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Nigerian Lymphatic Filariasis:

Elephantiasis Red Flag Filariasis

NMU HL 322 WINTER 2014

What is Lymphatic Filariasis?

Lymphatic filariasis is more commonly known as elephantiasis (WHO). 90% of all lymphatic filariasis are caused by a parasite called Wuchereria bancrofti. Lymphatic filariasis caused by W. bancrofti is also known as Bancrofts filarial. It is found in tropical environments. The disease is transmitted by Anopheles mosquitoes that contain the parasitic larvae. When the mosquito bites a human, the larva are injected into the blood stream. From here they migrate to the lymphatic system and develop into adults. These adults produce larvae (Leventhal, 2629). Some of these larvae stay in the human host, and cause more damage. Some exhibit periodicity. This means that some of the larvae present in the human host migrate to the blood found just under the skin at night so that the mosquitoes will bite the host and pick up the larvae so the cycle begins again(Leventhal,26-29). Some of the symptoms of this kind of infection are granulomatous lesions, chills, fever, eosinophilia and elephantiasis (Leventhal, 26-29). There are 73 countries that are have known infections, and this means there are nearly 1.4 billion people threatened by this disease. Of these 1.4 billion people, 120 million are actually infected, and 40 million are disfigured or unable to work due to its disfiguring effects. 65% of the 120 million live in South East Asia, 30% in Africa, and the other 5% are found in miscellaneous tropical areas. This disease has caused lymphedema in 15 million people and genital disease due to swelling in 25 million men(WHO). Of all the countries in Africa, Nigeria is the most endemic, and it is the third most endemic country in the entire world(Carter Center). There are 1.4 billion people at risk for lymphatic fliariasis, and of that, 25 million are at risk in Nigeria. That is 22% of Nigerias whole population(WHO).

Disease Prominence Graph

This graph depicts the decline of Lymphatic Filariasis over time as interventions are added . http://www.cartercenter.org/countries/nigeria-healthlymphatic-filariasis.html

W. bancrofti
This is a microscopic image of the adult worm that causes Lymphatic Filariasis https://www.bc.edu/content/bc/schools/cas/biology/rese arch/infect/filariasis.html

Nigeria Background
The environment of Nigeria is one of the factors that leads to increased risk for lymphatic filariasis. The activities of the people in Nigeria lead to an increase in the man - mosquito contact rates, which is the carrier of the parasite W. bancrofti that causes the disease. Some of the activities are rice farming, fishing, cassava processing and other outdoor activities (Omudu and Ochoga, 2011). Nigeria is the largest processor of cassava in the world (Adeniji and Ega, 2005) and the pots that cassava is fermented in are breeding sites for mosquitoes. The workers who are working in the rice farms, with the cassava, or other outdoor activities have an increased contact rate with mosquitoes and an increased risk to contract lymphatic filariasis. The typical Yakurr (Cross River State, Nigeria) farmer spends three-quarters of their daytime doing outdoor farming activities (Iboh, Okon et al, 2012). Also, many of the houses in Nigeria are built of mud walls, a thatched roof, and no ceiling (Iboh, Okon. et al, 2012), allowing the mosquitoes to enter the house with ease. Another reason for the prevalence is the beliefs of the people. Some believe it is caused by working in the sun too long, walking for too long, or stepping on a witch doctors charm. They believe to prevent the disease, avoid contact with people who are infected, keep yourself clean, or sacrifice to appease gods. The pharmaceutical companies GlakoSmithKline and Merck have agreed to donate the drugs required for lymphatic filariasis until it has been eradicated (WHO, 2012) but the drugs are rejected by a majority of adults. The people reject the drugs for multiple reasons, some of which are lack of trust in international aid and the difference in the medical and local understanding of lymphatic filariasis. A lot of the people question the motive behind the free distribution of drugs and some think that the drugs are a government experiment or a way to reduce population growth (Parker and Allen, 2013). Some people also associate the disease with

witchcraft and they think that if the disease is caused by witchcraft then the doctors won't be able to help them. These people will then visit local healers who can't help them either and the disease will eventually worsen and lead to swollen legs or genitals. A local healer was quoted saying, "... if you go to a

