LYMPHATIC FILARIASIS A MAJOR PUBLIC HEALTH CHALLENGE IN

LYMPHATIC FILARIASIS A MAJOR PUBLIC HEALTH CHALLENGE IN THE 21 ST CENTURY Carol Jones-Williams, Ph. D. Student, Epidemiology Walden University PUBH 8165 -10 Instructor: Dr. Robert Marino Spring 2010

Agenda n Introduction n Understanding neglected tropical diseases n Overview of Lymphatic Filariasis F n Modeling of successful programs

Learning Objectives n Understand the global impact of lymphatic filariasis n Discuss the epidemiology and etiology of lymphatic filariasis n Identify stages of lymphatic filariasis n Describe and provide examples of the treatment and prevention methods used for lymphatic filariasis n Identify issues of morbidity control and quality of life among individuals with lymphatic filariasis n Understand the burden of lymphatic filariasis on a global scale n Provide examples of control strategies to eliminate and/or eradicate lymphatic filariasis

LYMPHATIC FILARIASIS (A NEGLECTED TROPICAL DISEASE) n Affect more than 1 billion people n They cluster geographically and overlap; individuals often afflicted with more than one parasite or infection: Ø 149 countries and territories are affected by at least one neglected tropical disease Ø more than 70% of them are affected by two or more diseases Ø 28 countries are afflicted by more than six diseases simultaneously n Share some common features with other diseases: Ø Chagas disease Ø Dengue Ø Lymphatic filariasis n Ø Leishmaniasis Ø Onchoerciasis Infections caused by unsafe water, poor housing conditions and poor sanitation Retrieved from: http: //www. whqlibdoc. who. int/publications/2009/9789241598705_eng. pdf

IMPACT OF NEGLECTED TROPICAL DISEASES n Social stigma and prejudice n May lead to: Ø Long-term disability Ø Disfigurement Ø Impaired childhood growth Ø Adverse pregnancy outcomes Ø Reduced economic productivity n Vulnerable populations - women, children and ethnic minorities n Kill an estimated 534, 000 people worldwide every year n Financial burden – cost of drugs Ø US$ 0. 02 – 1. 50 Ø 1. 1. billion people live on less than US$ 1 /day Ø 2. 7 billion people live on less than US$ 2/day Retrieved from: http: //www. whqlibdoc. who. int/publications/2009/9789241598705_eng. pdf; World Health Organization (2009)

LYMPHATIC FILARIASIS n Lymphatic filariasis (LF) is also known as Elephantiasis n Infected by filarial worms - Wuchereria Bancrofti, Brugia malayi or B. timori n ≥ a billion people in more than 80 countries at risk n 120 million have already been affected n 40 million seriously incapacitated and disfigured by the disease n Located in sub-Saharan Africa, Egypt, Southern Asia, Western Pacific Islands, northeastern coast of Brazil, Guyana, Haiti, and Dominican Republic n 1/3 of infected people live in India and Africa; remainder live in South Asia, the Pacific and the Americas Fox (2010); World Health Organization (2000)

LYMPHATIC FILARIASIS Features n Swelling of the limbs and breasts (lymphoedema) n Swollen limbs with thickened, hard, rough and fissured skin (elephantiasis) n Swelling of scrotum or vulva (hydrocele) n Cause internal damage to the kidneys and lymphatic system n Present with nocturnal cough, wheezing and fever Retrieved from: http: //www. cdc. gov/healthywater/hygiene/disease/lymphatic_filariasis. html; Fox (2010)

LYMPHATIC FILARIASIS Lymphoedema of the arm World Health Organization (WHO), 2009. Online image. April 5, 2010 Figure 1 (a) Retrieved from: http: //www. searo. who. int/EN/Section 10/Section 2096_10583. htm

LYMPHATIC FILARIASIS Lymphatic filariasis causes gross disfigurement of the lower limbs Photo provided by Dr. Tilaka Liyange, Sri Lanka World Health Organization (WHO), 2009. Online image. April 5, 2010 Figure 1 (b) Retrieved from: http: //whqlibdoc. who. int/publications/2009/9789241598705_eng. pdf

