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Frontiers in Tropical Diseases ·

Volume 7 - 2026 | https://doi.org/10.3389/fitd.2026.1897015

Toward 2030 road map: accelerating filariasis elimination through next-generation point-of-care diagnostics

  • Alfred Kwesi Manyeh1
  • Leonard Edem Quarshie1
  • Monica Ahiadorme2*corresponding author
  1. 1Centre for Neglected Tropical Diseases Research, Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
  2. 2Department of Basic Sciences, School of Basic and Biomedical Sciences, University of Health and Allied Sciences, Ho, Ghana
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Abstract

Filariasis comprises neglected vector-borne parasitic diseases, including lymphatic filariasis (LF), onchocerciasis, loiasis, and mansonellosis, that affect hundreds of millions across tropical regions. Achieving the World Health Organization’s (WHO) 2030 elimination targets depends on accurate, field-deployable point-of-care (POC) diagnostics for endemicity mapping, mass drug administration, treatment-stopping decisions, and post-validation surveillance. Multiplex diagnostics are relevant not only in sub-Saharan Africa but also in the Americas, Asia, and the Pacific, where distinct filarial species and co-endemic infections create additional diagnostic challenges. This mini-review synthesizes the current POC diagnostic landscape. LF and onchocerciasis programmes rely on antigen and antibody tools, but these suffer declining sensitivity in low-prevalence post-mass drug administration settings, antigenic cross-reactivity, and failure to meet WHO target product profiles. Loiasis lacks a commercial POC test, creating life-threatening barriers to safe ivermectin delivery. Mansonellosis remains the most neglected, with no validated POC tool and poorly characterized cross-reactivity. Emerging innovations, such as multiplex rapid diagnostic tests, colorimetric loop-mediated isothermal amplification assays, and artificial intelligent-assisted microscopy, offer credible pathways forward. We recommend prioritized investment in loiasis and mansonellosis diagnostics, multiplex platforms, and sustainable procurement frameworks to support elimination by 2030.

Keywords

1 Introduction

Filariasis is a group of vector-borne parasitic diseases caused by tissue-dwelling nematodes that remain a major public health burden in tropical and subtropical regions. The principal human infections include lymphatic filariasis (LF), caused by Wuchereria bancrofti, Brugia malayi, and Brugia timori; onchocerciasis, caused by Onchocerca volvulus; loiasis, caused by Loa loa; and mansonellosis, caused by Mansonella perstans, Mansonella ozzardi, and Mansonella streptocerca (1, 2).

LF is endemic in 72 countries, with 657 million people in 39 countries requiring preventive chemotherapy as of 2023 (3, 4), and at least 36 million living with chronic manifestations such as lymphoedema and hydrocele, which contribute to disability, stigma, and poverty (5). Onchocerciasis is the second leading infectious cause of blindness worldwide after trachoma, with an estimated 20.9 million people currently infected and 252.3 million living in areas requiring preventive chemotherapy in 2024. More than 99% of cases occur in sub-Saharan Africa, where the disease causes severe skin disease in 14.6 million people and vision loss in approximately 1.15 million (6–8).

Although loiasis has historically been considered relatively benign, cohort studies demonstrate that a high Loa loa microfilaraemia level is associated with serious multi-organ complications, including renal, cardiac, and neurological sequelae, and a significantly increased mortality risk (9, 10). Mansonellosis, despite being the most widely distributed filarial infection, remains understudied and neglected with substantial endemicity in sub-Saharan Africa and parts of the Americas, but no comprehensive control programme in place (11).

The World Health Organization (WHO) 2030 Roadmap for Neglected Tropical Diseases (NTDs) sets ambitious targets: elimination of LF as a public health problem in 58 endemic countries, interruption of onchocerciasis transmission in 12 priority countries, and morbidity control for all filarial diseases by 2030 (12). Mass drug administration (MDA), typically involving ivermectin (IVM), diethylcarbamazine (DEC), and/or albendazole (ALB), depending on local co-endemicity, remains the cornerstone of these programmes (12). Achieving and verifying elimination requires a robust diagnostic framework across the programme lifecycle: from baseline mapping to guide MDA initiation, through transmission assessment surveys (TASs) to inform cessation, to post-MDA surveillance and formal validation of elimination (12).

