spatial dimensions of filariasis in kumbakonam control unit

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SPATIAL DIMENSIONS OF FILARIASIS IN KUMBAKONAM CONTROL UNIT, TAMIL NADU, INDIA: 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

Transcript of spatial dimensions of filariasis in kumbakonam control unit

SPATIAL DIMENSIONS OF FILARIASIS IN KUMBAKONAM CONTROL UNIT, TAMIL NADU, INDIA: 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

Structure

87

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, Thiruvarur,

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. `Mahamaham’ 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 Thanjavur 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 Kumbakonam Taluk of Thanjavur District. The

town is bounded by two rivers, the Kaveri 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 Tiruchirappalli, 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 Mettur Dam 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 Nagapattinam 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 Darasuram 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. Brahmins 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 Central Tamil dialect. 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 Mayiladuthurai 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 Chidambaram 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

Area in Sq Km

Percentage to 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 vegetation cover

X8 0.886 0.883

Dimension II: Perception about the Environment Environmental perception about the disease

X4 0.963 0.885

Perception about mosquito menace

X7 0.837 0.801

Perception about open drainage pits

X9 0.625 0.704

Usage of mosquito bite protection methods

X16 0.581 0.701

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 number of days

X23 0.634 0.606

Satisfaction about the treatment by MO’s.

X24 0.619 0.618

Dimension IV: Health care Towards the Disease Towards anti-mosquito spray regularly

X17 0.518 0.728

Collection of blood smears regularly

X18 -0.452 0.599

Provision of Tablets regularly X21 0.692 0.566 Co-operation with the field worker

X19 0.425 0.529

Dimension V: Psychological Attitudes and Awareness Treatment by family members X28 0.745 0.567 Treatment by neighbors and relatives

X29 0.763 0.486

Personal Psychology X31 0.565 0.458 Preventive efforts to curtail the disease

X25 0.431 0.456

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 variance

11.601 19.830 27.083 33.829 39.826 40.000

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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APPENDIX - I

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

from the disease (Filariasis)? In years:

12 How did you to know about this disease

On his/her own

13 Do you known the reason behind the disease

Yes/no

14 Do you know that your environment is the reason for it?

Yes/no

15 Do you know that it is caused by the mosquitoes?

Yes/no

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 occurrence

Year **

Date_ Treat

40 Balamurugan S/o Palanivel

3x Karuppur road M 40 LL & RL

15 5/1/1998

39 Ramesakumar S/o Narayanan

Karuppur road M 18 RL 4 5/1/1998

50 Vinoth S/o Arokiyaraj

24, Chennai road M 10 LL 8 5/8/1998

20

Manjula W/o Shanmugam

16-c, Suruttai pattai Melakottiyur

F

27 RL 7 30/9/1998

14 Mariyamal W/o Chandrakasan

4-5, Mudukku street F 50 RL & LL

8 8/6/1998

13 S. Kannan S/o Srinivasan

10, Krishnan koil West street.

