad Melacauvari 28 Narayanaswamy 19-c, Chekkadai st. M 70 RL 10 16/8/2000 s/o Diraiswamy Melacauveri 82 Viswanathan Thirumanjan st. M 60 LL 4 25/4/2000 s/o Rathinam Cauvery badithurai 81 Alamelu 46-b, Kalyanaraman F 55 RL 6 10/5/2000 street 80 Nagarajan 3-e, Kalyanaraman M 60 LL & RL 15 9/5/2000 s/o Subramaniyan street 78 Santhi w/o 15-d, Appukutti lane F 35 LL 8 2/5/2000 Marimuthu 79 Sarasvathi 26, Balacheetti street F 52 LL 30 8/5/2000 w/o Banchanathan 76 Laxmi 14-b, Appukutti lane F 77 LL & RL 10 2/5/2000 w/o Muthiya pillai 77 Ananthi 11, Appukutti lane F 28 LL 3 2/5/2000 w/o Maruthu 69 Ganasen 23, Chakrabani east M 50 LL 2 4/4/2000 street 68 Pangajam 14, Chakrabani east F 28 RL 5 27/2/2000 w/o Krishna street moorthy 74 Singaravel 5, P.S. Shanmugam M 48 LL 3 25/4/2000 s/o street Kunjithapatham 72 Vijayam 20, Chakrabani st. F 55 LL & RL 8 25/4/2000 w/o Veeraragavan south madavilagam 71 Vasantha 9-a, Sakrabani st. south F 48 LL 2 2/11/2000 w/o subramaniyan madavilagam 75 Danam 19, Thiyaki ramasamy F 50 RL 5 25/4/2000 w/o Natrajan street 73 Gokila 6, Keelaiyyan street F 50 RL 3 17/4/2000 w/o Pakkirisamy 70 Balasubramaniyan 5, Chakrabani north M 73 LL 20 7/4/2000 street 65 Hemalatha 80, Kamashi joshiyar F 25 LL 2 27/4/2000 w/o Shankaran street 66 Bhuvaneswari 16, kamakshi joshiyar F 28 RL 5 27/2/2000 street 61 Parani kumar 13, Karunai kollai north M 30 RL 5 26/3/2000 s/o Laksmanan street 63 Aboorvam Karunai kolai north F 80 RL & LL 15 28/3/2000 w/o Muthiya street

64 Shanmugam 47, Karunaikollai west M 76 RL 7 30/3/2000 s/o Pakriswamy street 62 Ramalingam 16, Karunai kollai north M 65 RL 10 27/3/2000 s/o Saravanamuthu street 144 Vijaya Pattusariyar street F 41 RL & LL 10 22/2/2000 142 Subramanian 9, Pattusariyar street M 63 RL 15 21/2/2000 143 R. Rajavelu 17, Pattusariyar street M 39 LL 20 22/2/2000 141 Chinnaponnu 25, Moorthi chetti street F 55 LL 2 4/1/2000 140 Balaraman 28-a, Moorthi chetti M 45 RL 20 4/1/2000 street 132 Durgadevi 1, Kumbeswarar F 13 RL 2 4/1/2000 131 Jayalakshmi 68/27, Kumbeswarar F 35 RL 4 4/1/2000 w/o Ravichandran 136 Sethuraman 6, Kumbeswarar M 62 RL 8 4/1/2000 sanathi 133 Viswanathan 4-a, Thirumajan street. M 55 RL 20 4/1/2000 s/o Rathinam Cauveri badithurai 139 Swaminathan 26-d, Periyakadai M 58 RH 5 4/1/2000 street. Kumbeswara koil 135 Subbaiyan Senbagam lorry M 55 LL 2 4/1/2000 booking 146 Krishnamurthy Kathiravan hard ware, M 42 RL 5 7/3/2000 Dukkambalayam street 147 Daramalingam Fruit vendor tip street M 66 RL 3 8/3/2000 148 Muthammal Arunagiripettai F 63 RL 15 9/3/2000 145 Pechimuthu 27, F.S.R. big street M 60 LL 5 4/1/2000 166 PeriyanayakiS 54, Selva sarangabani F 18 LL 15 7/4/2000 w/o Veeramuthu street 167 Rajalakshmi 64, Selva sarangabani F 45 RL 18 7/4/2000 w/o Soundara rajan street 168 Rasul bevi Selva sarangabani F 28 RH 28 3/8/2000 w/o Dajudeen street 169 Lakshmi 11, Sarangabani street F 55 RL 9 4/1/2000 172 Nachiyappan 18, Kavara street M 55 LL 9 9/3/2000 171 Padmavathi 18-f, Kottan cheeti F 60 RL 15 9/3/2000 c/o Ravi street 212 Logambal 13 B.A road F 85 RL 18 18/4/2000 c/o Neelavathi 217 Gowri 13, Palaniyandavar F 30 RL 15 5/5/2000 w/o Sekar sannathi 214 Jayalaxmi 63/64 Vadhava street F 45 RH 12 15/5/200 c/o Kamaraj 215 Srinivasan 46, Palaniyandavar M 20 LL 10 4/5/2000 s/o Radhakrishnan sannathi street 216 Lakshmi 80, Palaniyandavar F 65 LL 12 13/5/2000 w/o Moorthy sannathi street 218 Renganayaki 22, Machakkara street F 65 RL 10 17/5/2000