Despite progress, diagnostic tools remain largely inadequate for elimination programmes. Conventional methods, such as night blood microscopy for LF, skin-snip microscopy for Onchocerca volvulus, and daytime blood films for Loa loa and Mansonella, demand skilled personnel, laboratory infrastructure, and timed blood sampling, limiting scalability (13, 14). Point-of-care (POC) rapid tests have improved LF and onchocerciasis programmes, but are constrained by cross-reactivity, reduced sensitivity in low-prevalence post-MDA settings, and performance gaps relative to WHO target product profiles (15–19). For Loa loa, no commercial POC tests exist despite its critical role in safe IVM deployment (14, 20). Mansonellosis diagnostics remain reliant on microscopy, with no validated POC tools available, despite the broad distribution and interference with serological assays (11).

This mini-review summarizes the current POC diagnostic landscape for human filarial diseases, highlighting recent advances, persistent limitations, and priorities for future development.

2 Point of care diagnostics for filarial diseases

2.1 Lymphatic filariasis

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) has a well-established POC diagnostic toolkit that supports mapping, monitoring, surveillance, and elimination validation, including antigen detection with the immunochromatographic test (ICT) card (21), its successor, the Filariasis Test Strip (FTS) (22), and antibody detection with the Brugia Rapid Test (23, 24). Detection of circulating filarial antigen (CFA) remains central, with the ICT card historically used for mapping and transmission assessment surveys (TAS) (22, 25) before being replaced by the FTS following field evaluations demonstrating improved sensitivity in endemic settings and operational advantages, while both assays utilize daytime finger-prick blood (26). WHO TAS guidance and subsequent elimination-validation frameworks also support the use of Brugia-based serology in appropriate endemic settings (25). More recently, Brugia Test Plus (BT+) has been incorporated into national programme activities in Timor-Leste, contributing to surveillance that supported WHO validation of LF elimination in 2024 (27).

Limitations include reduced sensitivity in programmatic settings in low-prevalence, post-MDA contexts, inability to detect prepatent infections, and cross-reactivity with high L. loa microfilaraemia. Antigen tests may miss residual infections because CFA levels can fall below the detection threshold (28–30). The STANDARD Q Filariasis Antigen Test (QFAT) is a promising next-generation CFA assay, but requires further validation (31). For Brugia spp., CFA tests are unsuitable (22); the Brugia Rapid IgG4 antibody test, which targets recombinant BmR1, demonstrates good sensitivity and specificity (23), but variability and the inability to distinguish active infection remain challenges (32). No Brugia-specific antigen test exists (28).

2.2 Onchocerciasis

Diagnosis has traditionally relied on skin-snip microscopy, which is highly specific but loses sensitivity as microfilarial densities decline under MDA, and is poorly accepted by affected communities (33, 34). WHO no longer recommends skin-snip for stopping MDA, favouring serological and entomological approaches (35). The Ov-16 IgG4 rapid diagnostic test (RDT) is now the principal POC tool, especially in children where seroprevalence indicates recent transmission (35, 36). Limitations include antibody persistence after transmission decline and reduced utility in adults (37). Newer Ov-16 biplex assays aim to improve specificity, with some capable of detecting both O. volvulus and L. loa antibodies from a single finger-prick (38, 39). Communities generally prefer RDTs to skin-snips, but persistent seropositivity after prolonged IVM treatment complicates programme decisions (37, 40).

2.3 Loiasis

Loiasis remains the most difficult filarial infection to diagnose at POC. No commercial rapid test exists; microscopy of daytime blood remains the standard (14). This poses major barriers in Central Africa, where co-endemicity with onchocerciasis and LF complicates IVM-based MDA due to risk of severe adverse events in individuals with high microfilarial loads (20).

The LoaScope, a smartphone-coupled video microscope, can quantify L. loa microfilariae (MF) in finger-prick blood within minutes (41, 42). A landmark study in Cameroon showed that ‘test-and-not-treat’ strategies using LoaScope enabled safe IVM delivery to >15,000 participants without serious adverse events (42, 43). Serological tools, including LlSXP-1 lateral flow assays and biplex antibody tests, are under development (38), but they measure exposure rather than microfilarial density and cannot replace quantitative screening. A scalable, commercial POC test for L. loa quantification remains a critical priority.