M 55 RL 3 8/6/1998

12 Rajeshknna C/o Rajendran

4, South street . Melakottiyur

M 18 LL 8 8/6/1998

7 Selambarasan C/oAmbalavanan

41, Swamimalai Main road

M 9 LL 8 18/6/1998

8 Swaminathan S/o Rathinam

13-A, Swamimalai Main road

M 65 RL 5 18/6/1998

6 Venkatraman S/o Lakshmanan

44, Swaminalai Main road

M 20 LL 10 18/6/1998

4 Selvam S/o Karumpairam

Moopa koil west street M 39 RL 5 11/6/1998

1 Jagaghalaprathaban 26 Moopakoil west street M 35 RL 4 11/6/1998 96 Balakrishnan

C/o Srinivasan 29,A, Sudamani Colony M 22 RL 4 5/10/1998

88 Malika W/o Durairaj

22, Pettaiyadavar Street F 23 LL 5 5/7/1998

89 Ganesan S/oVennyappan

22, Pettai north M 41 RL 7 8/10/1998

107 Jayalaxmi W/o Subramanian

2, Mukkannar Street F 24 LL 5 29/4/1998

108 Jaybal S/o Saminathan

99, Mukkannr Street M 35 RL 7 27/10/1998

225 Parvathy W/o Raj

Kattunayakkan Street F 30 RL 6 5/10/1998

260 Umma W/o Gurusamy

19, Mariyaman Koil Street

F 16 LL 8 15/12/1998

261 Mohan S/o Moorthy

28, Mari Amman koil Street

F 30 RH 6 28/7/1998

259 Hayarnesabeevi D/oAbdulhamid

13-9, Thaikal Street F 42 RL & LL

10 21/9/1998

37 Kamala W/o Rathinavel

1/A, Brameshpuram Valinadapu

F 28 LL 4 23/7/1998

67 Kannan S/o Kaliyamoorthi

7, Srinivasa Nandavanam

M 23 RL 8 28/1/1998

44 Sellammal W/o Vellayutham

M.M.R Nagar Perumandi Main Road

F 45 RL 5 29/7/1998

43 Keerteega D/o Murugan

16, Perumandi Main Road, North Street.

F 8 RL 6 28/7/1998

45 Kalyamoorthy S/o Marimuthu

11-F Perumandi Main Road

M 52 LL 8 29/7/1998

42 Balu S/o Kumbalingam

1, Perumandi Main Road, Sudukkadu Steet.

