Knowledge, attitudes and perceptions regarding lymphatic filariasis: study on systematic noncompliance with mass drug administration

ABSTRACT The aim of this study was to investigate the epidemiological characteristics, antigenic profile, perceptions, attitudes and practices of individuals who have been systematically non-compliant in mass drug administration (MDA) campaigns targeting lymphatic filariasis, in the municipality of Olinda, State of Pernambuco, Northeastern Brazil. A pretested questionnaire was used to obtain information on socioenvironmental demographics, perceptions of lymphatic filariasis and MDA, and reasons for systematic noncompliance with treatment. A rapid immunochromatographic test (ICT) was performed during the survey to screen for filariasis. It was found that the survey subjects knew about filariasis and MDA. Filariasis was identified as a disease (86.2%) and 74.4% associated it with the presence of swelling in the legs. About 80% knew about MDA, and the main source of information was healthcare workers (68.3%). For men the main reasons for systematic noncompliance with MDA were that “the individual had not received the medication” (p=0.03) and for women “the individual either feared experiencing adverse reactions”. According to the ICT, the prevalence of lymphatic filariasis was 2%. The most important causes of systematic noncompliance were not receiving the drug and fear of side-effects. For successful implementation of MDA programs, good planning, educational campaigns promoting the benefits of MDA, adoption of measures to minimize the impact of adverse effects and improvement of drug distribution logistics are needed.

Integrated morbidity management for lymphatic filariasis and podoconiosis, Ethiopia

Problem Lymphatic filariasis and podoconiosis are the major causes of tropical lymphoedema in Ethiopia. The diseases require a similar provision of care, but until recently the Ethiopian health system did not integrate the morbidity management. Approach To establish health-care services for integrated lymphoedema morbidity management, the health ministry and partners used existing governmental structures. Integrated disease mapping was done in 659 out of the 817 districts, to identify endemic districts. To inform resource allocation, trained health extension workers carried out integrated disease burden assessments in 56 districts with a high clinical burden. To ensure standard provision of care, the health ministry developed an integrated lymphatic filariasis and podoconiosis morbidity management guideline, containing a treatment algorithm and a defined package of care. Experienced professionals on lymphoedema management trained government-employed health workers on integrated morbidity management. To monitor the integration, an indicator on the number of lymphoedema-treated patients was included in the national health management information system.Local setting In 2014, only 24% (87) of the 363 health facilities surveyed provided lymphatic filariasis services, while 12% (44) provided podoconiosis services.Relevant changes To date, 542 health workers from 53 health centres in 24 districts have been trained on integrated morbidity management. Between July 2013 and June 2016, the national health management information system has recorded 46 487 treated patients from 189 districts.Lessons learnt In Ethiopia, an integrated approach for lymphatic filariasis and podoconiosis morbidity management was feasible. The processes used could be applicable in other settings where these diseases are co-endemic

Avaliação epidemiológica de doenças negligenciadas em escolares: filariose linfática e parasitoses intestinais / Epidemiological assessment of neglected diseases in children: lymphatic filariasis and soil-transmitted helminthiasis

OBJETIVO: Descrever a prevalência de infecção filarial e de parasitoses intestinais em escolares numa área endêmica de filariose e refletir sobre a opção terapêutica utilizada no Brasil no tratamento coletivo para filariose. MÉTODOS: Estudo transversal envolvendo 508 alunos na faixa etária de 5-18 anos cadastrados em escolas públicas do município de Olinda-PE. Realizou-se a investigação da parasitose intestinal em três amostras de fezes, analisadas pelo método de Hoffmann, Pons e Janer. A investigação filarial foi feita com teste antigênico pela técnica de imunocromatográfica rápida (ICT) e pesquisa de microfilárias, utilizando filtração em membrana de policarbonato. Para análise de dados utilizou-se a estatística descritiva através do programa EpiInfo versão 7. RESULTADOS: A prevalência de filariose por ICT foi de 13,8% e por microfilaremia de 1,2%, enquanto a de parasitoses intestinais foi 64,2%. A concomitância do diagnóstico filarial e de parasitoses intestinais foi de 9,4% e, 31,5% eram isentos de ambas as parasitoses. Entre os indivíduos com parasitoses intestinais, 55% eram monoparasitados e 45% poliparasitados. A presença de geohelmintos ocorreu em 72,5% dos parasitados. No grupo com infecção filarial a ocorrência de geohelmintíase foi de 54,5%. CONCLUSÕES: O diagnóstico simultâneo de infecção filarial e parasitose intestinal, bem como a elevada frequência de geohelmintos justificam uma reavaliação da estratégia terapêutica do tratamento coletivo no programa de filariose no Brasil.