235 Lakshmi Gowthameswarar north F 60 RL&LL 20 19/6/2000 c/o Ganasekaran street 238 Ganakam 28/189 Gandhiyadigal F 62 RL 20 1/7/2000 c/o Gurumoorthy salai 234 Saroja 28/38 Manai street F 43 RL 20 5/7/2000 w/o Ranganathan 236 Manimeakalai 61/26 a F 33 RL 10 30/10/2000 w/o Ravichandran Kasiviswanathar north street 244 Ranga 26/3, Bharathiyar street M 40 RL 45 3/1/2000 s/o Selvam 243 Gangaiyammal 11, Bharathiyar street F 82 RL 20 3/1/2000 249 Sagunthala 330, Bharathiyar street F 60 LH 8 3/8/2000 w/o Sundaram 245 Elangovan 11, Bharathiyar street M 30 RL 8 3/1/2000 248 Periyanayagi 4-d, Bharathiyar street F 70 RL 4 6/11/2000 w/o Ravi 250 Sengamalam 326, Bharathiyar street F 65 RL 10 8/8/2000 53 Anthoni mozhi 1061, Autonagar F 45 RL 2 5/6/2000 w/o Anthonidass 56 Nachithramary 1009, Auto nagar F 58 RL 5 6/6/2000 w/o Addikkalam 55 Anthoniyammal 1006, Auto nagar F 52 RL 6 6/6/2000 w/o Adaikalaswamy 54 Rajammal 1055, Auto nagar F 62 LL 2 6/6/2000 w/o Sakthvel 52 Jayalakshmi 21, Sathira F 40 LL 2 26/5/2000 w/o Chinnappillai st.neelathanallur road 51 Unnamalai 136/6, Gandipattai F 60 LL 2 14/3/2000 w/o Raja 49 K. Muthusamy 11 b.c., Perumandi M 52 LL 6 15/5/2000 s/o main road Krishnapadiyachi 48 Ramalingam 8 a Perumandi main M 75 LL 2 15/5/2000 s/o Kannusamy road 196 Mariyammal 2/925, Mullai nagar F 80 RH 10 27/7/2000 w/o Govindan 185 Jebaludeen 1,Kothan ottai street M 60 LL 22 2/3/2000 s/o Abdulrazhq 191 Sundareswari 41,Sengankanni F 47 LL 2 28/6/2000 w/o Thangaperumal ** Presence of disease for the period specified Source: Filarial Control Unit, Kumbakonam