M 34 LL 28 28/7/1998

41 Gopal S/o Vaithilingam

12, Perumandi Main Road, First Street

M 52 RL 4 28/7/1998

155 R. Banchamoorthy S/o Raman

WECP Kumbakonam M 35 RH 4 27/10/1998

153 Alamelu W/o Subaiyan

Kamakodinagar Santhu F 35 LL 7 29/7/1998

** 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

occurrence Year **

Date _treat

99 Kanimozhi D/o V. Perumal

Mallukachetti St F 13 LL 5 6/10/99

97 Sokkalingam S/o Sambasivam

5. Nellukadai St M 37 RH 7 28/10/99

109 Kamala W/o Jayabal

99, Mukkannar St F 33 LL 6 8/10/99

** 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

occurrence Year **

Date 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

w/o Rengachari 28,Chetti new street F 45 RL 15 9/2/2000

114 Geetha w/oLakshmanan

41, Chetti new street F 45 LL & RL 8 11/2/2000

115 Giyaudeen A.r.r. road, 130, chetti new street

M 50 LL 15 12/2/2000

113 Rajamannar s/o Balakrishnan

39, Chetti new street M 75 LL 10 11/2/2000

116 Laxmiammal c/o thulasiraman

A.r.r road chetti new street

F 65 LL 20 15/2/2000

118 Annapurani c/o Loganathan

Chetti new street F 56 LL 25 14/2/2000

117 Vasumathi w/o Chakrabani

138, A.r.r road Chetti new street

F 53 RL 5 14/2/2000

125 Baskar s/o Samy

9, Palaniyappa colony M 35 LL 7 20/1/2000

177 Krishnamurthy s/o Ramasamy

22/23, Thuvarankurichi new street

M 63 RL 12 8/2/2000

175 K. Sethuraman s/o k. Subaiyan

40, Thuvarang kuruchi street

M 53 LL 8 8/2/2000

176 Rukmani 25-f, Thuvarang kuruchi middle street

F 60 RL&LL 25 8/2/2000

174 Krishnamurthy s/o Ramasamy Ayer

38, Thuvarang kuruchi street

M 61 RL&LL 10 27/1/2000

189 Kanagavalli w/o Paramanantham

Amman koil street F 43 RL 10 8/3/2000

197 Amsavalli w/o Kathiresan

2/920, Mullai nagar F 70 LL 10 27/7/2000

198 Sundarambal 2/998, Mullai nagar F 55 LL 10 27/7/2000 188 Lelismary

w/o Susai 17,Singarathoppu F 50 RL 15 6/3/2000

190 Arokyasamy d/o Thamburaj

41, Sengankanni F 17 RL 5 28/6/2000

195 Muthukrushnan 171,Vivekananthanagar M 76 LH 6 21/7/2000 193 Samboornam

w/o Gobalakrushnan 155, Vivekanantha nagar

F 65 L;L 10 21/7/2000

192 Pangajam w/o Ramaiyan

29, Vivekananda nagar F 44 LL 3 19/7/2000

194 Kamala w/o Paramasivam

169, Vivekanantha nagar

F 40 LL 15 21/7/2000

179 Rajeswari 636,Ottai south street F 55 RH 6 7/11/2000 180 Poonkothai

w/o Duraisamy 614,Ottai south street F 40 RL 8 8/11/2000

181 Maruthai 614,Ottai south street M 30 RL 10 9/11/2000 182 Panchauarnam

w/o Thangaraj 674,Ottai south street F 35 LL 20 20/2/2000

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

w/o Swaminathan 3,Kothan ottai street F 40 RL 8 2/3/2000

183 Anchamal w/o Ramachandran

2, Kothan ottai street F 51 RL&LL 10 23/2/2000

199 Sornnamal w/o Ramamurthy

52,Thoppu street F 65 RL 15 18/3/2000

201 Vasudevan s/o Palaiya

46, Ramachandrapuram

M 50 RL&LL 20 23/3/2000

202 Lakshmanan s/o Thangamuthu

46, Ramachandrapuram

M 30 LL 20 25/3/2000

204 Padma w/o Balakrushnan

13, Sowrastra middle street

F 66 RL&LL 20 10/4/2000

208 S.p. Vijaya 22,Sowrastra middle street

F 61 RL 5 12/4/2000