OBJECTIVE: To report the prevalence of lymphatic filariasis and intestinal parasitic infections in school-aged children living in a filariasis endemic area and discuss about the therapeutic regimen adopted in Brazil for the large-scale treatment of filariasis. METHODS: A cross-sectional study including 508 students aged 5-18 years old, enrolled in public schools within the city of Olinda, Pernambuco. The presence of intestinal parasites was analyzed using the Hoffman, Pons and Janer method on 3 stool samples. The diagnosis of filarial infection was performed using the rapid immunochromatographic technique (ICT) for the antigen, and the polycarbonate membrane filtration for the presence of microfilariae. Descriptive statistics of the data was performed using EpiInfo version 7. RESULTS: The prevalence of filariasis was 13.8% by ICT and 1.2% by microfilaraemia, while intestinal parasites were detected in 64.2% of cases. Concurrent diagnosis of filariasis and intestinal parasites was 9.4%, while 31.5% of students were parasite-free. Among individuals with intestinal parasites, 55% had one parasite and 45% had more than one parasite. Geohelminths occurred in 72.5% of the parasited individuals. In the group with filarial infection the prevalence of soil-transmitted helminthiasis was 54.5%. CONCLUSIONS: The simultaneous diagnosis of filariasis and intestinal parasites as well as the high frequency of geohelminths justify the need to reevaluate the treatment strategy used in the Brazilian filariasis large-scale treatment program.

Construction of a recombinant plasmid harbouring the glyceraldenyde-3-phosphate dehydrogenase gene of periodic Brugia malayi and observation on DNA immunity.

Purpose: Controlling and eliminating lymphatic filariasis will require further research of preventative measures and implementation. Parasite is dependent on glycolysis for ATP production. The glycolytic enzyme glyceraldenyde-3-phosphate dehydrogenase (GAPDH) plays an important role in glycolysis and therefore is either a potential target for anti-parasite drug development or a vaccine candidate. Therefore, we tried to investigate the DNA vaccine-elicited immune responses in BALB/c mice. Materials and Methods: We cloned a gene encoding the glyceraldehyde-3-phosphate dehydrogenase (GAPDH) from periodic Brugia malayi into vector pcDNA3.1. Mice were injected at a dosage of 100 μg recombinant plasmid DNA with CpG intramuscular injection and immunized three times at 2-week intervals. pcDNA3.1 and normal saline were used as control. The tissue of muscles at the 4 weeks after the third injection was collected and target genes were detected using RT-PCR. The humoral responses elicited in mice by inoculation with the recombinant plasmid pcDNA3.1-BmGAPDH were detected using a standard ELISA. Two weeks after the third immunization, stimulation index (SI) was measured using the MTT method and the level of secreted IL-4 and INF-g were detected using ELISA. Results: Specific gene fragment coding GAPDH was amplified and the recombinant plasmid pcDNA3.1-BmGAPDH was constructed. Post-challenge sera from the mice immunized with the DNA vaccine had specific antibody titres of 1:1600 to 1:6400, and the highest titre was observed in the mice that were inoculated by pcDNA3.1-BmGAPDH/CpG at 6 weeks. At 4 weeks after immunization, the spleens of the mice were obviously enlarged. The proliferation of spleen T lymphocytes seen on the MTT assay was higher in the pcDNA3.1-BmGAPDH group than in the control group (P value <0.05). The levels of IL-4 and INF-g in serums from the immunized mice were significantly higher than that of the control (P value <0.05). Conclusions: We conclude that the recombinant eukaryotic plasmid pcDNA3.1-BmGAPDH could elicit humoral and cellular immune responses in mice.

Evaluation of toxicity of plant extracts against vector of lymphatic filariasis, Culex quinquefasciatus.

Background & objectives: Conventional insecticides are generally used as larvicides to control Culex quinquefasciatus, vector of lymphatic filariasis. This study was undertaken to evaluate the larvicidal activity of some potential larvicidal plants leaf extracts against Cx. quinquefasciatus larvae. Methods: The toxic effects of petroleum ether leaf extracts of plants viz., Argemone mexicana (Mexican prickly poppy), Clausena dentata (Dentate), Cipadessa baccifera (Rana bili), Dodonaea angustifolia (Hop bush) and Melia dubia (Pride of India) were evaluated under laboratory conditions in individual and in combination against 3rd - 4th instar larvae of Cx. quinquefasciatus. Results: The results indicated that among the selected plants, A. mexicana showed maximum larvicidal activity with an LC50 value of 48.89 ppm. Its toxicity was enhanced when the extract was mixed (1:1) with that of C. dentata as the LC50 value became 28.60 ppm indicating synergistic action of A. mexicana. Interpretation & conclusions: Our results showed high larvicidal potential in A. mexicana leaf extract, and it also showed additive effect when mixed with C. dentata extract.

