Pursuant to …;

REGARDING THE ISSUE OF ISSUING THE GUIDELINES FOR DIAGNOSIS AND TREATMENT OF FILARIASIS AT HEALTH CARE FACILITIES AND THE GUIDELINES FOR ORGANIZING MASS TREATMENT TO ELIMINATE FILARIASIS IN COMMUNITIES.

THE MINISTER OF HEALTH

Pursuant to Decree No. 68/CP dated October 11, 1993 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;
Pursuant to Decision No. 4546/QĐ-BYT dated November 12, 2002 of the Ministry of Health, establishing the Scientific and Technological Council to review the contents of the Guidelines for Diagnosis and Treatment of Filariasis at Healthcare Facilities and the Guidelines for Organizing Mass Treatment to Eliminate Filariasis in Communities;
Pursuant to the minutes of the meeting of the Scientific and Technological Council of the Ministry of Health on November 22, 2002, reviewing the contents of the Guidelines for Diagnosis and Treatment of Filariasis at Healthcare Facilities and the Guidelines for Organizing Mass Treatment to Eliminate Filariasis in Communities;
Considering the proposal of the Director of the Central Institute of Malariology, Parasitology and Entomology at Document No. 1183/VSR dated December 6, 2002 regarding the issuance of the Guidelines for Diagnosis and Treatment of Filariasis at Healthcare Facilities and the Guidelines for Organizing Mass Treatment to Eliminate Filariasis in Communities;
In accordance with the proposals of the Heads of the Department of Science and Training, the Department of Treatment, and the Department of Preventive Medicine of the Ministry of Health,

DECISION:

Article 1. Now hereby promulgated together with this Decision:

1. The Guidelines for Diagnosis and Treatment of Filariasis at Healthcare Facilities

2. The Guidelines for Organizing Mass Treatment to Eliminate Filariasis in Communities

Article 2.

- The document prescribed in Point 1 of Article 1 shall be applied in the practice of diagnosis and treatment for patients at state and private healthcare facilities. When applying this document, the prescribing rights of medical practitioners shall be respected, and the medical practitioner shall be responsible for their treatment prescriptions.

- The document prescribed in Point 2 of Article 1 shall be applied in organizing mass treatment to eliminate filariasis in counties where the disease is circulating (with people carrying microfilariae of filaria in their blood), according to the prescription of the National Program to Eliminate Filariasis in Vietnam.

Article 3. This Decision takes effect from the date of issuance.

Article 4. The Head of the Office; Heads of the Departments of Science and Training, Treatment, and Preventive Medicine; Director of the Vietnam National Pharmaceutical Administration; Directors of Provincial Health Services under the central government; Directors of the Central Institute of Malariology, Parasitology and Entomology, the Quy Nhon Institute of Malariology, Parasitology and Entomology, and the Ho Chi Minh City Branch of the Institute of Malariology, Parasitology and Entomology; Principals of Medical Universities and Secondary Medical Schools are responsible for implementing this Decision./.

 

GUIDELINES

ORGANIZATION OF MASS TREATMENT TO ELIMINATE FILARIASIS IN COMMUNITIES
(issued together with Decision No. 5047/2002/QĐ-BYT dated December 16, 2002 of the Minister of Health).

At present, the World Health Organization has identified filariasis as a disease that can be eliminated and has proposed a global strategy to eliminate filariasis until 2020 (the goal being to reduce the prevalence of filariasis to less than 0.1% of the population). The main measures include:

- Mass treatment of the entire population in areas where filariasis is endemic using DEC combined with Albendazole.

- Care for those affected to prevent secondary infections.

Vietnam has been selected by the World Health Organization as one of four countries to implement the National Program to Eliminate Filariasis.

The National Program to Eliminate Filariasis for the period 2002-2006, funded by the World Health Organization, has been approved and permitted to proceed by the Prime Minister (Document No. 74/CP-QHQT dated January 16, 2002). The Government has assigned the Ministry of Health as the managing agency and the Central Institute of Malariology, Parasitology and Entomology as the implementing agency.