207 Sonnammal c/o J.R.Venkatraman

51, Sowrastra middle street

F 65 LL 12 12/4/2000

206 Ramamani c/o Sethuraman

13, Sowrastra middle street

F 58 LL 15 10/4/2000

205 Saraswathi w/o Govindan

27,Sowrastra F 40 RL&LL 10 30/3/2000

222 Jayalaxmi c/o Kamaraj

63/64 Yadhava street F 45 RH 12 6/6/2000

220 Renuka w/o Jothiraman

20/13 North erthkara street

F 41 RL 20 12/5/2000

223 Vasanthi w/o Kirushnamurthy

58/27 Kumaran street F 40 LL 5 6/6/2000

221 Pattammal w/o Palanisamy

35/23 Maruthuva street F 60 LL 20 15/5/2000

219 Govindasamy s/o Srinivasan

19,South Erthukara street

M 65 LL 3 3/5/2000

226 Alamelu ammal 57/23 Kaduvetti street F 70 LL 10 23/5/2000 227 Banumathi

w/o Sathiya 73/14 Indragandi salai F 42 LL 10 5/7/2000

231 Vachala c/o Prabu

10, Manai street F 35 LL 7 26/5/2000

230 Krishna Ayer 18,14 Manai street M 71 RL&LL 12 24/1/2000 228 Sarangapani

s/o Kuppusamy 14, Manai street M 65 LL 20 24/1/2000

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

w/o Santhanam 36, Arasallar vazhinadappu

M 70 LL 10 31/8/2000

263 Laxmi w/o Krishnasami

59, Arasallar vazhinadappu

F 65 RL 20 29/8/2000

266 Amirtham w/o Sadayappan

29g, Mariyamman koil street

F 50 RL 6 10/5/2000

262 Mohan s/o Moorthy

28, Mariyamman koil street

F 30 RH 6 28/7/2000

265 Umahabeba Mariyamman koil M 50 RL&LL 8 4/9/2000

w/o Mohamed street 258 Ganambal

w/o Subramaniyan 15, South valluvar street

F 48 RL 15 24/11/2000

267 Dhanalakshmi w/o Palanivel

33/14b, Veerapandiyan street

F 40 LL 10 23/9/2000

271 Saroja w/o Sowndarajan

7, Needamangalam main road

F 56 LL 7 18/8/2000

272 Marimuthu

30, Ambethkar street M 67 LL 20 19/8/2000

270 Segathambal w/o Thenyappan

87, Needamangalam main road

F 44 LL 2 10/8/2000

269 Kamala w/o Sampantham

33/6-B Karaikal main road

F 45 LL 3 9/8/2000

157 Kaliyamoorthy 18/7,Thilakar mela street

M 61 LL 12 11/2/2000

158 Cathedra 16/3, Whitaker mela street

F 48 LL 5 12/1/2000

159 Meenakshiyammal c/o Susila

23-a, Thilakar mela street

F 60 RL 10 20/1/2000

160 G. Chanthira w/o Krishna moorthy

18/c, Thilakar mela street

F 48 LL 10 20/1/2000

156 Kunchupillai 18, Thilakar mela street M 75 LL 22 11/1/2000 256 Yasotha 18/54-A, Kamarajar

salai F 50 LL 25 6/11/2000

257 Swaminathan 196 Prabu cycle company

M 50 LL 20 24/11/2000

255 Sowndaravalli S.b.m.c street F 65 LL 20 8/9/2000 164 Jenifar 16-a, Pathimapuram

new bus stand F 14 RL 6 14/12/2000

165 S. Esthar 7, Pathimapuram new bus stand

F 50 LL 10 14/12/2000

151 Ahamadhunachiya w/o Ebrakin

2-f, Mothilal street F 60 LL 10 24/6/2000

152 Vangmanirao s/o Ramaiya rao

Krishnappanakan north street

M 70 LL &RH 10 24/6/2000

149 Kartik s/o Kaliyamoorthy

18-n, Mothi lal street M 17 LL & RL 4 12/6/2000

150 Nalini c/o Janakarajan

18-m, Mothilal street F 42 RL & LL 10 12/6/2000

57 G.D. Shagunthala 79/36, Periyar colony F 44 LL 20 5/1/2000 59 Nallammal

w/o Arunachalam 10, Kuyavan street F 70 RL & RH 7 12/9/2000

60 Subbammal w/o Sokkaiya

1-a, Kuyavan street F 60 RL 15 12/9/2000

38 Jagaparali w/o Karimravuthar