2.4 Mansonellosis

Mansonellosis is the most neglected of the human filarial infections from a diagnostic perspective. Despite > 114 million infections across Africa and the Americas (44–46), no validated commercial POC test exists. Diagnosis relies on microscopy: thick blood films for M. perstans and M. ozzardi, and skin-snips for M. streptocerca. These methods require expertise and lose sensitivity at low parasite densities. M. perstans MF circulate continuously, allowing daytime sampling, but morphological identification is difficult (11, 45).

Recent advances include loop-mediated isothermal amplification (LAMP) assays targeting species-specific repeats (Mp419 for M. perstans, Mo2 for M. ozzardi) with high sensitivity and specificity (46, 47). Multiplex LAMP assays for O. volvulus, L. loa, and M. perstans have been demonstrated in Cameroon (47), but remain research tools limited by reagent stability and training needs. Importantly, Mansonella infections can confound serological assays for W. bancrofti and O. volvulus, inflating prevalence estimates (44). Developing validated, field-deployable POC tests for Mansonella spp. is a critical priority in filarial diagnostics. The current pipeline POC diagnostic tools for the major human filarial infections, including their sensitivity/specificity, programme applications, critical limitations, and pipeline developments, are summarized in Table 1.

Table 1. Summary of current and pipeline POC diagnostic tools for human filarial infections.

FilariaCurrent POC tool(s)Sensitivity/specificityKey programme useCritical limitation(s)Pipeline toolsReferences
W. bancroftiFTS, QFATHigh specificity in endemic-use contexts; sensitivity reduced in low-prevalence or post-MDA settingsMapping, TAS, post-MDA surveillanceCross-reactivity with L. loa; reduced sensitivity after treatment; no perfect field test for very low-density infectionLAMP(22, 26, 31, 62, 75, 84)
Brugia sppBrugia rapid antibody testGenerally good performance in endemic settings, but varies by assay and prevalenceMapping and surveillance in brugian-endemic areasAntibody detection does not prove active infection; performance may vary at low prevalenceBrugia Test Plus (BT+); multiplex serology assays(23, 28, 32, 84, 85)
O. volvulusOv-16 IgG4 RDTUseful for elimination surveillance, performance depends on threshold and settingStop-MDA surveillance and elimination mappingDetects exposure, not active infection; persistent seropositivity complicates interpretationImproved Ov-16 formats, biplex RDTs(35–38, 40)
Loa loaNo commercial POC test; LoaScopeLoaScope is highly accurate for safety screening in validation studiesPre-MDA safety screeningRequires device, training, and smartphone infrastructureOv/Loa biplex RDT; Loa LAMP assays(38, 41, 42, 86)
MansonellaNo validated commercial POC test; microscopyMicroscopy limited by low-density infection and species differentiation issuesNone routine for elimination programmesNo commercial assay; morphology-based diagnosis requires expertise; serology may be cross-reactive in co-endemic settingsSpecies-specific LAMP; multiplex molecular assays(11, 44–47)

FTS, Alere Filariasis Test Strip; TAS, Transmission Assessment Survey; QFAT, Q Filariasis Antigen Test; LAMP, Loop-Mediated Isothermal Amplification. POC, Point of care; RDT, Rapid Diagnostic test; Ov, Onchocerca volvulus; IgG, Immunoglobulin G; MDA, Mass Drug Administration.

3 Barriers to POC diagnostics in filariasis

Across all four filarial diseases, interconnected obstacles limit the development, uptake, and programmatic impact of POC diagnostic tools. These barriers arise from biological complexity, programme design, and structural market gaps, underscoring systemic weaknesses that constrain elimination efforts.

3.1 Co-endemicity and cross-reactivity

Co-endemicity in Central and West Africa is a challenge. Mapping analysis estimates that 8.7 million people live in areas co-endemic for onchocerciasis and high-risk loiasis (≥30,000 mf/mL), requiring individualized test-and-treat strategies before any IVM-based MDA can be safely initiated (48).