Spatial Distribution of Filarial Cases: 2001

ID Name Address Sex Age Place of Year Date_ occurrence ** Treat 10 Ramasamy 11-a, Swami main road M 86 R.L 28 12/6/01 s/o Venugopal 11 Sivagamiammal 12, Swami main road M 70 R.L 3 12/601 w/o Rathinam 15 Govindaraj 4/5, Melakottiyur south M 59 LL&RL 45 18/6/01 s/o Natesan street 3 Rani 26-f, Moopa koil west F 50 RL & LL 5 21/8/01 w/o Murugesan street. 2 Ananda kumar 26-c, Moopa koil west M 17 LL 7 21/8/01 s/o Veeramuthu street. 5 Alamelu w/o 34/70, Moopa koil west F 70 RH 4 21/8/01 Rajangam street. 9 Pakrisamy 44, Swami main road M 42 LH 4 1/6/01 s/o Kaliyappan 16 Mageswari 14, Melakottiyur south F 39 RL & LL 6 26/6/01 w/o Shankar st. 19 Ramjan 26/35, Vannaiyadi st. F 35 R.L 4 25/801 mela cauvery 18 Rasulpeew 5, Earakaram vazhi F 50 R.L 10 10/7/01 w/o Abdulrahman naddappu 30 Thanalakshmi 40, Puthupettai F 39 RH 4 12/8/01 33 Halinipeevi w/o. North muslim st F 60 R.L 11 25/6/01 Mohamadsalam melacauvey 29 Mohammadibrahim Asath colony M 65 R.L 7 12/7/01 melacauvary 36 Ramesh 15/25, Thattara st M 32 R.L 5 13/8/01 s/o Appumani 34 Makalakshmi 21, Thattara st F 40 R.L 7 10/8/01 d/o Ragavan 35 Soundravalli Thattara st F 45 LL 9 10/8/01 85 Sellamal 113/6, Solaiyappan st F 57 LL 2 2/1/01 w/o Vijaragavan 86 Sarasvathi 104/118, Solayappan st F 57 RL & LL 9 5/1/01 w/o Venkatraman 87 Chandrasekhar 13, Babu reddikulam M 43 R.L 2 5/7/01 s/o Ramasamy 83 Barimalam 2/47, Ellukuttai metu st F 35 R,L 6 29/3/01 w/o Selvaraj 84 Sundaramoorthi 46/4, Viyasar st M 58 R.L 8 9/4/01 c/o Chakkrabani 91 Jegatham 309, Pettai pasikaran F 80 R.L 40 23/1/01 w/o Rethinam santhu 90 Danalakshmi 30/31, Pettai pasikaran F 55 LL 20 23/1/01 w/o Ramakrishnan 95 Danalakshmi 50, Pettai north F 80 R.L 15 9/8/01 w/o Vadivel 94 Vembu 40/7,Pettai north F 28 R.L 3 5/8/01 d/o Ramamurthy 92 Pirema 4, Pettai north F 40 R.L 57 19/3/01 w/o Venkadasan 93 Malika 59, Pettai north F 45 R.L 20 24/11/01 w/o Sokkalingam eastapuram 98 Kalidoss Rathamettal kuttiyan st M 38 R.L 6 13/3/01 s/o Banchanathan 101 Danalakshmi 3/4, Mallukacheeti st F 65 RL & LL 10 12/3/01 w/o Srinivasan 105 Ganam Poiyadhapillaiyar koil F 65 RL & LL 20 8/5/01 w/o Kanakasabai 104 Cadbury 40, Viyabari st F 29 R.L 8 22/1/01 w/o Madhavan 102 Maniyammal 89,Nanayakara st F 42 R.L 3 22/1/01 w/o Murukaiyan 103 Visvalinkam 32,Nanayakara st M 64 RL & LL 25 22/1/01 s/o Ramalingam 106 Meenakhi 25-a,Vinaithedhal st F 59 R.L 10 8/5/01 w/o Raman 129 Jalaxmiw/o Selvam 22, K.V. Melaveethi F 41 LL 8 12/11/01 126 Anjammal 18-c, K.V keelaveethi M 40 R.L 11 4/5/01 w/o Rathakrisnan 127 Rajeswari 5/3, K.V north F 50 LL 5 20/2/01 w/o Chinnappa 128 Karthikkannan K.V north M 57 R.L 3 21/2/01 s/o Magalingam 173 Vinayakamoorthi 6-c, Old place F 32 RH 7 21/6/01 s/o Thangavel 130 Booma w/o 76/41, Singara chetti st F 50 RL & LL 3 22/3/01 Panneerselvam 138 Ranjutham 29, Thanjai main road F 45 R.L 10 24/4/01 Kubaswaran koil 137 Jalaxmi 11,Kumbeswaran koil F 51 R.L 7 16/4/01 w/o Krishnan st 46 Manimaran Perumandi st M 35 RH 8 26/4/01 w/o Theyakarajan 47 Murugadass Perumandi st M 22 LL 7 26/4/01 s/o Kaliyamoorthi 200 Nithiya Linekarai thoppu st M 52 LL 20 17/3/01 w/oRajaraman 203 Surya 13/8, F 45 R.L 25 4/5/01 w/o Janakiraman Ramachandirapuram 224 Deenashkumar 27/13, River bank st M 22 LL 5 23/1/01 s/o Kaliyamoorthi 240 Suriya 4/40, J.P west st M 50 LL 20 24/5/01 w/o R.K.Kannan 241 Lakhmi w/o 102, J.P east st F 50 R.L 5 3/9/01 Krishnamurthy 253 Hemavathi 25/10, Eallaieechetti st F 3 R.L 2 11/10/01 s/o Ashogan 254 Rajamani 46,Visvanathan colony F 51 LL 6 13/2/01 w/o Balakrishnan 239 Kaliani 188/3, Ganthiyadikal F 65 RL & LL 2 22/6/01 c/o Somu salai 237 M.Lakshmi w/o 50/6, Mahamagakula m F 50 R.L&LH 10 3/7/01 Krishnamurthy 154 Muthulakshmi 1401, Kamakodinagar F 68 LL 16 6/2/01 w/o Natarajan south 110 Vijalakshmi 25, Mukkannar st F 68 R.L 20 30/1/01 w/o Thandabani 213 Pusba w/o 18/13, Natanagobal st F 52 LL 5 17/4/01 Krishnamoorthy ** Presence of disease for the period specified Source: Filarial Control Unit, Kumbakonam