kms Nagar M 40 LL 5 9/6/2000

17 Sellanal w/o Ganesan

18, Earakaram Val nadappu

F 37 LL 37 28/6/2000

31 Ambiga 40, Asath colony F 50 RL 3 19/3/2000

w/o Krishnamoorthy 32 Rukkumani

d/o Manikkam 45, Puthupettai M 60 LL 20 10/3/2000

26 R. Veeramani s/o Rmachandran

Chekkadi st. Melacaueri

M 20 LL 41 13/7/2000

25 Chinnapilai w/o Mottiyapathar

19/20, Cheakkadi st. Melacauveri

F 18 RL & LL 18 12/7/2000

24 Naduncheliyan s/o Chenniyan

61, Kaliyamman koil st. Melacauveri

M 27 LL 27 3/7/2000

23 Saravanan

s/o Thirunawgrasu Kelarkudi st. Melacauvari

M 30 RL 5 3/7/2000

22 Devi w/o A. Moorthy

19/45, Cheakadi st. Melacauvari

F 32 LL 6 3/7/2000

27 Murugesan s/o Govindan

12-a, Korikkaithotam Melacauveri

M 50 LL 9 21/8/2000

21 Hajamaydeen s/o Bhair mohamad

5. Main road muslim st. Melacauvari

M 65 RL 2 16/8/2000

28 Narayanaswamy s/o Diraiswamy

19-c, Chekkadai st. Melacauveri

M 70 RL 10 16/8/2000

82 Viswanathan s/o Rathinam

Thirumanjan st. Cauvery badithurai

M 60 LL 4 25/4/2000

81 Alamelu 46-b, Kalyanaraman street

F 55 RL 6 10/5/2000

80 Nagarajan s/o Subramaniyan

3-e, Kalyanaraman street

M 60 LL & RL 15 9/5/2000

78 Santhi w/o Marimuthu

15-d, Appukutti lane F 35 LL 8 2/5/2000

79 Sarasvathi w/o Banchanathan

26, Balacheetti street F 52 LL 30 8/5/2000

76 Laxmi w/o Muthiya pillai

14-b, Appukutti lane F 77 LL & RL 10 2/5/2000

77 Ananthi w/o Maruthu

11, Appukutti lane F 28 LL 3 2/5/2000

69 Ganasen 23, Chakrabani east street

M 50 LL 2 4/4/2000

68 Pangajam w/o Krishna moorthy

14, Chakrabani east street

F 28 RL 5 27/2/2000

74 Singaravel s/o Kunjithapatham

5, P.S. Shanmugam street

M 48 LL 3 25/4/2000

72 Vijayam w/o Veeraragavan

20, Chakrabani st. south madavilagam

F 55 LL & RL 8 25/4/2000

71 Vasantha w/o subramaniyan

9-a, Sakrabani st. south madavilagam

F 48 LL 2 2/11/2000

75 Danam w/o Natrajan

19, Thiyaki ramasamy street

F 50 RL 5 25/4/2000

73 Gokila w/o Pakkirisamy

6, Keelaiyyan street F 50 RL 3 17/4/2000

70 Balasubramaniyan 5, Chakrabani north street

M 73 LL 20 7/4/2000

65 Hemalatha w/o Shankaran

80, Kamashi joshiyar street

F 25 LL 2 27/4/2000

66 Bhuvaneswari 16, kamakshi joshiyar street

F 28 RL 5 27/2/2000

61 Parani kumar s/o Laksmanan

13, Karunai kollai north street

M 30 RL 5 26/3/2000

63 Aboorvam w/o Muthiya

Karunai kolai north street

F 80 RL & LL 15 28/3/2000

64 Shanmugam s/o Pakriswamy

47, Karunaikollai west street

M 76 RL 7 30/3/2000

62 Ramalingam s/o Saravanamuthu

16, Karunai kollai north street

M 65 RL 10 27/3/2000

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

street M 45 RL 20 4/1/2000

132 Durgadevi 1, Kumbeswarar F 13 RL 2 4/1/2000 131 Jayalakshmi

w/o Ravichandran 68/27, Kumbeswarar F 35 RL 4 4/1/2000

136 Sethuraman 6, Kumbeswarar sanathi

M 62 RL 8 4/1/2000

133 Viswanathan s/o Rathinam

4-a, Thirumajan street. Cauveri badithurai

M 55 RL 20 4/1/2000

139 Swaminathan 26-d, Periyakadai street. Kumbeswara koil

M 58 RH 5 4/1/2000

135 Subbaiyan Senbagam lorry booking

M 55 LL 2 4/1/2000

146 Krishnamurthy Kathiravan hard ware, Dukkambalayam street

