LYMPHATIC FILARIASIS

DR.K.A.NAZAR

DSO i/c,DMO(H),PALAKKAD

LYMPHATIC FILARIASIS
Infection with 3 closely related Nematodes
Wuchereria

bancrofti Brugia malayi Brugia timori

* Transmitted by the bite of infected mosquito responsible for considerable sufferings/deformity and disability * All the parasites have similar life cycle in man * Adults seen in Lymphatic vessels * Offsprings seen in peripheral blood during

DISEASE MANIFESTATION
Disease manifestation range from None Acute-Filarial fever Chronic-Lymphangitis, Lymphadenitis, Elephantiasis of genitals/legs/arms Tropical Pulmonary Eosinophilia (TPE) Filarial arthritis Epididimoorchitis

DISTRIBUTION
Prevalent

world wide in the Tropics and Sub-tropical regions of Africa Asia Western Pacific Parts of Central & South America

Lymphatic Filariasis Endemic Countries & Territories

Endemic Countries

Global Distribution Map

REGION WISE LF PREVALENCE

S. No

Regions

Population (Millions)

Total No. of cases W.bancrofti 50.57 (8.97) 62.35 (2.25) 1.80 (29.11) 0.40 (0.09) 115.12 (3.04) B.malayi -- -12.91 (0.47) -- --- -12.91 (0.47)

1. Sub-Saharan Africa 2. Asia 3. Pacific Islands 4. Latin America World

564 2770 6.18 441 3781

GLOBAL SCENARIO
Population

at risk : No. of countries : Mf carriers : Diseased : Hydrocele : Lymphoedema : TPE :

1.2 Billion > 80 76 Million 44 Million 27 Million 16 Million 1 Million

NATIONAL SCENARIO
Total

Population : Population at risk

(in 16 States & 5 UTs)
Total
No.

110 C :45.4 C 51.7 M

22.5 M 29.2 M 12.9 M

infected

(Wb - 99.4 % and Bm - 0.6 %)

of diseased : Mf carriers : Hydrocele :

AGENT FACTORS
S.no

1. 2. 3. 4. 5. 6. 7. 8.

Parasite W.bancrofti B.malayi

B.timori O.volvulus L.loa M.perstans M.streptocerca M.ozzardi

Mosquito
Culex Mansonia Anopheles/ Mansonia

Disease
LF LF LF

Simulium flies

River Blindness

Chrysops flies S/c swellings Culicoides Culicoides Culicoides Serous cavity

CULEX SPECIES

MANSONIA SPECIES

AEDES SPECIES

MORPHOLOGY - W.BANCROFTI

W.bancrofti is a sexually dimorphic species. The adult male worm is long and slender, between four and five centimeters in length, a tenth of a centimeter in diameter, and has a curved tail. The female is six to ten centimeters long, and three times larger in diameter than the male. Microfilariae are sheathed, and approximately 245 to 300 m in length.

MORPHOLOGY - B.MALAYI

B.malayi microfilariae are slightly smaller than those of W.bancrofti. Microfilariae are sheathed, and about 200 to 275 m. Not much is known about the adult worms, as they are not often recovered One distinctive feature of B.malayi is that the microfilarial nuclei extends to the tip of the tail

HOST FACTORS
Man Natural Host Age All age (6 months) Max: 20-30 years Sex Higher in men Migration leading to extension of infection to non-endemic areas Immunity may develop after long year of exposure (Basis of immunity-not known)

SOCIAL & ENVIRONMENTAL FACTORS

1.

2.
3. 4.

Associated with Urbanization, Poverty, Industrialization, Illiteracy and Poor sanitation. Climate: is an important factor which influences: The breeding of mosquito Longevity (Optimum temperature 20-300C & Humidity 70%) The development of parasite in the vector Sanitation, Town planning, Sewage & Drainage.

WUCHERERIA LIFE CYCLE

MODE OF TRANSMISSION & INCUBATION PERIOD

Lymphatic Filariasis is transmitted by the bite of Infected mosquito which harbours L3 larva. L1: 1-3 hours L2: 3-4 days L3: 5-6 days Pre-patent period: (L3 to Mf) Not known Clinical Incubation period: 8-16

LYMPHATIC FILARIASIS DIAGNOSTIC METHODS

DIAGNOSIS OF LYMPHATIC FILARIASIS

Lymphatic Filariasis can be diagnosed clinically and through laboratory techniques. Clinically, diagnosis can be made on circumstantial evidence with support from antibody or other laboratory assays as most of the LF patients are amicrofilaraemic and in the absence of serological tests which is not specific other than CFA (ICT). In TPE, serum antibodies like IgG & IgE will be extremely high and the presence of IgG4 antibodies indicate active infection.