Spatial Distribution of Filarial Cases: 2008

ID Name Address Sex Age Place of Year Date_ occurrence ** Treat 123 Laxmiammal 163, Chetti new street F 68 RL 10 20/2/2008 w/o Dulasiraman 121 Rajamannar 73/39, Chetti new street M 75 LL 7 14/2/2008 w/o Santha 122 Indrani w/o Mani 91/48, Chetti new street F 39 LL 5 15/2/2008 120 Gowri w/o 47/28, Chetti new street F 52 RH 20 14/2/2008 Rengasamy 124 Annaborani 32/188, Chetti new st F 60 LL 17 21/2/2008 c/o Loganathan 119 R.Rathakrishnan 1, Chetti new street M 62 R,L 25 13/2/2008 178 Saraswathi 22, Kothan new street F 57 LL& RL 15 19/2/2008 211 Sethuraman 13/18, Sourastra middle M 62 LL 8 22/4/2008 street 210 Sornammal 51, Sourastra middle st F 73 RL 5 23/4/2008 242 Suria 4/9, J.P. west street F 45 LL 15 16/5/2008 251 Gangaiyammal Bharathiyar nagar F 52 RL 20 5/1/2008 w/o Mathavan 252 Periyanayagi 11-c,Bharathiyar nagar F 45 LH 9 6/2/2008 268 Rani w/o Ratha 28/24,Veera pandiya st. F 44 RL 6 30/1/2008 161 Meenakshiammal 23-a, Thilakar mela st. F 62 LL 7 22/1/2008 163 Ganthimathi 18/17, Thilakar mela M 63 LL 12 23/1/2008 w/o Kaliyamoorthi street 162 Kunchupillai 18-c, Thilakar mela M 77 LL&lh 20 23/2/2008 c/o Thangamani street 58 D.Shagunthala 36, Periyar colani F 49 R,L 7 2/4/2008 170 Periyanayaki 38/54, Sarangabani st F 77 RL&LL 20 27/2/2008 ** Presence of disease for the period specified Source: Filarial Control Unit, Kumbakonam CORRELATION MATRIX