M 42 RL 5 7/3/2000

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

w/o Veeramuthu 54, Selva sarangabani street

F 18 LL 15 7/4/2000

167 Rajalakshmi w/o Soundara rajan

64, Selva sarangabani street

F 45 RL 18 7/4/2000

168 Rasul bevi w/o Dajudeen

Selva sarangabani street

F 28 RH 28 3/8/2000

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

c/o Ravi 18-f, Kottan cheeti street

F 60 RL 15 9/3/2000

212 Logambal c/o Neelavathi

13 B.A road F 85 RL 18 18/4/2000

217 Gowri w/o Sekar

13, Palaniyandavar sannathi

F 30 RL 15 5/5/2000

214 Jayalaxmi c/o Kamaraj

63/64 Vadhava street F 45 RH 12 15/5/200

215 Srinivasan s/o Radhakrishnan

46, Palaniyandavar sannathi street

M 20 LL 10 4/5/2000

216 Lakshmi w/o Moorthy

80, Palaniyandavar sannathi street

F 65 LL 12 13/5/2000

218 Renganayaki

22, Machakkara street F 65 RL 10 17/5/2000

235 Lakshmi c/o Ganasekaran

Gowthameswarar north street

F 60 RL&LL 20 19/6/2000

238 Ganakam c/o Gurumoorthy

28/189 Gandhiyadigal salai

F 62 RL 20 1/7/2000

234 Saroja w/o Ranganathan

28/38 Manai street F 43 RL 20 5/7/2000

236 Manimeakalai w/o Ravichandran

61/26 a Kasiviswanathar north street

F 33 RL 10 30/10/2000

244 Ranga s/o Selvam

26/3, Bharathiyar street M 40 RL 45 3/1/2000

243 Gangaiyammal 11, Bharathiyar street F 82 RL 20 3/1/2000 249 Sagunthala

w/o Sundaram 330, Bharathiyar street F 60 LH 8 3/8/2000

245 Elangovan 11, Bharathiyar street M 30 RL 8 3/1/2000 248 Periyanayagi

w/o Ravi 4-d, Bharathiyar street F 70 RL 4 6/11/2000

250 Sengamalam 326, Bharathiyar street F 65 RL 10 8/8/2000 53 Anthoni mozhi

w/o Anthonidass 1061, Autonagar F 45 RL 2 5/6/2000

56 Nachithramary w/o Addikkalam

1009, Auto nagar F 58 RL 5 6/6/2000

55 Anthoniyammal w/o Adaikalaswamy

1006, Auto nagar F 52 RL 6 6/6/2000

54 Rajammal w/o Sakthvel

1055, Auto nagar F 62 LL 2 6/6/2000

52 Jayalakshmi w/o Chinnappillai

21, Sathira st.neelathanallur road

F 40 LL 2 26/5/2000

51 Unnamalai w/o Raja

136/6, Gandipattai F 60 LL 2 14/3/2000

49 K. Muthusamy s/o Krishnapadiyachi

11 b.c., Perumandi main road

M 52 LL 6 15/5/2000

48 Ramalingam s/o Kannusamy

8 a Perumandi main road

M 75 LL 2 15/5/2000

196 Mariyammal w/o Govindan

2/925, Mullai nagar F 80 RH 10 27/7/2000

185 Jebaludeen s/o Abdulrazhq

1,Kothan ottai street M 60 LL 22 2/3/2000

191 Sundareswari w/o

41,Sengankanni F 47 LL 2 28/6/2000

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 occurrence

Year **

Date_ Treat

10 Ramasamy s/o Venugopal

11-a, Swami main road M 86 R.L 28 12/6/01

11 Sivagamiammal w/o Rathinam

12, Swami main road M 70 R.L 3 12/601

15 Govindaraj s/o Natesan

4/5, Melakottiyur south street

M 59 LL&RL 45 18/6/01

3 Rani w/o Murugesan

26-f, Moopa koil west street.

F 50 RL & LL 5 21/8/01

2 Ananda kumar s/o Veeramuthu

26-c, Moopa koil west street.

M 17 LL 7 21/8/01

5 Alamelu w/o Rajangam

34/70, Moopa koil west street.

F 70 RH 4 21/8/01

9 Pakrisamy s/o Kaliyappan

44, Swami main road M 42 LH 4 1/6/01

16 Mageswari w/o Shankar

14, Melakottiyur south st.