To implement the program to achieve the goal of eliminating filariasis by 2010, the Ministry of Health issues these Guidelines for Organizing Mass Treatment to Eliminate Filariasis in Communities.

I. DRUGS AND USE

 1.1. Drugs used:

- Diethylcarbamazine (DEC): (brand name: Banocide, Hetrazan, Notezine...) in tablet form of 50mg, 100mg, 300mg.

DEC has the effect of killing microfilariae and partially kills adult worms. The half-life of DEC in the body is 2-12 hours, and the drug is mainly excreted through the kidneys.

- Albendazole: (brand name: Alzental, Zentel...) in tablet form of 400mg.

When used alone, albendazole does not kill microfilariae but can inhibit the reproduction of adult worms. When used in combination with DEC, albendazole enhances the effectiveness of microfilaricidal action against both Wuchereria bancrofti and Brugia malayi.

 1.2. Dosage and method of use:

- For mass treatment to eliminate filariasis, DEC and albendazole are used in combination. A single dose is taken annually for 4-6 consecutive years.

- Combined dosage of DEC and albendazole:

- From 24 months to 10 years old: 100mg DEC (1 tablet) + 400mg albendazole (1 tablet).

- From 11 to 15 years old: 200mg DEC (2 tablets) + 400mg albendazole (1 tablet).

- Over 15 years old: 300mg DEC (3 tablets) + 400mg albendazole (1 tablet).

- Take the medication with cooled boiled water after meals (preferably after dinner). Avoid alcohol during the medication period and do not take it with any other type of medication.

 1.3. Contraindications:

- Acute illness, fever.

- Pregnant women, lactating mothers.

- Children under 24 months old.

- History of allergy to the drug.

- Cases of debility, senility (over 70 years old).

- To ensure safety in mass treatment, do not treat individuals with any of the following chronic conditions: asthma, heart, liver, kidney, mental disorders.

 1.4. Precautions:

- Close monitoring of children from 24 months to 5 years old is necessary.

 1.5. Adverse effects of the drug and how to handle them:

1.5.1. Adverse effects: Usually occur within three days after taking the medication.

Possible symptoms include:

- Feeling tired, uncomfortable.

- Headache.

- Loss of appetite, nausea, vomiting.

- Itching.

- Particularly in individuals with microfilariae in the blood, symptoms may include fever (as a reaction of the body to the destruction of microfilariae), lymphadenitis, epididymitis, and orchitis...

These symptoms are usually transient and require no specific treatment.

1.5.2 Handling when encountering adverse reactions:

- Mild level: headache, fatigue, mild fever (below 38.5°C), discomfort, nausea: drink sugar water and rest at home.^°C), discomfort, nausea: drink sugar water and rest at home.

- When there is high fever (>38.5°C), vomiting, increased headache, severe itching... it is necessary to transfer to the nearest healthcare facility for examination, determination of the cause, and appropriate treatment. Antipyretics (such as paracetamol) and antihistamines (such as syrup Phenergan) can be used. In severe cases, corticosteroids may be administered.^°C), vomiting, increased headache, severe itching... require transfer to the nearest healthcare facility for examination, determination of cause, and treatment. Fever-reducing medications (paracetamol...) and antihistamines (syrup phenergan...) may be used. In severe cases, corticosteroids may be administered.

II. STEPS TO ORGANIZE MASS TREATMENT

 2.1 Preparation work:

 2.1.1. Propaganda and education are the top priority activities, conducted through various forms, especially direct propaganda at households and schools to ensure that the public fully understands and voluntarily takes the medication, achieving at least 80% coverage among the target population.

 2.1.2. Training for leaders of People's Committees at the commune level, health workers at the commune and village levels, and volunteers who distribute medication on the disease filariasis, methods to eliminate filariasis, how to compile household lists, contraindications, treatment effects, and adverse reactions of DEC and albendazole, distribution methods, monitoring, and handling adverse reactions... The trainers for these courses are specialized health workers from provincial and district levels who have been trained by the project.