LYMPHATIC FILARIASIS Elephantiasis of the right leg and swelling in the left Elephantiasis of the leg World Health Organization (WHO), 2009. Online image. April 5, 2010 Figure 1 (c) Retrieved from: http: //www. searo. who. int/EN/Section 10/Section 2096_10583. htm

LYMPHATIC FILARIASIS Below is a graphic illustration of elephantiasis of the vulva in a 40 year-old woman with 8 -year history of progressive elephantoid vulva swelling. Elephantoid lesion before surgery Springer-Verlag 2008. Online image. April 5, 2010 Figure 1 (d) Archives of Gynecology & Obstetrics (2008). Retrieved from: http: //www. searo. who. int/EN/Section 10/Section 2096_10583. htm

LYMPHATIC FILARIASIS Photomicrograph showing transverse section of adult filarial worm with granuloma (H&E, ﾗ 400) in a breast nodule Association of Surgeons of India, 2009. Online image. April 4, 2010 Figure 1 (e) Indian Journal of Surgery (2009). Retrieved from: http: //web. ebscohost. com. ezp. waldenulibrary. org

LYMPHATIC FILARIASIS Cause n Thread-like, parasitic filarial worms that live in humans n Worms lodge in the lymphatic system n They live for 4 - 6 years, producing millions of immature microfilariae (minute larvae) World Health Organization (2000)

LYMPHATIC FILARIASIS Transmission n Life cycle of parasite occurs in the mosquito and in humans n When a mosquito bites a human, it picks up microfilariae (MF) which undergoes a number of developmental stages n MF travels back to the mouth of the mosquito, and when the mosquito bites another human, it deposits the parasite into the skin of human which travels to lymphatic system n Parasite grows to adulthood. Worms mate and the female releases more MF into the lymphatic system where it is picked up by the mosquito which then transmits the disease n Infective stage takes about 7 – 21 days n Infection is acquired during childhood causing damage to the lymphatic system and kidneys Penzer (2007); Streit, T. & Lafontant, J. G. (2008); World Health Organization (2000)

TRANSMISSION OF LYMPHATIC FILARIASIS Life cycle of Wuchereria bancrofti World Health Organization (WHO), 2009. Online image. April 5, 2010 Figure 2 Retrieved from: http: //www. searo. who. int/EN/Section 10/Section 2096_10583. htm

LYMPHATIC FILARIASIS Signs and Symptoms n Disease takes many years to manifest itself n Absence of outward clinical manifestations of symptoms n Worst symptoms of chronic disease occur more often in men than women n 10 -50% of men suffer from genital damage n Elephantiasis affect up to 10% men and women n Chronic and acute manifestations develop more often in refugees/newcomers n Lymphoedema may develop within six months and elephantiasis about a year after arrival World Health Organization (2000)

LYMPHATIC FILARIASIS Diagnosis n Difficult to diagnose in the past; easier now with new technology n Diagnostic tests include ➢ card test which detects circulating parasite antigens without need for laboratory facilities ➢ serum antifilarial immunoglobulin (Ig. G) n Easier identification of occurrence of infection n Better monitoring of treatment and control programs World Health Organization (2000)

LYMPHATIC FILARIASIS Stages of Lymphatic filariasis (Dreyer staging) Dreyer Stage Characteristic Clinical Features 1 Swelling is reversible (goes away) overnight 2 Swelling is not reversible (does not go away) overnight 3 Presence of shallow skin folds (base of fold can be seen with movement of leg) 4 Presence of skin knobs 5 Presence of deep skin folds (base of fold can only be seen if opened up) 6 Presence of “mossy lesions”. Warty-looking epidermal skin lesions 7 Unable to care for self or perform daily activities British Journal of Dermatology (2006)

LYMPHATIC FILARIASIS Lymphoedema of left leg of Guyanese female Dreyer stage 6 British Association of Dermatologists, 2006. Online image. April 4, 2010 British Journal of Dermatology (2006). Retrieved from: http: //web. ebscohost. com. ezp. waldenulibrary. org