WHO guidelines specify regimen changes depending on the co-endemicity: ALB alone in loiasis areas, IVM plus ALB in onchocerciasis zones, and DEC plus ALB where onchocerciasis is absent (12). Without rapid, field-deployable tools to identify species and infection intensity, programmes cannot safely implement correct interventions.

Antigenic cross-reactivity further undermines accuracy. High-density L. loa infections can yield false-positive LF antigen results. A study in Cameroon showed ICT positivity ≥1% only in villages with >15% L. loa prevalence, despite absence of W. bancrofti by microscopy and molecular testing (30, 49). Molecular work identified specific L. loa proteins responsible for cross-reactivity with LF RDTs, including FTS (50). This suggests that portions of LF prevalence maps in Central Africa may reflect loiasis rather than bancroftian filariasis, with serious implications for MDA resource allocation. Similar risks exist with Mansonella antigens, though evidence remains limited (49). Overall, reliance on single-antigen, single-species POC tests is inadequate in co-endemic settings. Addressing these limitations will require the development of more specific multiplex diagnostic platforms, together with complementary confirmatory approaches capable of accurately distinguishing co-endemic filarial infections.

3.2 Sensitivity limitations in post-MDA settings

Diagnostic performance becomes increasingly difficult to interpret at the near-elimination stage. As MDA reduces prevalence and infection intensity, antigen and antibody signals weaken. Consequently, several studies have evaluated whether lower programmatic antigen-prevalence thresholds could better support elimination decisions in low-endemic and post-MDA settings, while recognizing that any reduction in these thresholds must be balanced against reduced specificity and the risk of false-positive programmatic conclusions (26, 51–53). Importantly, these studies address programmatic decision thresholds rather than the underlying positivity cut-off of the ICT or FTS assays.

For LF, sensitivity loss is well documented. In West Africa, the ICT card detected just 35.7% of ELISA-positive individuals, showing that antigen tests may miss most residual infections in post-MDA settings (29). Surveys in Samoa and Myanmar demonstrated that combining antigen and antibody markers (Wb123, Bm33 and Bm14) provides complementary information for surveillance of residual transmission. While antigen tests indicate active infection, antibody markers reflect exposure and may remain detectable after parasite clearance, thereby improving the sensitivity of transmission surveillance but not necessarily confirming ongoing infection (54, 55).

For onchocerciasis, the Ov-16 IgG4 antibody develops approximately 12–15 months after infection and may persist long after parasite clearance or treatment. As a result, Ov-16 seropositivity reflects exposure rather than necessarily indicating active infection, limiting its utility for short-term monitoring of treatment response (56). Field evaluations in South Sudan demonstrated suboptimal sensitivity and specificity (57), while concordance studies in Cameroon identified gaps in prevalence detection (36). WHO guidelines therefore recommend Ov-16 serology primarily in children younger than 10 years for MDA stopping decisions (58), thereby reducing the influence of historical antibody responses. However, this strategy does not fully overcome the limited sensitivity of Ov-16 assays for detecting low-level or recent transmission. A Bayesian analysis across Mozambique, Ghana, and Benin found that although Ov-16 RDTs met sensitivity targets, none achieved the required specificity of >99.8% (59), raising concerns about diagnostic uncertainty in elimination settings. While premature MDA cessation has been documented in LF programmes using antigen-based surveillance (60, 61),the implications for onchocerciasis remain less certain because elimination decisions incorporate serological, epidemiological, and entomological evidence.

3.3 Operational, commercial, and regulatory barriers

Even technically adequate tools face deployment challenges. Early ICT cards required strict cold chain storage (15, 62); although FTS improved stability, fragility and moisture susceptibility persist (31, 62). The LoaScope requires hardware, smartphone compatibility, and trained staff, limiting use to research settings rather than routine MDA (42, 63).

At the structural level, the market for filariasis diagnostics offers limited commercial incentives for manufacturers, as procurement is largely dependent on WHO and donor-supported mechanisms rather than routine commercial demand (64). As a result, procurement remains concentrated within WHO and donor programmes, providing little incentive for sustained product development, manufacturing, and scale-up (28, 65). Funding for LF diagnostics continues to rely heavily on donor-supported procurement, underscoring the fragility of long-term supply security and the sustained availability of essential tools (28, 65, 66). WHO’s Diagnostic Technical Advisory Group (DTAG) has acknowledged this market failure, citing prolonged development timelines, limited manufacturer engagement, and high unit costs (67–69). Human resource constraints, including staff turnover, and limited diagnostic capacity, further undermine diagnostic reliability (70, 71).

