The Lymphatic Filariasis (LF) research forum: Towards developing a strategic plan for research to support the Global Program to Eliminate LF (GPELF)

The Global Program to Eliminate Lymphatic Filariasis (GPELF), now four years old and clearly providing enormous health benefits from its broad deworming effects in the poorest sectors of the developing world, represents a societal investment already measured in the tens of millions of dollars. Despite rapid progress in scaling up the program to more than 38 endemic countries (or perhaps even because of this rapid progress), there is one element essential for ultimate program success that is now being severely neglected - research, both operational and basic (upstream). The dramatic research successes in developing effective tools and strategies during the 1980s and 1990s provided the foundation for the GPELF. Generous public-private partnerships enabled its implementation, in concert with the 1997 formal resolution by the World Health Assembly calling for the elimination of LF as a public health problem worldwide. Implementation alone, however, does not guarantee success. An essential characteristic of all successful public health programs is the continuing involvement of an active research community ready to provide solutions for program problems as they arise and for anticipated problems or barriers that might appear during program activities. Indeed, such operational research must be especially vigorous and focused in programs (such as the GPELF) with a time-limited goal for disease elimination. For lessons to be learned, program strategies improved, and activities made more effective and cost-efficient, there must be a problem-solving research community actively engaged with the ongoing program initiatives and focused on their challenges. Furthermore, for diseases such as LF, the neglected 10/90 diseases of poverty, where research funds are particularly limited, it is especially critical that the most acute research needs of the program be accurately identified, effectively prioritized, and clearly laid out so that the research community and the organizations supporting it can recognize the most important opportunities available and focus their resources accordingly. It was toward this end that efforts were made during 2003-2004 to gather diverse and valued input from a very broad representation of the filariasis community, both program and research oriented. More than 90 research, clinical, and public health experts in LF came together in meetings (Annexes 1-3) and deliberations for the purpose of creating a comprehensive, collective assessment of today's LF research horizon and research needs. While there was broad agreement that the GPELF remains very much on target, in-depth assessments were made of ways to improve program support or increase understanding for each of the most important issues related to operational and basic, upstream research. For each of these domains, needs and opportunities were first defined and then prioritized. For program-oriented, operational research the greatest needs fall into four clusters: 1) to establish the tools and measures of program success by a) evaluating comparatively the diagnostics and sampling strategies available, both in humans and in vectors, b) testing the endpoints for declaring transmission interruption, c) creating/testing sets of indicators developed to monitor i) morbidity-control/ disability-prevention efforts, ii) multi-disease integrated program activities, iii) the GPELF impact on national health systems, 2) to enhance current program effectiveness by a) identifying adjunctive measures that could reduce the number of mass drug administrations (MDAs) required to achieve success (e.g., vector control, modified regimens of available drugs), b) refining predictive models for decision-making, c) improving methods and tools to treat difficult populations (especially urban and Loa-endemic communities), d) integrating LF programs with others having cost-effective complementarities, e) optimizing social mobilization techniques, and f) developing creative advocacy and fundraising strategies, 3) to ensure good clinical/morbidity management by a) standardizing clinical terminology and technical approaches to patient assessment, b) establishing best practices for home-based care for lymphedema, surgical care for hydrocoele/lymphocoele, and treatment for individuals with LF infection, c) assessing reversibility of clinical/subclinical LF disease, 4) to protect effectiveness of drug-based PELFs by a) establishing a definition for decreasing drug sensitivity, b) developing parasite repositories and surveillance for genotypic signs of drug resistance, c) continuing new and alternative drug development. Particularly important for upstream research study are those issues defining the 1) effect of LF co-infections on clinical expression of other diseases and on responsiveness to routine vaccines, 2) mechanisms that determine the pathogenesis of lymphatic disease and its clinical expression, 3) susceptibility and resistance to LF and the effect of MDA on natural immunity to LF in treated populations, 4) genomics and proteomics of filarial parasites It is clear that public health programs require both implementers and problem solvers. When problems loom large, society invests greatly in problem solving (i.e., research). When solutions are found, investments appropriately shift towards implementation. It is essential to recognize, however, that the need for problem solving (even to develop increased program efficiencies or cost-effectiveness) remains, and if not supported, threatens the very success of the program, putting at risk not only society's initial investment but also the health and welfare of the underserved populations for whom the program was created. The LF Research Community and their programmatic colleagues have deliberated extensively to define how best to strengthen the GPELF to ensure its immediate success and to enhance its research base to ensure long-term availability of problem solving research to provide solutions for program needs that are sure to arise. The clearer understanding that has emerged now promises to create a much stronger, more effective partnership between the implementing and research communities of the GPELF and the public and private funding organizations whose support is so essential for program success.