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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 109-113  

Coexistent malaria and filaria among the febrile patients attending for malaria diagnosis: A clinic-based study


1 Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
2 Department of Life Science, Presidency University, Kolkata, West Bengal, India
3 Department of Zoology, P. R. Thakur Govt. College, Ganti, West Bengal, India
4 Director, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India

Date of Submission18-Aug-2020
Date of Acceptance30-Sep-2020
Date of Web Publication23-Jan-2021

Correspondence Address:
Moytrey Chatterjee
Department of Microbiology, Calcutta School of Tropical Medicine, C R Avenue, Kolkata - 700 073, West Bengal
India
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DOI: 10.4103/tp.TP_93_20

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   Abstract 


Context: Both malaria and lymphatic filariasis (LF) are mosquito-borne diseases caused by protozoal and nematode parasites, respectively, and are serious public health problem in India. Although the vectors of the diseases are different, they can coexist in favorable conditions. Fever is the common symptom for both the diseases, but the emphasis is given for diagnosis and treatment of malaria due to its life-threatening severity, LF remained neglected. Detection and management of microfilaria are equally important. During the diagnosis of malaria, a few microfilaria were detected, which prompted us to undertake this study with following objectives.
Objectives: The objective of the study was to determine the incidence of microfilaremia among the febrile patients attending for malaria diagnosis.
Subjects and Methods: Thick and thin peripheral blood smears from all patients attended were examined following Giemsa staining. Different malarial indexes were analyzed.
Results: Out of 8681 patients examined, 1778 were positive for Plasmodium vivax and 328 for Plasmodium falciparum with a slide positivity rate 20.48%. Twenty-six patients were positive for microfilaria of Wuchereria bancroftii among which five were coinfected with P. vivax and one with P. falciparum. Most of the microfilaria-positive patients were adult and originally from northern districts of Bihar.
Conclusions: High incidence of microfilaria among febrile patients attending for malaria is alarming for urban Kolkata. Although the patients were originally from Bihar, they are staying in Kolkata for a long time, might be a source for transmission. Epidemiological study by collecting night blood samples and entomological survey is highly suggestive to explore local transmission if any.

Keywords: India, lymphatic filaria, microfilaria, Plasmodium falciparum, Plasmodium vivax, Wuchereria bancroftii


How to cite this article:
Acharya A, Rakshit A, Halder S, Chatterjee M, Chakrabarti S, Saha P, Bera DK, Chakraborty B, Kundu PK, Ghosh T, Maji AK. Coexistent malaria and filaria among the febrile patients attending for malaria diagnosis: A clinic-based study. Trop Parasitol 2020;10:109-13

How to cite this URL:
Acharya A, Rakshit A, Halder S, Chatterjee M, Chakrabarti S, Saha P, Bera DK, Chakraborty B, Kundu PK, Ghosh T, Maji AK. Coexistent malaria and filaria among the febrile patients attending for malaria diagnosis: A clinic-based study. Trop Parasitol [serial online] 2020 [cited 2021 Mar 9];10:109-13. Available from: https://www.tropicalparasitology.org/text.asp?2020/10/2/109/307800




   Introduction Top


Both malaria and filaria are mosquito-borne parasitic diseases caused by different groups of parasites and different species of mosquitoes. Malaria is a major disease burden in developing countries and is one of the deadliest parasitic diseases in tropics and subtropics both in terms of mortality and morbidity.[1] It is caused by the five species of the protozoan parasite belonging to the genus Plasmodium: Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, Plasmodium Malariae, and Plasmodium knowlesi.[1] A total of 228 million cases reported globally, with 405,000 deaths in 2019.[2] Lymphatic filariasis (LF) is one of the neglected tropical diseases caused by nematode parasite belonging to Family “Filarioidea,” which includes Wuchereria bancrofti, Brugia malayi, and Brugiya timori. LF is prevalent in 81 countries including India.[3] Among them, 39 counties are from African region and 9 from the South East Asian region.[3] Globally, 856 million people in 52 countries require preventive chemotherapy to stop the spread of infection.[4] About one-third of the global burden of LF is contributed by India. About 31 million people are estimated to be the carriers of microfilaria and over 23 million suffer from filarial disease manifestations.[5] In India, LF is endemic in 17 states and six union territories. A total of 250 districts have been identified as endemic for filariasis, with a population of about 600 million are at risk.[6] Bancroftian filariasis caused by W. bancrofti, accounts for 90% of the infections, and occurs in tropical regions of Asia, Africa, the Pacific islands, and in parts of South America.[7] Culex quinquefasciatus is the predominant vector for W. bancrofti. Brugian filariasis is less common and found in Asia, whereas Brugia timori is restricted to Timor and Sunda islands.[8] Two species Mansonia muniformis and Mansonia annulifera are the principal vector of brugian filaria. Human is the only definite host for Wuchereria bancrofti in opposition to B. malayi can be found in humans, monkeys, and felines. In rural and urban India, W. bancrofti is transmitted by the ubiquitous vector C. quinquefasciatus contributing 90% of the cases in the country.[6]

