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LYMPHATIC FILARIASIS
A MAJOR PUBLIC HEALTH CHALLENGE
IN THE 21ST CENTURY
Carol Jones-Williams, Ph.D. Student, Epidemiology
Walden University
PUBH 8165-10
Instructor: Dr. Robert Marino
Spring 2010
Agenda

Introduction

Understanding neglected tropical diseases

Overview of Lymphatic Filariasis

Modeling of successful programs
Learning Objectives

Understand the global impact of lymphatic filariasis

Discuss the epidemiology and etiology of lymphatic filariasis

Identify stages of lymphatic filariasis



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Describe and provide examples of the treatment and prevention
methods used for lymphatic filariasis
Identify issues of morbidity control and quality of life among
individuals with lymphatic filariasis
Understand the burden of lymphatic filariasis on a global scale
Provide examples of control strategies to eliminate and/or eradicate
lymphatic filariasis
LYMPHATIC FILARIASIS
(A NEGLECTED TROPICAL DISEASE)

Affect more than 1 billion people

They cluster geographically and overlap; individuals often afflicted
with more than one parasite or infection:
 149 countries and territories are affected by at least one neglected
tropical disease
 more than 70% of them are affected by two or more diseases
 28 countries are afflicted by more than six diseases simultaneously

Share some common features with other diseases:
 Chagas disease
 Dengue
 Lymphatic filariasis

 Leishmaniasis
 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

Social stigma and prejudice

May lead to:
 Long-term disability
 Disfigurement
 Impaired childhood growth
 Adverse pregnancy outcomes
 Reduced economic productivity

Vulnerable populations - women, children and ethnic minorities

Kill an estimated 534,000 people worldwide every year

Financial burden – cost of drugs
 US$ 0.02 – 1.50
 1.1. billion people live on less than US$ 1 /day
 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


Lymphatic filariasis (LF) is also known as Elephantiasis
Infected by filarial worms - Wuchereria Bancrofti, Brugia malayi or B.
timori

≥ a billion people in more than 80 countries at risk

120 million have already been affected
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40 million seriously incapacitated and disfigured by the disease
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Located in sub-Saharan Africa, Egypt, Southern Asia, Western Pacific
Islands, northeastern coast of Brazil, Guyana, Haiti, and Dominican
Republic
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


Swelling of the limbs and breasts (lymphoedema)
Swollen limbs with thickened, hard, rough and fissured skin
(elephantiasis)

Swelling of scrotum or vulva (hydrocele)
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Cause internal damage to the kidneys and lymphatic system

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/Section10/Section2096_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/Section10/Section2096_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/Section10/Section2096_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

Thread-like, parasitic filarial worms that live in humans

Worms lodge in the lymphatic system

They live for 4 - 6 years, producing millions of immature microfilariae
(minute larvae)
World Health Organization (2000)
LYMPHATIC FILARIASIS
Transmission






Life cycle of parasite occurs in the mosquito and in humans
When a mosquito bites a human, it picks up microfilariae (MF) which undergoes a
number of developmental stages
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
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
Infective stage takes about 7 – 21 days
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/Section10/Section2096_10583.htm
LYMPHATIC FILARIASIS
Signs and Symptoms

Disease takes many years to manifest itself

Absence of outward clinical manifestations of symptoms

Worst symptoms of chronic disease occur more often in men than women

10-50% of men suffer from genital damage
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Elephantiasis affect up to 10% men and women


Chronic and acute manifestations develop more often in
refugees/newcomers
Lymphoedema may develop within six months and elephantiasis about a
year after arrival
World Health Organization (2000)
LYMPHATIC FILARIASIS
Diagnosis

Difficult to diagnose in the past; easier now with new technology

Diagnostic tests include
➢ card test which detects circulating parasite antigens without need for
laboratory facilities
➢ serum antifilarial immunoglobulin (IgG)

Easier identification of occurrence of infection

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

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

Health education messages should be straightforward and aimed at
whole communities
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Messages should address basic skin care and exercise
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Identify endemic areas
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Implement community-wide mass treatment programs to treat entire
at-risk populations
Implement community education programs to raise awareness in
affected patients
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
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Disease has increased over the years because of expansion of slum
areas and poverty
Disease prevents patients from having a normal working life
Disease exerts a heavy social burden due to concealment of disease
and social stigmatization
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?

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

Barriers to implementing filariasis elimination programs:
➢
➢
➢
➢

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
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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. PLoS Neglected Tropical Diseases, Vol. 3(4), p. 1-7. DOI:
10.1317/journal.pntd.00000414. (AN 47507254).
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).
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).
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.
Monge-Maillo, B., Jimenez, B. C. et al. (2009). Imported Infectious Diseases in Mobile
Populations, Spain. Emerging Infectious Diseases, Vol. 15(11), p1745-1752. DOI:
10.3201/eid1511.090718. (AN 44983291).
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/s00404-008-0628-1. (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/s12262-009-0053-0. (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
McPherson, 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.1365-2133.2005.07081x. (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/Section10/Section2096_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/fs102/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/Section10/Section2096_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/Section10/Section2096_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/Section10/Section2096_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.