Regulatory frameworks add complexity. WHO has piloted an Expert Review Panel for NTD diagnostics, but its long-term impact remains uncertain. Meanwhile, the European Union In Vitro Diagnostic Regulation (EU IVDR) has increased compliance costs, with concerns about reduced availability of some tools (72, 73). Key programmatic barriers to the effective use of POC diagnostics in filariasis are summarized in Table 2.

Table 2. POC diagnostic challenges in filariasis.

ChallengeFilaria(e) affectedSpecific manifestationProgrammatic consequenceReferences
Co-endemicity and treatment safetyLF, Onchocerciasis, Loa loaIVM can trigger SAEs in people with high Loa loa microfilaremia, test-and-treat or test-and-not-treat approaches may be needed in co-endemic settingsMDA may be delayed, modified, or interrupted in affected areas(43, 48)
Cross-reactivity and inflated prevalence estimatesLF; co-endemic onchocerciasis/Loa loa/Mansonella settingsHigh Loa loa microfilaremia can cause false-positive ICT/FTS results for W. bancrofti; Mansonella may contribute to cross-reactivity in some settingsEndemicity may be misclassified, resources misallocated, and elimination decisions distorted(49, 50)
Post-MDA sensitivity gapLF (W. bancrofti and Brugia spp.)CFA-based tests may be less informative in low-prevalence settings; antibody markers such as Wb123, Bm33, and Bm14 may be more useful near eliminationTransmission may persist, undetected and MDA may be stopped prematurely(29, 54)
Absence of commercial POC testsLoa loa; Mansonella spp.No widely used validated commercial serological RDTs are available; LoaScope remains non-scaled, and Mansonella diagnosis relies largely on microscopyMDA safety cannot be assured in Loa loa endemic areas and Mansonella epidemiology remains incompletely defined(42, 63)
Cold chain, cost and supply chainLFFTS is ambient-stable and stored at ambient temperature; procurement dependence and limited market competition still constrain accessStock-outs, delayed testing, and programme disruption may occur(15, 62)
Regulatory and WHO prequalification gapsAll filarial diseasesFew filarial POC tests have WHO prequalification; regulatory requirements remain uneven and may increase manufacturer burdenProcurement is less secure and routine quality assurance remains limited(72, 73).

MDA, Mass drug administration; POC, Point of care; WHO, World Health Organization; LF, Lymphatic filariasis; IVM, Ivermectin; SAE, Severe adverse events; ICT, Imunochromatographic card test; FTS, Alere Filariasis Test Strip; CFA, circulating filarial antigen; RDTs, rapid diagnostic tests.

4 Emerging advances in filariasis POC diagnostics

Despite the formidable challenges described above, a new generation of diagnostic innovations is beginning to address technical and programmatic gaps. Advances include improved antigen platforms, field -deployable molecular assays, artificial intelligence (AI)-assisted microscopy, and integrated surveillance strategies, each offering pathways toward the next-generation toolkit required for elimination.

4.1 Multiplex and biplex rapid diagnostic tests

Recent progress includes multiplex RDTs capable of detecting antibody responses to multiple filarial species from a single finger-prick blood sample. Although antibody responses do not necessarily indicate active infection and may persist following parasite clearance, multiplex antibody RDTs are valuable for integrated surveillance, mapping co-endemic infections, identifying populations with recent or historical exposure, and guiding decisions on where further parasitological or molecular investigations are warranted. Campillo et al. (2024) evaluated a biplex RDT detecting L. loa and O. volvulus in a single lateral-flow format, demonstrating its potential for use in co-endemic settings, although further validation is needed. This approach may also help identify individuals at risk of severe adverse events before IVM-based MDA and assists in distinguishing true Ov-16 seropositivity from potential cross-reactivity associated with loiasis.