LYMPHATIC FILARIASIS Macerated interdigital lesion and dystrophic nails in left foot with lymphoedema Dreyer stage 3 British Association of Dermatologists, 2006. Online Image. April 4, 2010 British Journal of Dermatology (2006). Retrieved from: http: //web. ebscohost. com. ezp. waldenulibrary. org

LYMPHATIC FILARIASIS Advanced skin changes in an adult with lymphoedema in Tanzania Sara Burr. Online image. April 5, 2010 Journal of Lymphoedema (2007). Retrieved from: http: //www. lymphormation. org/journal/content/0202_filariasis. pdf

LYMPHATIC FILARIASIS Treatment: Communities n Primary goal is to eliminate microfilariae from the blood of infected individuals ➢ Annual treatment involve using combination of anti-filarial drugs: - diethylcarbamazine citrate (DEC) with albendazole ivermectin and albendazole regular use of DEC fortified salt ➢ Single dose treatment must be carried out for 4 – 6 years World Health Organization (2000); Centers for Disease Control and Prevention (2010)

LYMPHATIC FILARIASIS Treatment: Individual ➢ Albendazole and DEC effective in killing adult-stage filarial parasites (necessary for complete cure of infection) ➢ Rigorous hygiene to affected limb ➢ Care of skin and exercise to increase lymphatic drainage in lymphoedema World Health Organization (2000); Fox (2010)

LYMPHATIC FILARIASIS Morbidity Intervention Strategies n Health education messages should be straightforward and aimed at whole communities n Messages should address basic skin care and exercise n Identify endemic areas n Implement community-wide mass treatment programs to treat entire at-risk populations n Implement community education programs to raise awareness in affected patients n Partnerships with private, public, and international organizations Penzer (2007)

SKIN CARE Checking between toes for entry points. Encouraging self-care — person washing their own limb. Sara Burr. Online image. April 5, 2010 Journal of Lymphoedema (2007). Retrieved from: http: //www. lymphormation. org/journal/content/0202_filariasis. pdf

HOW TO LOOK AFTER BIG FOOT Educational Resource Developed by the International Skin Care Nursing Group in Tanzania. Online image. April 5, 2010 Journal of Lymphoedema (2007). Retrieved from: http: //www. lymphormation. org/journal/content/0202_filariasis. pdf

LYMPHATIC FILARIASIS Economic and Social Impact n Disease has increased over the years because of expansion of slum areas and poverty n Disease prevents patients from having a normal working life n Disease exerts a heavy social burden due to concealment of disease and social stigmatization n Marriage, in many instances is often impossible World Health Organization (2000)

LYMPHATIC FILARIASIS In the tropics the most degraded environments are often linked with poverty, and with lymphatic filariasis British Association of Dermatologists, 2006. Online image. April 4, 2010 Streit, T. & Lafontant, J. G. (2008). Retrieved from: http: //web. ebscohost. com. ezp. waldenulibrary. org

WHAT’S NEXT? n Global Elimination of Lymphatic Filariasis ➢ Primary prevention of new cases using mass drug administration ➢ Secondary and tertiary prevention of patients’ morbidity associated with the disease: – access to healthcare – education n Barriers to implementing filariasis elimination programs: ➢ ➢ n Financing Developing infrastructure capable of distribution of drugs to at-risk populations Difficulty achieving and maintaining high coverage levels for 5 or more years Diminished Compliance Modeling other successful programs: ➢ Guyana Experience ➢ China Experience Lammie, Milner & Houston (2007)