Perfil epidemiológico de pacientes atendidos no ambulatório do Serviço de Referência Nacional em Filarioses, no período de 2002 a 2008 / Epidemiological profile of patients seen at the clinic of the Department of National Reference filariasis in the period 2002-200

A filariose linfática é uma parasitose debilitante, endêmica em regiões tropicais e subtropicais, que acomete cerca de 120 milhões de pessoas em todo mundo. O agente etiológico responsável por essa enfermidade no Brasil é o helminto da espécie Wuchereria bancrofti. Atualmente, a Região Metropolitana do Recife (RMR), em Pernambuco, é a localidade de maior endemicidade e onde ainda há registros de transmissão ativa desta infecção. Nesse estado encontramos o Serviço de Referência Nacional em Filarioses (SRNF), localizado no Centro de Pesquisas Aggeu Magalhães - Fundação Oswaldo Cruz e único serviço nacionalmente reconhecido referente a esse agravo. Credenciado oficialmente no ano de 2002, o SRNF desenvolve atividades clínicas, laboratoriais, pesquisa e assistência relacionadas à investigação e ao acompanhamento de pacientes filarêmicos. O presente trabalho descreve o perfil epidemiológico dos pacientes atendidos pelo SRNF, durante o período de 2002 a 2008. Optamos por um estudo do tipo transversal, no qual trabalhamos com informações existentes nos prontuários dos pacientes atendidos no SRNF durante o período mencionado. Em 1.109 prontuários de atendimento selecionados para o estudo, 358 foram definidos como sendo de indivíduos positivos ou microfilarêmicos, baseado na técnica da filtração em membrana, ou seja, presença de formas embrionárias do verme em amostras biológicas de sangue. A demanda maior de pacientes encaminhados ao SRNF (85,4 por cento) correspondeu aos residentes na RMR, tendo o município de Jaboatão dos Guararapes à maior ocorrência de indivíduos infectados (76,8 por cento). Os homens apresentaram maior número de manifestações clínicas (55,4 por cento), sendo a queixa mais referida hidrocele. A faixa etária com maior positividade concentrou-se entre os 18 e 28 anos. Os casos positivos ocorreram em maior número na população do gênero masculino, que apresentou uma prevalência de 1,59 em relação à população do gênero feminino. A partir destes achados consideramos que o perfil epidemiológico apresentado pelos pacientes atendidos no SRNF não é diferente dos outros descritos na literatura sobre tal matéria. Pretendemos usar as informações encontradas na obtenção de elementos que proporcionem o desenvolvimento da qualidade dos serviços prestados e melhoria do Serviço de Referência.

A complexidade do custo socioeconômico da filariose linfática / The complexity of the socioeconomic costs of lymphatic filariasis

A falta de conhecimento do impacto socioeconômico das diversas doenças é, geralmente, um dos maiores obstáculos para a obtenção de verbas para investimentos em pesquisa aplicada, assim como para iniciar a implementação de programas de controle necessários aos países em desenvolvimento. Os autores analisam e ressaltam aspectos relevantes da complexidade de quantificação do impacto socioeconômico da filariose linfática e enfatizam as lacunas existentes em algumas áreas do conhecimento, que ainda não foram devidamente exploradas para os portadores da doença. Aos dados de literatura aliam os ecos do aprendizado adquirido através do atendimento de pacientes portadores de infecção e doença bancroftiana em serviço terciário de referência do Núcleo de Ensino Pesquisa e Assistência em Filariose (NEPAF), Recife, Brasil. O impacto social, no seu sentido mais abrangente, mostra indícios fortes de perdas na qualidade de vida dos pacientes, infelizmente ainda pouco documentadas e, até certo ponto, de muito difícil contabilização, pelo tão peculiar abandono social das comunidades endêmicas.