F 39 RL & LL 6 26/6/01

19 Ramjan 26/35, Vannaiyadi st. mela cauvery

F 35 R.L 4 25/801

18 Rasulpeew w/o Abdulrahman

5, Earakaram vazhi naddappu

F 50 R.L 10 10/7/01

30 Thanalakshmi 40, Puthupettai F 39 RH 4 12/8/01 33 Halinipeevi w/o.

Mohamadsalam North muslim st melacauvey

F 60 R.L 11 25/6/01

29 Mohammadibrahim Asath colony melacauvary

M 65 R.L 7 12/7/01

36 Ramesh s/o Appumani

15/25, Thattara st M 32 R.L 5 13/8/01

34 Makalakshmi d/o Ragavan

21, Thattara st F 40 R.L 7 10/8/01

35 Soundravalli Thattara st F 45 LL 9 10/8/01 85 Sellamal

w/o Vijaragavan 113/6, Solaiyappan st F 57 LL 2 2/1/01

86 Sarasvathi w/o Venkatraman

104/118, Solayappan st F 57 RL & LL 9 5/1/01

87 Chandrasekhar s/o Ramasamy

13, Babu reddikulam M 43 R.L 2 5/7/01

83 Barimalam w/o Selvaraj

2/47, Ellukuttai metu st F 35 R,L 6 29/3/01

84 Sundaramoorthi c/o Chakkrabani

46/4, Viyasar st M 58 R.L 8 9/4/01

91 Jegatham w/o Rethinam

309, Pettai pasikaran santhu

F 80 R.L 40 23/1/01

90 Danalakshmi w/o Ramakrishnan

30/31, Pettai pasikaran F 55 LL 20 23/1/01

95 Danalakshmi w/o Vadivel

50, Pettai north F 80 R.L 15 9/8/01

94 Vembu d/o Ramamurthy

40/7,Pettai north F 28 R.L 3 5/8/01

92 Pirema w/o Venkadasan

4, Pettai north F 40 R.L 57 19/3/01

93 Malika w/o Sokkalingam

59, Pettai north eastapuram

F 45 R.L 20 24/11/01

98 Kalidoss s/o Banchanathan

Rathamettal kuttiyan st M 38 R.L 6 13/3/01

101 Danalakshmi w/o Srinivasan

3/4, Mallukacheeti st F 65 RL & LL 10 12/3/01

105 Ganam w/o Kanakasabai

Poiyadhapillaiyar koil F 65 RL & LL 20 8/5/01

104 Cadbury w/o Madhavan

40, Viyabari st F 29 R.L 8 22/1/01

102 Maniyammal w/o Murukaiyan

89,Nanayakara st F 42 R.L 3 22/1/01

103 Visvalinkam s/o Ramalingam

32,Nanayakara st M 64 RL & LL 25 22/1/01

106 Meenakhi w/o Raman

25-a,Vinaithedhal st F 59 R.L 10 8/5/01

129 Jalaxmiw/o Selvam 22, K.V. Melaveethi F 41 LL 8 12/11/01 126 Anjammal

w/o Rathakrisnan 18-c, K.V keelaveethi M 40 R.L 11 4/5/01

127 Rajeswari w/o Chinnappa

5/3, K.V north F 50 LL 5 20/2/01

128 Karthikkannan s/o Magalingam

K.V north M 57 R.L 3 21/2/01

173 Vinayakamoorthi s/o Thangavel

6-c, Old place F 32 RH 7 21/6/01

130 Booma w/o Panneerselvam

76/41, Singara chetti st F 50 RL & LL 3 22/3/01

138 Ranjutham 29, Thanjai main road Kubaswaran koil

F 45 R.L 10 24/4/01

137 Jalaxmi w/o Krishnan

11,Kumbeswaran koil st

F 51 R.L 7 16/4/01

46 Manimaran w/o Theyakarajan

Perumandi st M 35 RH 8 26/4/01

47 Murugadass s/o Kaliyamoorthi

Perumandi st M 22 LL 7 26/4/01

200 Nithiya Linekarai thoppu st M 52 LL 20 17/3/01

w/oRajaraman 203 Surya

w/o Janakiraman 13/8, Ramachandirapuram

F 45 R.L 25 4/5/01

224 Deenashkumar s/o Kaliyamoorthi

27/13, River bank st M 22 LL 5 23/1/01

240 Suriya w/o R.K.Kannan

4/40, J.P west st M 50 LL 20 24/5/01

241 Lakhmi w/o Krishnamurthy

102, J.P east st F 50 R.L 5 3/9/01

253 Hemavathi s/o Ashogan

25/10, Eallaieechetti st F 3 R.L 2 11/10/01

254 Rajamani w/o Balakrishnan

46,Visvanathan colony F 51 LL 6 13/2/01

239 Kaliani c/o Somu

188/3, Ganthiyadikal salai

F 65 RL & LL 2 22/6/01

237 M.Lakshmi w/o Krishnamurthy

50/6, Mahamagakula m F 50 R.L&LH 10 3/7/01

154 Muthulakshmi w/o Natarajan

1401, Kamakodinagar south

F 68 LL 16 6/2/01

110 Vijalakshmi w/o Thandabani

25, Mukkannar st F 68 R.L 20 30/1/01

213 Pusba w/o Krishnamoorthy

18/13, Natanagobal st F 52 LL 5 17/4/01

** 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 occurrence

Year **

Date_ Treat

123 Laxmiammal w/o Dulasiraman

163, Chetti new street F 68 RL 10 20/2/2008

121 Rajamannar w/o Santha

73/39, Chetti new street M 75 LL 7 14/2/2008

122 Indrani w/o Mani 91/48, Chetti new street F 39 LL 5 15/2/2008 120 Gowri w/o

Rengasamy 47/28, Chetti new street F 52 RH 20 14/2/2008

124 Annaborani c/o Loganathan

32/188, Chetti new st F 60 LL 17 21/2/2008

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

street M 62 LL 8 22/4/2008

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

w/o Mathavan Bharathiyar nagar F 52 RL 20 5/1/2008

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 w/o Kaliyamoorthi

18/17, Thilakar mela street

M 63 LL 12 23/1/2008

162 Kunchupillai c/o Thangamani

18-c, Thilakar mela street

M 77 LL&lh 20 23/2/2008

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;j pd ; ,lg ;gh pkhd';fs; : xU g [t pj ; jfty; bjhFg;gikg ;g pd ; mQFKiw

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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

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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.

**************