 2.1.3. Compiling household lists and identifying those eligible for medication.

Health workers from the District Health Center train and guide health station staff to compile household lists by village and commune to estimate drug requirements; identify those eligible for medication.

Commune health workers need to carefully inquire about the medical history of each family member to detect those who fall under contraindications and should not take the medication to eliminate filariasis, and record them in the household list.

This list must be reviewed and decided upon by the doctor of the District Health Center before distributing the medication.

 2.1.4. Planning for drug procurement and distribution:

 - The Provincial Malaria Prevention Center or the Provincial Preventive Health Center (if the province does not have a Malaria Prevention Center) is responsible for receiving drugs from the central level and distributing them to District Health Centers; District Health Centers distribute to Commune Health Stations; Commune Health Stations distribute drugs to Village Health Stations.

 - Each level needs to determine the time and place for receiving drugs, storage locations, persons responsible for receiving, storing, and distributing drugs. Medication is provided to village health workers along with instructions for use.

 - Determine the date for taking medication for each village and commune during the mass medication campaign.

 2.1.5. Preparing to handle adverse reactions:

 - Commune Health Stations prepare emergency medications and measures to handle adverse reactions, assigning health workers to provide round-the-clock emergency care during the medication period and for three days afterward.

 - The District Health Center prepares mobile emergency teams to support communes when needed, clearly defining contact addresses (phone numbers) for convenient communication between levels.

 2.2 Organizing medication intake:

 2.2.1 On the day of medication intake:

 - People's Committees at all levels and health authorities at the provincial, district, and commune levels assign personnel to directly oversee the organization of mass medication intake.

 - Immediately before administering the medication, reconfirm contraindications or temporary deferrals for medication intake at each household. In addition to the old contraindication list, pay attention to new illnesses or recent alcohol consumption.

 - Administer medication according to the household list and previously announced plan. Record the list of people taking medication thoroughly.

 - Take medication on a full stomach (preferably after dinner), using cooled boiled water in clean containers, and under the supervision of the medication distributor to prevent the situation where people receive but do not take the medication. During the medication period, avoid alcohol consumption. After taking the medication, individuals can engage in normal activities but should avoid strenuous work.

 - It is not advisable to administer medication on extremely hot and humid days.

 - To prevent and handle potential adverse reactions, the District Health Center assigns doctors and Commune Health Stations to monitor medication intake in villages and hamlets on the day of medication intake and for at least three days afterward, promptly addressing any adverse reactions.

 - Each district should organize medication intake in 1-2 communes first to gain experience before expanding to other communes.

 2.2.2 After the day of medication intake:

 - The District Health Center assigns personnel to continue post-medication follow-up, detecting and promptly treating any adverse reactions (fever, headache, dizziness, abdominal pain...). Record and statistically report those experiencing reactions and their treatments.

 - When adverse reactions occur, remain calm, examine, treat, and explain to patients and families to reassure them and avoid panic. Distinguish adverse reactions from symptoms of other diseases.

 - After completing the mass medication campaign, conduct statistics and report: number of people taking medication, quantity of medication received, quantity used, surplus medication, projected quantity for the next year, number of people showing medication reactions, and submit to the upper-level Project Management Board within the specified timeframe.

 - Compile a list of individuals who were unable to take medication due to illness, absence, etc., to plan supplementary medication intake appropriately. Commune Health Stations report and organize supplementary medication intake sessions under the guidance of the District Health Center.

III. IMPLEMENTATION

 3.1. Provincial People's Committees benefiting from the project are responsible for organizing the implementation of the project locally, particularly ensuring safe and high-coverage mass medication intake. They instruct People's Committees at the district and commune levels in beneficiary areas to implement the following requirements:

3.1.1. Direct the operation of the local project management board to develop and implement plans effectively to achieve the project's objectives.

3.1.2. Create favorable conditions for the implementation of the project at the local level.

3.1.3. Mobilize relevant departments to organize well the propaganda and mobilization work to encourage the public to fully participate in mass drug administration campaigns and other project activities.