Lack of knowledge of the socioeconomic impact of various diseases is generally one of the biggest obstacles to obtaining funds for investment in applied research and for starting to implement control programs that are needed in developing countries. The authors analyze and emphasize important aspects of the complexity of quantifying the socioeconomic impact of lymphatic filariasis. They highlight the gaps that exist within some fields of knowledge and that these gaps have still not been properly explored with regard to individuals with this disease. They bring together the data in the literature and echoes from their own experience gained through caring for patients with Bancroftian infection and disease at a tertiary referral service (NEPAF - Filariasis Care, Research and Teaching Center, Recife, Brazil). The social impact, in its broadest sense, consists of strong indications of losses of quality of life among patients. Unfortunately, this is still poorly documented and, up to a certain point, very difficult to quantify because of the very particular social abandonment of the endemic communities.

Transmission dynamics of diurnally subperiodic lymphatic filariasis transmitted by Ochlerotatus (Finlaya) niveus in the Andaman & Nicobar Islands.

BACKGROUND & OBJECTIVE: In India diurnally subperiodic filariasis is prevalent only in the Nicobar district of Andaman and Nicobar Islands, with significant health problem. Sample surveys indicated that this form of filariasis is restricted to a small region of Nancowry group of islands with Ochlerotatus niveus as the vector. We therefore carried out a comprehensive study to assess the transmission dynamics of LF in Teressa island in Nicobar district in view of its control and evaluation of interventions. METHODS: Entomological studies were carried out for a period of twelve months covering all the seasons in the year, by means of man landing catches in Teressa Island, an endemic island for this form of filariasis. Parameters viz., the annual biting rate (ABR), annual infective biting rate (AIBR), annual transmission index (ATI), risk of infection index (RII) and annual transmission potential (ATP), which reflect the dynamics and intensity of transmission of filariasis, were estimated. Host efficiency of Oc. niveus was also assessed. RESULTS: The number of vectors biting a person in a year was estimated to be 21851, of which 107 were harbouring infective parasite. Risk of infection intensity was 0.02332. Every person in this study area was at the risk of receiving an estimated number of 22 infective stage larvae per year. The host efficiency index of Oc. niveus indicated that over 40 per cent of the microfilariae ingested were able to develop into infective stages. The ATP was 169 with evidence of year round transmission. The pattern of monthly transmission potential suggested that the intensity of transmission was high during summer months. INTERPRETATION & CONCLUSION: Perennial transmission of subperiodic Wuchereria bancrofti in the typical forest ecosystem was evident in Teressa Island with transmission parameters suggesting that summer is a high risk season for transmission. Personal protection measure is the method of choice to protect from the risk of infection, because of day biting, exophilic and exophagic behaviour of the vector and larvae are not amenable to larvicidal measures. An alternative method to control the transmission would be to use selective or periodic mass chemotherapy to reduce the parasite load in this community.

Identification of 38kDa Brugia malayi microfilarial protease as a vaccine candidate for lymphatic filariasis.

A FPLC purified 38kDa protease (Bm mf S-7) isolated from B. malayi microfilarial soluble antigen was identified. It showed pronounced reactivity with sera collected from 'putatively immune' asymptomatic and amicrofilaraemic individuals residing in an endemic area for bancroftian filariasis. Further the immune protective activity of Bm mf S-7 antigen was evaluated in susceptible hosts, jirds (Meriones unguiculatus) against B. malayi filarial infection. The antigen showed 89% cytotoxicity against mf and 87-89% against infective (L3) larvae in in vitro antibody dependent cellular cytotoxicity Assay (ADCC) and in situ micropore chamber methods. Bm mf S-7 immunized jirds after challenge infection showed 81.5% reduction in the adult worm burden. The present study has shown that, the 38kDa microfilarial proteases (Bm mf S-7) could stimulate a strong protective immune response against microfilariae and infective larvae in jird model to block the transmission of filariasis. Analysis of IgG subclasses against Bm mf S-7 revealed a significant increase in IgG2 and IgG3 antibodies in endemic normals. Lymphocyte proliferation to Bm mf S-7 was significantly high in endemic normal group as compared to that in clinical and microfilarial carriers. Significantly enhanced levels of IFN-gamma in the culture supernatant of PBMC of endemic normals followed by stimulation with Bm mf S-7 suggest that the cellular response in this group is skewed towards Th 1 type.

Tolerability and efficacy of a three-age class dosage schedule of Diethylcarbamazine citrate (DEC) in the treatment of microfilaria carriers of Wuchereria bancrofti and its implications in mass drug administration (MDA) strategy for elimination of lymphatic filariasis (LF).