The World Health Organization (WHO) targeted elimination of both the diseases. In 2015, the WHO formulated “Global Technical strategy for malaria 2016–2030” with the vision of a world free of malaria by 2030.[9] LF is identified as a potentially eradicable disease.[10] The WHO initiated the Global Programme to Eliminate Lymphatic Filariasis in 1997 with a target of global elimination of LF by 2020.[11] To reach the goal, two main strategies were undertaken; preventive chemotherapy to interrupt the transmission by reducing the burden of parasite and management of morbidity due to the disease. Preventive chemotherapy provided through mass drug administration (MDA) showed promising results in interruption of disease transmission during the first decade of implementation.[3]

In most part of India, after eight rounds of MDA, the prevalence of microfilaremia and antigenemia among children went down well below 1%, the cut off mark for stopping MDA.[12] In spite of taking several activities, few areas of the country showed a high prevalence of microfilaremia with ongoing transmission even after more than a decade of LF elimination program.[13] Fever is the common symptom for both the diseases. During the routine diagnosis of malaria among febrile patients, we found microfilaria in a few cases. Coexistent malaria with filaria has been reported earlier from India[14] and other countries.[15],[16] No such record is available from urban Kolkata. The present work was designed to determine the incidence of microfilaria among febrile patients attending for diagnosis and treatment of malaria in a tertiary care hospital in Kolkata.


   Subjects and Methods Top


The present work was an observational study conducted from March to November 2019 at Malaria Clinic of Calcutta School of Tropical Medicine, Kolkata. Most of the patients attending the malaria clinic were from middle to low socioeconomic class and were local resident of the central part of Kolkata along with migratory labour from neighboring states such as Bihar and Jharkhand. Full residential address along with any migratory history was properly recorded during clinical examination of the patients. All febrile patients attending the malaria clinic were included for this study. Thick and thin peripheral blood smear was prepared on grease-free glass slides. The thin smear was dipped into methanol for fixation. After air dried, the thick smear was de-hemoglobinized with distilled water and air dried. Both thick and thin smears were stained with Giemsa solution with buffer water (pH 7.2) at the ratio of 1:3 for 10 min.[17]

Stained smears were examined by skilled laboratory technologist and cross-checked by microbiologists. At first, the entire thick smears were examined under low objective lens (4×) for detection of filarial parasite and then examined under oil emersion objective lens (100×) for detection and proper species identification of malaria parasites. A blood slide was declared negative for malaria, when examination of at least 100 fields in thick smear did not show any parasite. Apart from this, most of the malaria-positive cases were confirmed by rapid diagnostic test using dual malaria antigen kit ((PfHRP-2 and pLDH). The malaria patients were treated as per NVBDCP guideline. The falciparum mono-infected patients were treated with artesunate + sulphadoxine and pyrimethamine (AS + SP). Artesunate was given 4 mg/kg body weight over 3 days, while SP as a single dose on day 1 (25 mg/kg body weight for sulphadoxine and 1.25 mg/kg body weight for pyrimethamine) along with primaquine on day 2 (0.75 mg/kg body weight, single dose). Vivax mono-infected cases were treated with chloroquine at 25 mg/kg given over 3 days along with primaquine 0.25 mg/kg for 14 days. The microfilaria-positive cases were treated with tablet diethylcarbamazine – 100 mg thrice daily for a period of 21 days along with cetirizine (5 mg) for a period of 14 days.

Ethical aspects

The data presented in this article were generated during routine diagnosis of malarial parasites among the febrile patients attending malaria clinic attached to the protozoology unit. Ethical clearance is not applicable for this study. The permission was obtained from the head of the institute for publication of the data.