The SD Bioline Onchocerciasis/LF IgG4 Rapid Test, which detect W. bancrofti and O. volvulus antibodies, has been used in integrated surveys in Mali, demonstrating the feasibility of combined surveillance (74). The logical next step would be a broader multiplex platform covering LF, onchocerciasis, loiasis, and mansonellosis, although current commercial tools remain limited to narrower biplex formats (14).

4.2 Field-deployable molecular amplification: LAMP and NINA-LAMP

LAMP offers a molecular alternative to PCR in resource-limited settings. Operating at constant temperature, LAMP provides colorimetric readouts without laboratory instrumentation. Poole et al. (2017) demonstrated NINA-LAMP assays for B. malayi, W. bancrofti, and O. volvulus using a portable heater, with results interpretable by visible colour change (75).

Amambo et al. (2023) evaluated LAMP assays for O. volvulus, L. loa, and M. perstans in Cameroon, confirming strong field performance (47). Poole et al. (2019) further developed assays for M. perstans and M. ozzardi, achieving detection limits of 0.1 pg and 0.01 pg, respectively, without cross-amplification.

Despite these advances, key barriers remain, including reagent stability, cold-chain requirements, operator training and limited translation beyond research prototypes (47, 76).

4.3 AI-assisted digital microscopy

AI-assisted microscopy may help address shortages of trained microscopists and improve the standardization of slide interpretation in endemic settings (66, 77). Lin et al. (2024) developed an edge-AI system running on a smartphone linked to a conventional microscope, enabling real-time detection of MF without internet connectivity (77). The system demonstrated the ability to differentiate L. loa, M. perstans, W. bancrofti, and B. malayi with strong validation performance (77).

This approach is particularly relevant for loiasis and mansonellosis, where microscopy remains a key diagnostic method and rapid POC alternatives are limited (66). It may also strengthen microscopy-based diagnosis of LF by improving automated detection of W. bancrofti and B. malayi MFs, thereby reducing reliance on highly trained microscopists and improving consistency in field-based interpretation (66).

By automating slide reading and reducing operator dependence, AI-assisted microscopy could support field-level diagnosis and surveillance by non-specialist health workers in endemic settings (66, 78). Wider deployment will require validation across endemic contexts, simplification of workflows, and integration into routine health system operations (66, 78).

5 Future directions

Most advances remain at prototype stage. Priorities include field-ready, affordable diagnostics suited to co-endemic settings, especially quantitative tools for L. loa microfilaraemia and improved assays for Mansonella spp (14, 79). Multiplex POC platforms capable of detecting multiple infections simultaneously should be a focus (80).

Progress will also depend on tools that are simple, thermostable, and compatible with health-system workflows (81), alongside stronger pathways for quality assurance, procurement, and operational validation to ensure prototypes reach programme delivery (82, 83).

6 Conclusion

POC diagnostics are central to filariasis elimination, guiding endemicity mapping, MDA safety, treatment-stopping decisions, and post-validation surveillance. The current landscape shows progress for LF and onchocerciasis, persistent gaps for loiasis, and limited development for mansonellosis. Challenges include co-endemicity, cross-reactivity, reduced sensitivity post-MDA, and weak commercial incentives.

Emerging tools, including multiplex RDTs, LAMP assays and AI-assisted microscopy offer promise, but their impact depends on translation from prototype to deployment. With the 2030 WHO elimination deadline approaching, sustained investment will be essential to validate and scale field-ready diagnostics.

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Footnotes

Edited by: Nikhilesh Joardar, Vishwanath Karad MIT World Peace University, India

Reviewed by: Krishnamoorthy Kaliannagounder, Vector Control Research Centre (ICMR), India

Statements

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Author contributions

AM: Conceptualization, Writing – review & editing, Supervision. LQ: Writing – original draft. MA: Conceptualization, Writing – original draft, Writing – review & editing, Supervision.

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Citation

Manyeh, A. K., et al. (2026). Toward 2030 road map: accelerating filariasis elimination through next-generation point-of-care diagnostics. Frontiers in Tropical Diseases, Volume 7. https://doi.org/
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7 - 2026

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Copyright © 2026 Manyeh, Quarshie and Ahiadorme.

License: https://creativecommons.org/licenses/by/4.0/

*Correspondence: Monica Ahiadorme

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