3.1.4. Direct and inspect the safety assurance and high coverage rates during mass drug administration campaigns.

 3.2. Provincial Health Departments benefiting from the project shall be responsible before the Provincial People's Committee and the Ministry of Health for directly organizing and implementing the project and conducting mass drug administration campaigns locally.

3.2.1. Direct the Provincial Malaria Prevention Center (or Provincial Preventive Health Center) to advise the Provincial People's Committee on developing plans to implement the project locally, particularly ensuring safety and achieving high coverage rates during mass drug administration campaigns.

3.2.2. Direct the Provincial Malaria Prevention Center (or Provincial Preventive Health Center) and District Health Centers to train commune-level staff thoroughly on specialized technical guidance for lymphatic filariasis treatment at healthcare facilities and mass drug administration campaigns to eliminate lymphatic filariasis in the community.

3.2.3. Direct District Health Centers benefiting from the project to develop detailed plans to implement the project, especially measures to ensure safety and achieve high coverage rates during mass drug administration campaigns.

3.2.4. Mobilize medical staff from provincial and district levels to participate in organizing mass drug administration campaigns, assist communes in correctly identifying eligible recipients, contraindicated individuals, promptly detect and manage adverse reactions. Report promptly any difficulties and incidents occurring during mass drug administration campaigns to the Ministry of Health (Preventive Medicine Department, Treatment Department) and the Central Institute of Malariology, Parasitology and Entomology for support in resolution.

3.2.5. Organize well the investigation and evaluation of the project's implementation results locally.

 3.3. The Central Institute of Malariology, Parasitology and Entomology, the Quy Nhơn Institute of Malariology, Parasitology and Entomology, and the Ho Chi Minh City Branch of the Institute of Malariology, Parasitology and Entomology are responsible for performing specific tasks as follows:

3.3.1. Be accountable to the Ministry of Health for directing localities to implement the project and organize mass drug administration campaigns in accordance with the guidelines issued by the Ministry of Health.

3.3.2. The Central Institute of Malariology, Parasitology and Entomology serves as the main provider of drugs and various record books, forms for recording and reporting to support mass drug administration; organize interim and final reviews, report results to the Ministry of Health (Treatment Department, Preventive Medicine Department).

3.3.3. Organize training for provincial and district health workers; provide instructional materials for localities to organize training and implementation. Support localities in training and investigating, evaluating project outcomes.

3.3.4. Inspect the preparation of localities before conducting mass drug administration campaigns, particularly measures to ensure safety and achieve high coverage rates.

3.3.5. Dispatch personnel to coordinate with local health authorities to supervise and direct during mass drug administration campaigns.

3.3.6. Timely compile results of drug administration rounds, report to the Project Management Board and the Ministry of Health, while summarizing experiences to disseminate to other localities.

 

 

GUIDELINES

DIAGNOSIS AND TREATMENT OF LYMPHATIC FILARIASIS AT HEALTH CARE FACILITIES (WITH CONDITIONS FOR DETECTING MICROFILARIAE AND FOLLOW-UP TREATMENT)
(issued together with Decision No. 5047/2002/QĐ-BYT dated December 16, 2002 of the Minister of Health).

I. OVERVIEW

Lymphatic filariasis is caused by a type of worm living in the lymphatic system. Adult worms live in lymph nodes or lymph vessels, producing microfilariae that circulate in the blood. Lymphatic filariasis can occur at any age, affecting both males and females. It causes many complications that significantly impact labor productivity, aesthetics, and daily life of patients.

In Vietnam, only two species of lymphatic filariasis have been identified: Wuchereria bancrofti and Brugia malayi nocturna. In the northern region, Brugia malayi is commonly found (about 90-95% of cases). In the southern region, recent surveys have only detected Wuchereria bancrofti. Microfilariae appear in peripheral blood at night between 8 PM and 4 AM. Brugia malayi has not been detected in animals (cats, monkeys) in Vietnam.