LABORATORY DIAGNOSIS 1. Demonstration of microfilarae in the peripheral blood a. Thick blood smear: 2-3 drops of free flowing blood by finger prick method, stained with JSB-II b. Membrane filtration method: 1-2 ml intravenous blood filtered through 3m pore size membrane filter c. DEC provocative test (2mg/Kg): After consuming DEC, mf enters into the peripheral blood in day time within 30 - 45 minutes.

2. Immuno Chromatographic Test (ICT): Antigen detection assay can be done by Card test and through ELISA. Circulating Filarial Antigen detection is regarded as Gold Standard for diagnosing Wuchereria bancrofti infection. Specificity is near complete, sensitivity is greater than all other parasite detection assays, will detect antigen in amicrofilaraemic as well as with clinical manifestations like lymphoedema, elephantiasis.

3. Quantitative (QBC):

Blood

Count

QBC will identify the microfilariae and will help in studying the morphology. Though quick it is not sensitive than blood smear examination.

4. Ultrasonography:
Ultrasonography using a 7.5 MHz or 10 MHz probe can locate and visualize the movements of living adult worms of W.b. in the scrotal lymphatics of asymptomatic males with microfilaraemia. The constant thrashing movements described as Filaria dance sign

5. Lymphoscintigraphy:
The structure and function of the lymphatics of the involved limbs can be assessed by lymphoscintigraphy after injecting radiolabelled albumin or dextran in the web space of the toes. The structural changes can be imaged using a Gamma camera. Lymphatic dilation & obstruction can be directly demonstrated even in early clinically asymptomatic stage of the disease.

6. X-ray Diagnosis:
X-ray are helpful in the diagnosis of Tropical pulmonary eosinophilia. Picture will show interstial thickening, diffused nodular mottling. 7. Haematology : Increase in eosinophil count

LYMPHATIC FILARIASIS CLINICAL MANIFESTATIONS

CLINICAL MANIFESTATIONS
1.

2.

Manifestations are 2 types Lymphatic Filariasis (Presence of Adult worms) Occult Filariasis (Immuno hyper responsiveness) Clinical Spectrum

None

Asymptomatic microfilaremia

Filarial fever

Chronic pathology

TPE

STAGES IN LYMPHATIC FILARIASIS

1.

2.

3.
4.

There are 4 stages : Asymptomatic amicrofilariaemic stage Asymptomatic microfilariaemic stage Stage of Acute manifestation Stage of Obstructive (Chronic) lesions

STAGE OF ASYMPTOMATIC AMICROFILARAEMIC

In

endemic areas, a proportion of population does not show mf or clinical manifestation even though they have some degree of exposure to infective larva similar to those who become infected. Laboratory diagnostic techniques are not able to determine whether they are infected or free.

STAGE OF ASYMPTOMATIC MICROFILARIAEMIC

Considerable

proportions are asymptomatic for months and years, though they have circulating microfilariae. They are an important source of infection. They can be detected by Night Blood Survey and other suitable procedures.

STAGE OF ACUTE MANIFESTATION

During initial months and years, there are recurrent episodes of Acute inflammation in the lymph vessel/node of the limb & scrotum that are related to bacterial & fungal super infections of the tissue that are already compromised lymphatic function. Clinical manifestations are consisting of: 1. Filarial fever (ADL-DLA) 2. Lymphangitis 3. Lymphadinitis 4. Epididimo orchitis

CHRONIC MANIFESTATION
Chronic (Obstructive) lesions takes 10-15 years. This is due to the permanent damage to the lymph vessels caused by the adult worms, the pathological changes causing dilation of the lymph vessels due to recurrent inflammatory episodes leading to endothelial proliferation and inflammatory granulomnatous reaction around the parasite. Initially, it starts with pitting oedema which gives rise to browny oedema leading to hardening he tissues. Still late, hyper pigmentation, caratosis, wart like lesions are developed. Eg. Hydrocele (40-60%), Elephantiasis of Scrotum, Penis, Leg, Arm, Vulva, Breast, Chyluria.

2. OCCULT FILARIASIS (TPE)

Occult or Cryptic filariasis, in classical clinical manifestation mf will be absent. Occult filariasis is believed to be the result of hyper responsiveness to filarial antigens derived from mf. Seen more in males. Patients present with paroxysmal cough and wheezing, low grade fever, scandy sputum with occasional haemoptysis, adenopathy and increased eosinophilia. X-ray shows diffused nodular mottling and interstial thickening.

PATHOLOGY OF LYMPHATIC FILARIASIS

The pathology associated with lymphatic filariasis results from a complex interplay of the pathogenic potential of the parasite, the tissue response of the host and external bacterial and fungal infections.
Most of the pathology associated with LF is limited to the lymphatics.

HYDROCELE

SCROTUM

PENIS

LEG

ARM

BREAST

CHYLURIA & HAEMATURIA

CLASSIFICATION OF LYMPHOEDEMA

1.