V.No Code X1 X2 X17 X18 X20 X21 X22 X23 X1 AOR -.248* -.203* X2 LOE -.294** .227* X3 PFD -.248* -.294** .337** X4 EID -.203* .337** X5 PAD .227* X6 PWS X7 PMM X8 PVC X9 PAD -.227* X10 ADF .287** X11 ASP X12 ALF .261** .318** X13 AST .206* .270** X14 UMC -.271** .215* X15 UON .233* X16 UGB X17 HPA .276** X18 CBS X19 CFW X20 SOD -.301** X21 COT X22 NDT X23 SHE X24 SEJ X25 PEC .289** X26 PDP X27 PSD X28 TFM X29 TYN X30 TYR -.200* X31 PAB .222* .239* X32 PAF .290**

V.No Code X24 X26 X27 X28 X29 X37 X38 X39G X1 AOR X2 LOE X3 PFD .261** .206* -.271** X4 EID .318** .270** .233* X5 PAD X6 PWS .287** X7 PMM .215* X8 PVC -.227* X9 PAD X10 ADF X11 ASP -.247* -.296** X12 ALF .247* .944** X13 AST -.296** .944** X14 UMC -.237* X15 UON -.237* X16 UGB X17 HPA X18 CBS X19 CFW X20 SOD -.244* X21 COT X22 NDT X23 SHE X24 SEJ X25 PEC X26 PDP X27 PSD X28 TFM -.208* X29 TYN X30 TYR -.206* X31 PAB X32 PAF

V.No Code X41 X43 X46 X47 X49 X50 X51 X56 X1 AOR -.301** X2 LOE X3 PFD .276** X4 EID X5 PAD X6 PWS X7 PMM X8 PVC X9 PAD X10 ADF X11 ASP X12 ALF X13 AST X14 UMC X15 UON X16 UGB -.244* X17 HPA X18 CBS .263** X19 CFW X20 SOD -.283** -.233* -.291** X21 COT .484** .327** X22 NDT -.283** .484** X23 SHE .263** -.233** .257** X24 SEJ -.291** -327** .257** X25 PEC -.253* X26 PDP X27 PSD X28 TFM .268** -.237* X29 TYN .327** -.227* X30 TYR .298** -.240* X31 PAB X32 PAF

V.No Code X58 X60 X62 X63 X65 X66 X67 X68 X1 AOR -.200* X2 LOE X3 PFD .289** X4 EID .222* X5 PAD .290** X6 PWS .239* X7 PMM X8 PVC X9 PAD X10 ADF -.208* -.206* X11 ASP X12 ALF X13 AST X14 UMC X15 UON X16 UGB X17 HPA X18 CBS -.253* X19 CFW X20 SOD .268** .327** .298** X21 COT X22 NDT X23 SHE -.237* -.227** -.240* X24 SEJ X25 PEC X26 PDP .740** .200** X27 PSD .740** .2000** X28 TFM .920** .286** -.219* X29 TYN .200* .200** .920** -.963** -.285* X30 TYR .286** .963** -.273** X31 PAB -.384** X32 PAF -.219* -.255* -.273** -.384** Source: Results of the SPSS package jkpH;ehL - Fk;gnfhzk; ahidf;fhy; neha; jLg;g[ ikaj;jpd; ,lg;ghpkhd';fs;: xU g[tpj; jfty; bjhFg;gikg;gpd; mQFKiw

rp. tonty;/ cjtpg;nghuhrphpah; kw;Wk; gFjpneu Ma;thsh;/ g[tpapay; Jiw/ murpdh; fiyf; fy;Y]hp (jd;dhl;rp)/ Fk;gnfhzk; - 612 001.