A six-age class dosage schedule of Diethylcarbamazine (DEC) of 50mg (1-2 years), 100mg (3-4 years), 150mg (5-8 years), 200mg (9-11 years), 250mg (12-14 years) and 300mg for above 14 years is being adopted for annual single dose MDA for LF elimination treat Wuchereria bancrofti microfilaria carriers. In order to increase the community compliance as well as to make the distribution easier during MDA, a revised 3 age class dosage schedule of 100mg (2-4 years), 200mg (5-14 years) and 300mg for above 14 years was evaluated for its tolerability and efficacy. By this change, it was observed that the 4-8 years age class is receiving 50 mg higher and 11-14 years age class is receiving 50mg lesser dose compared to the earlier class schedule. Therefore, the safety aspect in the age class of 4-8 years and efficacy component in the age class of 11-14 years were assessed. Apparently "healthy" asymptomatic microfilaraemic volunteers between the age class of 4-8 and 11-14 years were recruited for the study. The incidence of side reaction in the 4-8 years age class was 50.0% with 150mg dose and 66.7% with 200mg (P>0.05). No life threatening adverse reactions was observed in any dosage schedule. Fever, headache and myalgia, the predominant adverse reactions were mild and similar in both schedules. The mean intensity of the three major specific adverse reactions (fever, headache and myalgia) also did not differ significantly (P>0.05). For the purpose of LF elimination, efficacy in terms of reduction in mean microfilaria load is important. In the 11-14 year age class considerable reduction in the geometric mean density (GMD) was observed by day 90 and 180 post-therapy in both groups (250mg group and 200mg group) compared to pre-therapy level. By day 360 post-therapy, the difference was statistically not significant (P>0.05) (reduction of 72.2% in 250mg and 69.6% reduction in 200mg). The reductions in GMD were statistically significant when compared to pre-therapy levels in both the old (250mg) and new (200mg) doses. Thus, three- age class dosage schedule is as safe and efficacious as the six- age class schedule.

A produção do conhecimento científico e as políticas de saúde pública: reflexões a partir da ocorrência da filariose na cidade do Recife, Pernambuco, Brasil / Scientific knowledge and public health policies: reflections on the occurrence of filariasis in Recife, Pernambuco, Brazil

O artigo discute a relação entre a produção científica sobre a ocorrência da filariose bancroftiana no Brasil e o processo de formulação e implementação da política de saúde voltada ao seu controle. Para tanto, realiza uma revisão da produção do conhecimento e das políticas específicas, no período compreendido desde a criação do Programa de Combate à Filariose, em meados do século passado, até a criação do SUS, no marco da descentralização do controle das endemias. Centrando suas observações empíricas na ambiência da cidade do Recife, espaço urbano no qual ainda prevalece a filariose, ressalta os processos institucionais e destaca o papel dos distintos atores neles envolvidos. Partindo da hipótese de que se até à primeira metade do século vinte faltavam o conhecimento científico e o desenvolvimento tecnológico para o controle do problema, a seguir, quando esses avanços são disponibilizados, outros requerimentos, agora do campo da política, irão se impor, atuando como determinantes da persistência da endemia na cidade.

Controle da filariose linfática no Brasil, 1951-2000 / Control of lymphatic filariasis in Brazil, 1951-2000

No artigo de revisão, são analisadas as ações de controle da filariose no Brasil, no período de 1951 a 2000, avaliando o seu desmpenho, na perpectiva da eliminação da doença filarial como problema de Saúde Pública. Para tal, foi realizada pesquisa histórica a fontes bibliográficas, publicações, relatórios e outros textos referentes à características e à efetividade de campanhas e programas específicos no controle dessa endemia. Durante cerca de cinco décadas, as ações foram estruturadas numa lógica centralizadora, cujas atividades se baseavam na identificação dos indivíduos infectados. Os determinantes que levaram aos insucessos das campanhas e programas foram decorrentes de diversos elementos, entre eles a falta de uma política de saúde; da estrutura do modelo de assistência; da execução de ações nos diversos níveis da rede; além de defender um tipo de intervenção com caráter exclusivamente biológico verticalizado, e de ausência da participação da comunidade, entre outros. Nova proposta surgiu em 1996 com o Plano Nacional de eliminação da Filariose Linfática, ainda em fase de execução. O Plano mostra-se inovador, uma vez que suas ações são baseadas numa articulação entre as esferas de governo e em obdiência ao princípio do Sistema Único de Saúde (SUS), sendo sua coordenação delegada às Secretarias de Estado de Saúde e a execução às Secretarias Municipais de Saúde. A partir dessa proposta, o estudo das campanhas e programas especiais utilizados nas ações de controle da filariose no Brasil, poderá, ao longo dos anos, fornecer subsídios à melhor adequação do atual plano no país

Compliance with the mass chemotherapy program for lymphatic filariasis.