The disease is transmitted through mosquito bites. Common vector species in Vietnam include Mansonia annulifera, Mansonia uniformis (breeding in areas with water hyacinth), and Culex quinquefasciatus. When mosquitoes bite infected humans, microfilariae enter the mosquito and after some time develop into infective larvae. When biting healthy individuals, these larvae enter the human body and develop into adult worms. The incubation period from infection to microfilariae appearing in the blood is approximately three to seven months.

II. DIAGNOSIS

 2.1. Definitive diagnosis.

Most infected individuals (90-95%) with lymphatic filariasis (microfilariae in the blood) do not show clinical symptoms for many years or even throughout their lives. In symptomatic cases, various symptoms may occur, commonly including:

2.1.1. Acute symptoms:

- Fever: sudden onset of high fever, accompanied by fatigue and headache; often recurs in episodes lasting 3-7 days.

- Lymphangitis and lymphadenitis: usually occur a few days after fever. Red, painful inflammatory streaks along lymph vessels, typically on the inner side of the lower limbs. Groin lymph nodes may swell and become painful.

2.1.2. Chronic symptoms commonly seen:

- Genital inflammation or swelling such as epididymitis, orchitis, hydrocele. Chronic lymphadenopathy in the genital area may cause elephantiasis-like symptoms in the scrotum or breast.

- Elephantiasis of the lower extremities: resulting from chronic inflammation and obstruction of lymph vessels and nodes in the lower limbs, characterized by hard swelling and thickened skin. Swelling can range from the feet up to the thighs depending on severity.

- Chyluria: cloudy urine resembling rice washing water, which does not settle when left standing. Occasionally, it may contain blood. If there is a large amount of chyle in the urine, it may coagulate over time.

2.1.3. Epidemiological factor: the patient lives in an area where lymphatic filariasis is endemic.

 2.2. Clinical diagnosis.

 2.2.1. Cases with symptoms:

 - Detection of microfilariae in peripheral blood: draw peripheral blood at night (from 8 PM to midnight), prepare smears, stain and examine under a microscope for microfilariae. This is a simple and commonly used diagnostic technique that confirms the presence of circulating microfilariae in the patient. However, in cases of elephantiasis or hydrocele, the detection rate of microfilariae in the blood is very low (only about 3-5%).

 - If conditions permit:

 . Perform ultrasound to detect adult worms in lymph nodes and lymph vessels.

 . Conduct ELISA immune response tests to detect antibodies or antigens of lymphatic filariae in the patient's blood.

 2.2.2. Cases without symptoms:

 Mainly based on blood tests:

 - For Brugia malayi: draw peripheral blood at night (from 8 PM to midnight), prepare smears, stain and examine for microfilariae under a microscope.

 - For Wuchereria bancrofti: in addition to the nighttime blood test method to find microfilariae, there is now a rapid immuno-chromatographic test (ICT) which can be performed during the day.

 2.3. Differential diagnosis.

 2.3.1 Fever due to other causes:

 - Due to bacterial infections: usually have an entry point, an infection focus, and an increased neutrophil count in the blood formula.

 - Due to viruses: viral fever outbreaks occur, without recurrence.

 - Due to malaria: patients live in or recently returned from malaria-endemic areas; blood tests may show malaria parasites.

 2.3.2. Lymphangitis: may be due to bacterial infection. Differential diagnosis is made by blood test for microfilariae.

 2.3.3. Elephantiasis (hard edema): differentiate from edema caused by fungi, pelvic tumors, trauma... compressing lymph vessels. These cases are rare. Differential diagnosis is made by lymph node biopsy for fungi, or examination to detect tumors, trauma...

 2.3.4. Hydrocele due to renal causes (possibly due to tuberculosis, trauma...). A thorough examination is needed to rule out tuberculosis or trauma history in the renal region.

 2.3.5. Hydrocele due to chylous effusion needs to be differentiated from inguinal hernia. In inguinal hernia, the bowel can be pushed back or symptoms of bowel obstruction may appear.

III. TREATMENT

 3.1. Medications used.

 Diethylcarbamazine (DEC): trade name: Banocide, Hetrazan, Notezine... in tablet form 50mg, 100mg, 300mg.