2.
3. 4. 5.

Lymphoedema is classified into 7 stages on the basis of the presence & absence of the following: Oedema Folds Knobs Mossy foot Disability

STAGES OF LYMPHOEDEMA OF THE LEG (STAGE I)

Swelling reverses at night Skin folds-Absent Appearance of Skin-Smooth, Normal

STAGES OF LYMPHOEDEMA OF THE LEG (STAGE II)

Swelling not reversible at night Skin folds-Absent Appearance of skin-Smooth, Normal

STAGES OF LYMPHOEDEMA OF THE LEG (STAGE III)

Swelling not reversible at night Skin foldsShallow Appearance of skin-Smooth, Normal

STAGES OF LYMPHOEDEMA OF THE LEG (STAGE IV)

Swelling not reversible at night Skin folds-Shallow Appearance of skin - Irregular, * Knobs, Nodules

STAGES OF LYMPHOEDEMA OF THE LEG (STAGE V)

Swelling not reversible at night Skin folds-Deep Appearance of skin Smooth or Irregular

STAGES OF LYMPHOEDEMA OF THE LEG (STAGE VI)

Swelling not reversible at night Skin folds-Absent, Shallow, Deep Appearance of skin *Wart-like lesions on foot or top of the toes

STAGES OF LYMPHOEDEMA OF THE LEG (STAGE VII)

Swelling not reversible at night Skin folds-Deep Appearance of skinIrregular

Needs help for daily activities - Walking, bathing, using bathrooms, dependent on family or health care systems

LYMPHATIC FILARIASIS MANAGEMENT& CONTROL

TWIN PILLARS OF LYMPHATIC FILARIASIS ELIMINATION

Interrupt

transmission Control Morbidity (relief of suffering)

Community-level care of those with disease Lymphoedema Acute inflammatory attacks Hydrocele repair

MANAGEMENT OF LYMPHATIC FILARIASIS

1. 2.

Treating the infection

Treatment and prevention of Acute ADL attacks Treatment and Lymphoedema prevention of

3.

 Treating

the infection Remarkable advances in the treatment of LF have recently been achieved focusing not on individual but on community with infection, with the goal of reducing mf in the community, to levels below which successful transmission will not occur.

CHEMOTHERAPY OF FILARIASIS
Drugs effective against filarial parasites
1. 2. 3.

4.

Diethyl Carbomazine citrate (DEC) Ivermectin Albendazole Couramin compound

Treatment of microfilaraemic patients may prevent chronic obstructive disease and may be repeated every 6 months till mf and/or symptoms disappears.

DIETHYL CARBOMAZINE CITRATE

(HETRAZAN, BANOCIDE, NOTEZINE)

Mode of action: DEC do not have direct action of parasite but mediate through host immune system. Very effective against mf (Microfilariacidal) Lowers mf level even in single dose Effective against adult worms in 50% of patients in sensitive cases. Dose: 6mg/Kg/12 days Recent dosage: 6mg/Kg single dose Adverse reactions are mostly due to the rapid destruction of mf which is characterised by fever, nausea, myalgia, sore throat, cough, headache. No effect on the treatment of ADL Drug of choice in the treatment of TPE.

IVERMECTIN

Mode of action: Directly acts on mf and no action on adults. Very effective against mf (Microfilariacidal) Lowers mf level even in single dose of 200g 400g/Kg body weight No action on TPE Drug of choice in Co-endemic areas of Onchocerciasis with LF. Adverse reactions are lesser but similar to that of DEC Microfilariae reappears faster than DEC

ALBENDAZOLE
This antihelmenthic kills adult worms No action on microfilariae Dose: 400mg/twice day /2 weeks With combination of DEC & Ivermectin, it enhances the action of the drugs. It induces severe adverse reactions in hydrocele cases due to the death of adult worms.

Treatment and Prevention of ADL The most distressing aspect of LF is the acute attacks of ADL, which results in considerable economic loss and deterioration of quality of life. Prompt treatment and prevention of ADL are of paramount importance. ADL may be seen both in early & late stages of the disease. It is due to the infection & inflammation of the skin and affected area due to entry of bacteria or fungus through the entry lesions. The skin becomes warm, tender, painful, swollen, red. Patient develops fever, headache, chills and sometimes nausea and vomiting. Occasionally becomes

First sign will be enlarged, tender and painful L.nodes. SS of inflammation appears later lasting for 4-5days. Peeling & darkening of skin is common. Repeated attacks increase the size of the legs. Management includes symptomatic treatment like relieving pain, care of entry lesions etc. In patients with late stages of oedema, long term antibiotic therapy using oral Penicillin or long acting parentral Benzathil Penicillin are used to prevent ADL.