THE END

Suggested Readings n Babu, B. V. , Mishra, S. , & Nayak, A. N. (2009). Marriage, Sex, and Hydrocele: An ethnographic study on the effect of filarial hydrocele on conjugal life and marriageability from Orissa, India. PLo. S Neglected Tropical Diseases, Vol. 3(4), p. 1 -7. DOI: 10. 1317/journal. pntd. 00000414. (AN 47507254). n Chadee, D. D. , Rawlins, S. , & Tiwari, T. S. B. (2003). Short communication: concomitant malaria and filariaris infections in Georgetown, Guyana. Tropical Medicine & International Health. Vol. 8(2), p. 140 -143. DOI: 10. 1046/j. 1365 -3156. 2003. 01001. x. (AN 9079322). n Huppatz, C. , Capuano, C. , et al. (2009). Lessons from the Pacific program to eliminate lymphatic filariasis: a case study of 5 countries. BMC Infectious Diseases, Vol. 9, p. 92 -97. BMC Infectious Diseases. DOI: 10. 1186/1471 -2334 -9 -2. (AN 43547147). n Lammie, P. , Milner, T. , & Houston, R. (2007). Unfulfilled potential: using diethylcarbamazinefortified salt to eliminate lymphatic filariasis. Bulletin of the World Health Organization. Vol. 85(7), p. 501 -568. n Monge-Maillo, B. , Jimenez, B. C. et al. (2009). Imported Infectious Diseases in Mobile Populations, Spain. Emerging Infectious Diseases, Vol. 15(11), p 1745 -1752. DOI: 10. 3201/eid 1511. 090718. (AN 44983291). n Streit, T. , & Lafontant, J. G. (2008). Eliminating Lymphatic Filariasis: A view from the field. Annals of the New York Academy of Sciences. Vol. 1136, p. 53 -63. DOI: 10. 1196/annals. 1425. 036. (AN 32677465).

REFERENCES Adesiyun, A. G. & Samaila, M. O. (2008). Huge filarial elephantiasis vulvae in a Nigerian woman with subfertility. Archives of Gynecology & Obstetrics. Vol. 278(6), p. 597 -600. DOI: 10. 1007/s 00404 -008 -0628 -1. (AN 34851598). Retrieved on April 5, 2010 from: http: //web. ebscohost. com. ezp. waldenulibrary. org Fox, L. M. (2010). Chapter 5 – Filariasis, Lymphatic – 2010 Yellow Book. Retrieved on April 5, 2010 from: http: //wwwnc. cdc. gov/travel/yellowbook/2010/chapter-5/lymphatic-filariasis. aspx Hygiene Related Diseases. Retrieved on April 5, 2010 from: http: //www. cdc. gov/healthywater/hygiene/disease/lymphatic_filariasis. html Behera, P. K. , Rath, P. K. , Panda, R. R. , Satpathy, S. , & Sarkar, B. K. (2009). Adult filarial work in the tissue section of a breast lump. Indian Journal of Surgery, Vol. 71(4), p. 210 -212. DOI: 10. 1007/s 12262 -009 -0053 -0. (AN 44190892). Retrieved on April 4, 2010 from: http: //web. ebscohost. com. ezp. waldenulibrary. org Lammie, P. , Milner, T. , & Houston, R. (2007). Unfulfilled potential: using diethylcarbamazinefortified salt to eliminate lymphatic filariasis. Bulletin of the World Health Organization. Vol. 85(7), p. 501 -568. Retrieved on March 27, 2010 from: http: //www. who. int/bulletin/volumes/85/7/06 -034108/en Mc. Pherson, T. , Persaud, S. , Singh, S. , Fay, M. P. , Addiss, D. , Nutman, T. B. , & Hay, R. (2006). Interdigital lesions and frequency of acute dermatolymphangioadenitis in lymphoedema in a filariasis-endemic area. British Journal of Dermatology. Vol. 154(5), p. 933 -941. DOI: 10. 1111/j. 1365 -2133. 2005. 07081 x. (AN 20433221). Retrieved on April 4, 2010 from: http: //web. ebscohost. com. ezp. waldenulibrary. org