DEC has the effect of killing microfilariae and partially kills adult worms. The half-life of DEC in the body is 2-12 hours, and the drug is mainly excreted through the kidneys.

 3.2. Dosage.

 - For W.bancrofti: DEC 6 mg/kg/day for 12 days. Total dose is 72 mg/kg.

 - For B.malayi: DEC 6 mg/kg/day for 6 days. Total dose is 36 mg/kg.

Treatment with the above dosage should be repeated after one month if microfilariae of lymphatic filariae are still detected in the blood test.

 3.3. Usage.

 3.3.1. Treatment of cases infected with lymphatic filariae with microfilariae in the blood but without clinical symptoms: use specific DEC medication with the dosage mentioned above (section 3.2).

 3.3.2. Cases infected with lymphatic filariae with microfilariae in the blood and with acute clinical symptoms such as fever, lymphadenitis, lymphangitis...:

 - During the acute phase, only symptomatic treatment is given: reduce fever, relieve pain (paracetamol may be used), rest, do not use specific DEC medication (as it may cause lymphangitis and lymphadenitis).

 - Antibiotics for secondary infection: in severe cases, systemic antibiotics can be taken orally or injected depending on the severity of the secondary infection.

 - After the acute phase, specific DEC medication can be used to eliminate lymphatic filariae with the dosage mentioned above (section 3.2).

 3.3.3. Cases with elephantiasis symptoms (limb edema, scrotal edema, breast edema...):

 - Only use DEC medication if microfilariae are detected in the blood test: take specific DEC medication with the dosage mentioned above (section 3.2).

 - In patients with elephantiasis, bacterial superinfection plays an important role. To prevent superinfection and alleviate damage to the affected body parts:

 . Wash the affected limb twice a day with clean water and soap, dry gently with a soft towel. Pay attention to folds, crevices, and nails.

 . Exercise, gently massage the legs to enhance circulation.

 . Elevate the legs at night or use light compression bandages like girdles to avoid stasis in the affected limbs.

 During bacterial superinfections, topical antibiotics (ointments or powders) can be used. In severe cases, systemic antibiotics (oral or injectable) may be necessary.

 3.3.4. Treatment of cases with chyluria:

 - Only use DEC medication if microfilariae are detected in the blood test: take specific DEC medication with the dosage mentioned above (section 3.2).

 - Follow a diet low in fat and high in protein.

 - Rest.

 - For patients with persistent and severe chyluria: referral to specialized treatment (surgical if possible) is required.

 3.4. Contraindications.

 Do not administer DEC medication for lymphatic filariasis in the following cases:

- Acute illness, fever.

- Pregnant women, lactating mothers.

- Children under 24 months old.

- History of allergy to the drug.

 - Be cautious when administering the drug and closely monitor patients with asthma and other chronic diseases (heart, liver, kidney...).

 3.5. Side effects of the drug and management.

 3.5.1. Side effects:

 Usually occur within three days after taking the medication. Symptoms may include:

- Feeling tired, uncomfortable.

- Headache.

- Loss of appetite, nausea, vomiting.

 - Itching

 - Particularly in patients with microfilariae, symptoms may include: fever (a body reaction to the destruction of microfilariae), lymphangitis, lymphadenitis, spermatic cord, epididymis.

These symptoms are usually transient and require no specific treatment.

 3.5.2. Management of side effects:

- Mild level: headache, fatigue, mild fever (below 38.5°C), discomfort, nausea: drink sugar water and rest at home.^°C), discomfort, nausea: drink sugar water and rest in bed.

- When there is high fever (>38.5°C), vomiting, increased headache, severe itching... it is necessary to transfer to the nearest healthcare facility for examination, determination of the cause, and appropriate treatment. Antipyretics (such as paracetamol) and antihistamines (such as syrup Phenergan) can be used. In severe cases, corticosteroids may be administered.^°C), vomiting, increased headache, severe itching... require medical examination, determination of the cause, and treatment with antipyretics, analgesics (paracetamol...), antihistamines (syrup phenergan...), and in severe cases, corticosteroids.