   Results Top


During the study period, a total of 8681 febrile patients were examined, of which 1778 were positive for malaria parasite. Among the positive cases, 274 were diagnosed as P. falciparum and 1495 as P. vivax. Nine were mixed infection with both P. falciparum and P. vivax. The slide positivity rate was 20.48% and Pf% was 3.15. A total of 26 (0.29% of total febrile patients) cases were found to be positive for microfilaria of W. bancrofti. All microfilaria-positive cases were male, and they were categorized into four age groups. None of them found in 0–4 years and 4–9-year age group, whereas 3 (11.54%) were from 9 to 14-year age group and rest 23 (88.46%) were more than 14 years of age [Table 1]. The demography of 26 microfilaria-positive cases is given in [Table 1]. Six (23.07%) cases showed coinfection of microfilaria with malaria parasite, 1 (3.85%) with P. falciparum, and 5 (19.23%) with P. vivax [Figure 1]a, [Figure 1]b, [Figure 1]c, and 20 (76.92%) were positive for microfilaria alone. After analyzing the address and migratory history provided by the patients, it was found that, out of 26 microfilaria-positive cases, two were from West Bengal, one from Jharkhand, and 23 from northern districts of Bihar, namely, Sitamarhi, Vaisali, Madhubani, Muzaffarpur, and Darvanga. They were thoroughly asked about their migration history from their residential address and about any prior MDA or any antifilarial drug taken. None were found to take any antifilarial drugs. Out of two cases from West Bengal, one was from South Dinajpur district and other from Kolkata. It was interesting to note that the patient from Kolkata had no migration history.
Table 1: Demographical and parasitological data of microfilaria-positive patients attending malaria clinic (n=26)

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{Figure 1}


   Discussion Top


In the present study, we observe 26 febrile patients with microfilaria those were diagnosed during the diagnosis of malaria. In the study area, malaria is a major public health problem throughout the year. The environment is ideal for vectors, as malaria transmission is going on throughout the year, which can also support the existence of vector mosquitoes of filaria. Existence of vector species (Culex sp.) and the source of microfilaria may increase the risk of local transmission of filaria. In our study, one case was identified from urban Kolkata having no migratory history, which may explain the situation.

A significant number of patients attending the clinic were migratory worker mainly from Bihar and Jharkhand. Bihar has highest endemicity of filariasis over 17%.[18] Among the identified 26 patients, 23 were from Bihar, mainly from the northern districts. The patients were subsequently inquired about having the knowledge of the disease or any history of intake of any antifilarial drugs. However, it was found that these microfilaria-positive patients had no history of taking any antifilarial drugs. It may be due to nonavailability of drugs at their native places or frequent travelling, resulting in noncompliance of drugs or may be due to their absence at their own place during distribution of MDA of antifilarial drugs.

Microfilaria has a different periodicity in different geographical regions. Timings for collection of blood samples for diagnosis are important. It should be done when microfilaria appears in the blood stream to render the parasite detectable by the standard thin/thick films microscopy methods. [17, 19] Based on the time of appearance of the microfilaria in the blood, there are three recognized subtypes of W. bancrofti, namely, the nocturnally periodic, the nocturnally sub-periodic, and the diurnally subperiodic types.[20],[21],[22] W. bancrofti has shown nocturnal periodicity in India and other endemic countries of the world except pacific regions where nonperiodic or diurnal subperiodic forms have been reported. The presence of subperiodic form of W. Bancrofti filaria has been reported from Andaman and Nicobar Islands[23],[24] and a case report from Mysore, India.[25] Generally, 100 oil immersion fields of thick smear are examined for the detection of malaria parasite.[17] There is a chance of undetected microfilaria in case of low parasitemia, for which the entire thick smear should be scanned under scanner objective lens (4×). For detection of microfilaremia, examination of single smear from each patient is not sufficient. Repeat samples are needed for it at different time periods. Beside this, most of the microfilaremia is asymptomatic as it takes months to years to evolve clinical symptoms and are not attending any clinical setup for diagnosis or treatment. Such cases are one of the main obstacles to reach the goal set by the WHO for eliminating filaria by 2020 and serve as a potential reservoir for transmission in the community by the prevailing vectors.[26],[27] In the present study, only febrile patients were examined, those who attended the clinic for the diagnosis of malaria and blood samples were collected once during day time. Hence, the exact incidence may be higher than we observed.


   Conclusions Top


This study illustrates the situation of LF; who harbors microfilaria and might be a threat to the local community of urban Kolkata as they stay here over an extended period. A well-designed field-based survey by collecting night blood samples at their native places and their present location is highly suggestive to determine the exact burden of the disease. An entomological survey should also be carried out to find out vector species availability and microfilaria infectivity among the vector mosquitoes collected from and around their residence to explore ongoing local transmission, if any.

Acknowledgment

We would like to acknowledge to the Director, Calcutta School of Tropical Medicine for his kind permission for publication of this article. We are thankful to the patients for their cooperation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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