Fk;gnfhzk; gFjpapy; ahidf;fhy; nehapd; tuyhw;iw Muha[k; nghJ ,e;neha; kpf mjpfkhd kf;fis ghjpj;jpUf;fpwJ. ,jw;F kpfKf;fpa fhuzkhf ,g;gFjpapy; epytp tUk; nkhrkhd Rw;Wr;NHy; kw;Wk; ,ij njhw;Wtpf;f fhuzkhf ,Uf;Fk; “ahidf;fhy; Ez;fpUkpfs;” ,t;tpahjpia njhw;Wtpf;f xU J]z;Lnfhyhf mike;jpUf;fpd;wd. ePz;l fhykhfnt ,g;gFjpapy; cs;s tPLfspypUe;J Kiwg;go btspnaw;wf;Toa fHpt[ePh; epyj;jo tofhy; mikg;g[ mikf;fg;glknyna ,Ue;jpUf;fpwJ. ,jd; fhuzkhf bfhRf;fs; mjpfk; cw;gj;jpahfp mitfs; tay; gFjpfSf;Fr; brd;W jd; ,dj;jpid bgUf;fpf;bfhz;L mjd;_ykhf ahidf;fhy; Ez;fpUkpifis ,t;tplj;jpy; thH;e;J tUk; kf;fsplk; gug;gpf;bfhz;L ,Uf;fpd;wd. ,g;gFjpapy; ,e;j nehahdJ rw;nw Fiwe;J ,Ue;jhYk; mit KGikahf ,g;gFjpapypUe;J tpLtpf;fg;gltpy;iy. ,jid ikakhf bfhz;L ,lk; rhh;e;j kw;Wk; ,t;tplj;jpy; thGk; kf;fspd; kdepiy rhh;e;j xU Ma;tpid g[tpapay; hPjpahft[k;/ g[tpj;jfty; bjhFg;gikg;gpd; _ykhft[k; ,e;nehia v';'dk; fl;Lg;ghl;oy; bfhz;L tUtJ vd ,t;tha;twpf;ifapd; Kot[fs; bjhptpf;fpd;wd.

,t;tha;tpw;fhf Fk;gnfhzk; ahidf;fhy; jLg;g[ ikaj;jpy; ,Ue;J bgwg;gl;l g[s;sptptu';fisf; bfhz;L Fk;gnfhzk; efuj;ijr; rhh;e;j Rw;Wg;g[wr;NHy;/ kf;fspd; eilKiw thH;f;if/ mjdhy; mth;fs; njhw;Wtpj;j fHpt[ePh; njf;f';fs; kw;Wk; mjid gad;gLj;jp ahidf;fhy; Ez;fpUkpfs; tsUtjw;F VJthf cs;s NHiy gw;wpa[k;/ mjdhy; ghjpf;fg;gl;l nehahspfis gw;wp 1998 Kjy; 2008 tiu xU rpy fhyfl;l';fspy; g[s;sptptu';fis nrfhpj;J mitfisf; bfhz;L g[tpj;jfty; bjhFg;gikg;g[ cUthf;fg;gl;Ls;sJ. ghjpf;fg;gl;l ,e;nehahspfsplk; bkhj;jkhf 272 egh;fsplk; ,e;neha; bjhlh;ghd gy nfs;tpfSf;F gjpy;fis bgw;W mtw;iw bfhz;L ,e;neha;f;F fhuzkhf tps';Fk; kpf Kf;fpa fhuzpfis g[s;spapay; _yk; gFg;gha;t[ bra;J/ Ie;J kpfKf;fpakhd fhuzpfisa[k;/ mitfs; xt;bthd;Wf;Fk; mtw;wpy; cs;sl';fpapUf;Fk; khwpfSld; tptuzk; bra;ag;gl;Ls;sJ.

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