REFERENCES Penzer, R. (2007). Lymphatic filariasis and the role of nursing interventions. Journal of Lymphoedema. Vol. 2(2), p. 48 -53. Retrieved on April 5, 2010 from: http: //www. lymphormation. org/journal/content/0202_filariasis. pdf Streit, T. & Lafontant, J. G. (2008). Eliminating filariasis: a view from the fold. Annals of the New York Academy of Sciences. Vol. 1136, p. 53 -63. DOI: 10. 1196/annals. 1425. 036. (AN 32677465). Retrieved on April 4, 2010 from: http: //web. ebscohost. com. ezp. waldenulibrary. org World Health Organization (WHO). Communicable Diseases. Lymphatic Filariasis: The disease and its treatment. Retrieved on April 5, 2010 from: http: //www. searo. who. int/EN/Section 10/Section 2096_10583. htm World Health Organization (WHO). 2000. Lymphatic Filariasis: Fact Sheet No. 102. Retrieved on April 5, 2010 from: http: //www. who. int/mediacentre/factsheets/fs 102/en World Health Organization (WHO). 2009. Neglected Tropical Diseases, Hidden Successes, Emerging Opportunities. Retrieved on April 5, 2010 from: http: //whqlibdoc. who. int/publications/2009/9789241598705_eng. pdf

CREDITS “Elephantiasis of the right leg and swollen in the left”; “Elephantiasis of the leg. ” World Health Organization (WHO), 2009. Online image. http: //www. searo. who. int/EN/Section 10/Section 2096_10583. htm. April 5, 2010. “Elephantoid lesion before surgery. ” Springer-Verlag 2008. Online image http: //web. ebscohost. com. ezp. waldenulibrary. org. April 5, 2010. “Globe. ” Online image. http: //vvv. presentationpro. com/products/PD Category Descriptions. asp. April 5, 2010 “Globe in grass. ” Microsoft Clip Art. Online Image. http: //office. microsoft. com/en-us/clipart. April 5, 2010. “In the tropics the most degraded environments are often linked with poverty, and with lymphatic filariasis”. British Association of Dermatologists, 2006. Online image. http: //web. ebscohost. com. ezp. waldenulibrary. org. April 4, 2010. “Life cycle of Wuchereria Bancrofti. ” World Health Organization (WHO), 2009. Online image. http: //www. searo. who. int/EN/Section 10/Section 2096_10583. htm. April 5, 2010. “Lymphatic filariasis causes gross disfigurement of the lower limbs. ” World Health Organization (WHO), 2009. Online image. http: //whqlibdoc. who. int/publications/2009/9789241598705_eng. pdf. April 5, 2010. “Lymphoedema of the Arm. ” World Health Organization (WHO), 2009. Online image. http: //www. searo. who. int/EN/Section 10/Section 2096_10583. htm. April 5, 2010.

CREDITS “Lymphoedema of left leg of Guyanese female. Dreyer Stage 6. ” British Association of Dermatologists, 2006. Online image. http: //web. ebscohost. com. ezp. waldenulibrary. org. April 4, 2010. “Macerated interdigital lesion and dystrophic nails in left foot with lymphoedema. Dreyer Stage 3. British Association of Dermatologists, 2006. Online Image. http: //web. ebscohost. com. ezp. waldenulibrary. org. April 4, 2010. “Mosquito. ” Microsoft Clip Art. Online Image. http: //office. microsoft. com/en-us/clipart. April 5, 2010. “Photomicrograph showing transverse section of adult filarial worm with granuloma (H&E, ﾗ 400) in a breast nodule. Association of Surgeons of India, 2009. Online image. http: //web. ebscohost. com. ezp. waldenulibrary. org. April 4, 2010. Sara Burr. “Advanced skin changes in an adult with lymphoedema in Tanzania. ” Online image. http: //www. lymphormation. org/journal/content/0202_filariasis. pdf. April 5, 2010. Sara Burr. “Encouraging self care – person washing their own limb. ” “Checking between toes for entry points. ” Online image. http: //www. lymphormation. org/journal/content/0202_filariasis. pdf. April 5, 2010. Sara Burr. “How to look after big foot. ” Educational Resource Developed by the International Skin Care Nursing Group in Tanzania. Online image. http: //www. lymphormation. org/journal/content/0202_filariasis. pdf. April 5, 2010.