ADL

ADL

ADL

ENTRY LESIONS

ENTRY LESIONS

ULCERS

VECTOR CONTROL
Vector control involves anti larval measures, anti adult measures, personal prophylaxis. An integrated method using all the vector control measures alone will bring about sustained vector control. I. Anti larval measures: 1. Chemical control a. Mosquito larvicidal oil b. Pyrosene oil c. Organo phosphorous compounds such as Temephos, Fenthion, 2. Removal of pistia plants 3. Minor environmental measures

VECTOR CONTROL
II. Anti adult measures: Anti adult measures as indoor residual spay using DDT, HCH and Dieldrin. Pyrethrum as a space spray is also followed. III. Personal Prophylaxis: Reduction of man mosquito contact by using mosquito nets, screening of houses, etc.

MORBIDITY MANAGEMENT
Control

Morbidity (relief of suffering) # Community-level care of those with disease Lymphoedema Acute inflammatory attacks Hydrocele repair

ELIMINATION OF LYMPHATIC FILARIASIS BY 2015

International task force of disease control identified lymphatic Filariasis as an eradicable disease. Decision taken by the High level committee in Delhi on Jan 5th 2004. 250 districts of India ,in 20 endemic states/UT including that of Kerala.

The aim is to eliminate Lymphatic filariasis by 2015. -By annual MDA

STRATEGY

Single day annual administration of DEC is equally effective as 12 day regimen . Morbidity management of lymphatic filariasis.

IEC activities for protective and preventive measures.

Vector control measures.

KERALA

11 out of 14 districts are affected In Kerala 16 NFCP units,2 survey units and 11 Filaria clinics.

Presently activities are confined to the urban areas.

MDA programme in Alapuzha and Kozhikkodu districts-1997 2000-MDA in ALPY,KZD & Kannur districts.

MDA IN KERALA

DEC administration by house to house visit Target districts--TVM,KLM,ALPY,KOTM, EKM,THSR,PLKD,MLPM,KZHD,KNR and KSGD Population to be covered-2.8 Crores. Children below 2 Yrs, Pregnant women and severely ill patients are excluded

CONT.
Houses to be covered50 Lakhs One volunteer per 50 houses 1 lakh volunteer required Mopping up rounds to cover dropouts One supervisor for 10 volunteers Separate booths for major institutions Management of side reactions

PROGRAMME IMPLEMENTATION PLAN

Detailed plan proposal at state ,district levels.Preparation of the micro-plans at lower levels started.

Inter sectoral co-ordination committees -state level -District level -Block level,panchayat level,urban etc.

TRAINING &IEC ACTIVITIES

State, District, PHC &Volunteer level training Sensitization & advocacy work shops Press meetings Media work shops Printing of bit notices,drug distribution guidelines,posters,banners etc. TV programmes. Mike announcements

CONT
TV programmes Mike announcements Awareness programmes ,group talks etc. Squad work,house to house campaign Inaugurations-state level ,district, block &panchayat level

ACTIVITY DURING MDA DAY

Drug distribution on house to house basis Booth wise administration in Workplaces,Markets, Offices,Govt. & Private hospitals etc. Supervision & Monitoring Mopping up Organization of the RRT at various

DRUG DOSAGE SCHEDULE

Age in years
Below 2 Yrs 2-5 Yrs

Dose of DEC
NIL 100 mg

Number of tablets NIL

1 tab of 100 mg

6-14 Yrs
15 Yrs and above

200mg
300 mg

2 tab of 100 mg
3 tab of 100 mg

POST MDA ACTIVITIES

Organization of the coverage survey Post MDA review meetings Consolidation of the reports Monitoring and evaluation of the programme from the state level and by independent observers

THE ROLE VARIOUS DEPARTMENTS & LOCAL BODIES ARE VERY CRUCIAL
Local bodies

Lead role in Planning, implementation and monitoring Head of the co-ordination committee Financial support Propagation of the message and motivation of the people Co-ordination of various departments Identification of volunteers

MEDICAL EDUCATION DEPARTMENT

Resource person for various training Independent observers. Manpower as volunteers and supervisors Community medicine Dept. House surgeons, students,nursing students and other paramedical students IEC activities

SOCIAL WELFARE DEPARTMENT

Very important role in planning & implementation. Providing volunteers( AWWs, Helpers) As supervisors In Squad work, group talk, Inter personal communication

KUDUMBASHREE

At all levels planning and implementation of the programme Providing volunteers Local IEC ,IPC,mass campaigns

EDUCATION DEPT.
By taking pledge in schools-Message to households and community. NCC,NSS Volunteers as drug providers. Teachers as opinion leaders and for local IEC Source reduction measures

IMA/IAP/PRIVATE HOSPITALS
Private

doctors as opinion builders in the community Private hospitals as drug administration centers and for managing side effects if any in the field also Motivation of the public IEC health education Sentinel surveillance Manpower -volunteers

Thank you