OBJECTIVE: To evaluate compliance with the single dose mass chemotherapy program for control of filariasis, and to determine factors influencing compliance in the Gampaha district. DESIGN: A prospective study employing a pre-tested self-administered questionnaire. METHODS: Four groups comprising individuals over one year old with residence in the Gampaha district for over one year were surveyed. Data collection was started two weeks after the mass chemotherapy program. RESULTS: 2300 questionnaires were distributed, 1983 (86.2%) were returned, and 1935 (84.1%) were sufficiently complete for analysis (857 males; mean age 39 years, SD = 19.5). Over 96% had heard of filariasis and the mass chemotherapy program, but only 60.3% of those over 11 years of age were aware of asymptomatic carriage of the parasite. 1289 (66.6%) out of the total sample surveyed (1935 individuals) had obtained the diethylcarbamazine tablets, and 1221 (63.1%) had taken the drug. Of the possible demographic factors that could have influenced compliance only educational level seemed to play an independent significant role, compliance being lowest at both extremes of educational level. The main problem with compliance was obtaining the drug from distribution centres. CONCLUSIONS: Compliance with the mass chemotherapy program to control filariasis needs improvement. Strategies should include a better system for distributing the drug, and altering the content of the publicity material used by the program to target less compliant groups, and improve aspects of knowledge regarding filariasis that seem inadequate at present.

Avaliaçäo de indicador sócio-ambiental utilizado no rastreamento de áreas de transmissäo de filariose linfática em espaços urbanos / Evaluation of a social and environmental indicator used in the identification of lymphatic filariasis transmission in urban centers

O conceito de espaço socialmente organizado, subsidiado por novas técnicas de análise, mapeamento e espacializaçäo da ocorrência de eventos, tem orientado desenvolvimentos metodológicos inovadores no campo das intervençöes de saúde pública. Teve por objetivo avaliara a utilizaçäo de um indicador sócio-ambiental, construído através da metodologia de aplicaçäo de escores, na estratificaçäo do Município de Olinda, Pernambuco, em áreas com diferentes riscos de transmissäo da filariose bancroftiana. Procedeu -se ao mapeamento das áreas, localizaçäo dos domicílios amostrados e identificaçäo de todos os moradores com idade entre 5 e 65 anos para realizaçäo do inquérito parasitológico. Dentre as 3.232 pessoas examinadas, 42 foram positivas, obtendo-se prevalência de microfilaremia de 1,3 por cento. A análise estatística global da distribuiçäo dos casos mostrou evidências de agregaçäo espacial. Nos dois estratos de mais alto risco de transmissäo residiam 85,7 por cento dos positivos. A alta sensibilidade do indicador proposto justifica a sua utilizaçäo para o planejamento e execuçäo de intervençöes ao predizer o local de ocorrência da maioria dos casos de filariose.

Bases para tratamento da morbidade em áreas endêmicas de filariose bancroftina / Rational for morbity management in bancroftian filariasis endemic areas

A escolha da terapia mais apropriada para o paciente com bancroftose requer um conhecimento das diversas características clínicas da doença filarial e de sua patogênese. Como resultado de novos testes diagnósticos e avanços clínicos, näo apenas nosso entendimento sobre a filariose bancroftiana mudou rapidamente de forma, como as nossas idéias sobre o tratamento. No passado, acreditava-se que a elefantiase era causada pela reaçäo imunológica do hospedeiro ao parasita filarial. Posta dessa maneira, essa forma da doença seria o ponto final de uma inter-relaçäo hóspede-hospedeiro imutável, dada a inexistência de medicamentos ou de condutas que possibilitassem a sua involuçäo nos denominados "indivíduos imunologicamente predispostos". Entretanto, nos últimos anos, surgiram evidências de que o linfedema e a elefantiase tinham outro agente etiológico. O principal fator de evoluçäo para os quadros de linfedema e elefantiásicos seria o desenvolvimento de infecçöes bacterianas secundárias de repetiçäo. Hoje, é perfeitamente claro que outras formas de terapia de suporte (incluindo a educaçäo e o aconselhamento psicológico) säo necessárias e säo, muitas vezes, mais importantes que a terapia antiparasitária