http://www.premiumtimesng.com/bu siness/152301-nigerian-governmentprovide-incentives-10000-dryseason-rice-farmers-bauchi.html research in Nigeria. The Ministry of Health oversees all health programs that are going on in Nigeria. Each town or sometimes groups of towns in Nigeria has a village chief or traditional leadership council that has considerable control over what happens in their town. In order to do research or studies, it's required to go through these people and receive permission. In the study of the Yakurr people in Cross River State, Nigeria, the scientists who did the study had to receive ethical permission from the Federal Ministry of Health, the Paramount Ruler, and Community Heads of the local government (Iboh, Okon, et al, 2012). An example of political control of programs is in 2003 when three state governments in Nigeria halted polio vaccines. The political leaders of the Nigerian states Kano, Zamfara, and Kaduna brought polio immunization to a halt by telling parents not to have their children immunized. The leaders told the people that the vaccines are loaded with anti-fertility agents, HIV, and cancerous agents (Jegede, 2007) and the vaccines were halted for 11 months until the government of the states were appeased by tests on the safety of the vaccine.

hospital for an operation and it is caused by uchawi (witchcraft), you will die immediately" (Parker and Allen, 2013). The Political Aspect of Nigeria is another subject that should be addressed.
Nigeria's political system is modeled after the United States. They have an executive branch with a President, a legislative branch with a House and Senate, and a judiciary branch with a supreme court. The executive branch of the government is divided into 36 ministries and those ministries are responsible for different aspects of governing. The Federal Ministry of Health in Nigeria is the main group that clearance is required from in order to conduct surveys or

Cassava Pot http://ginascottzambia.blogspot .com/2013/10/ode-tonshima.html

Bronze statue made by the Yoruba people in Nigeria. The statue displays a man with swollen testicles caused by Elephantiasis. http://www.scienceandsociety.co. uk/results.asp?image=10474716

Elephantiasis
This man is infected with W. bancrofti. He is exhibiting the most disfiguring stage of this disease. It can affect many parts of the body. In this case it is his leg but other appendages may be affected as well. https://www.cartercenter.org/resources/pdfs/factsheets /lymphatic-filariasis-facts.pdf

History of Filariasis
The true origin of Lymphatic Filariasis seems to be unknown. However, there are beliefs that the infection dates back to 2000BC. The reasoning behind this belief is that there is a statue of Pharaoh Mentuhotep II with what appears to be swollen limbs, a characteristic of the disease (Cox). The in 600BC elephantiasis was described by doctors in the India region (Otsuji). The actual first written accounts of Lymphatic Filariasis were from Greece and Rome around 500AD. This disease was often confused with that of leprosy but in these places they realized they were actually different diseases and were able to even describe the two with different names (Cox). intermediate host was needed to transmit the infection (COX). 1947 marked the start of finding a cure for Lymphatic Filariasis, a compound called Hetrazan finally showed progress in getting rid of the parasite in trials. For the next 5 years there was significant progress where the treatment was made where they figured out the correct dosage of DEC and modified treatment of Hetrazan. (OTSUJI) In 1949, China had one of the largest number of Lymphatic Filariasis cases in the world. That year the Republic of China decided that they were going to gain control over this disease, that way their citizens can live without fear of contracting this painful disease. In 2006 they finally achieved this and Lymphatic Filariasis has been eradicated (DEJIAN).

Egypt
Pharaoh Mentuhotep II infected with Lymphatic Filariasis. Here he is depicted with a swollen leg, a characteristic symptom of the disease.
http://www.hat.net/album/middle_east/004_egypt/day_48_ egyptian_museum/detail020.htm

In Paris 1863 the first record of the infection was discovered, microfilariae was found, which is the early stage of a parasite. Then in 1877 Patrick Manson discovered that the parasite was being carried through mosquitos (Cox). He deduced this by obtaining blood from a mosquito and finding the same microfilariae in that blood. This theory he had was based on the studies of Fedchenko who found an

Economics of Nigeria
Nigeria has an economy that has been growing since 1991. However, as of recent years (after 2000) their gross domestic product has been growing at an astonishing rate, which peaked at 33.7% in 2004. This increase in the GDP (gross domestic product) growth has helped make Nigeria become one of many developing nations with their GDP now ranking at 39th in the world. The main product that Nigeria has to offer is petroleum which makes up 94% of their exports in three forms of petroleum; Crude 78%, gas 9.3 % and refined 6.7% (Simoes). Even with this data looking like Nigeria is poised to become a developed nation within the next decade there are gleaming faults in this thought. The main statistic is that just under half of the nation lives in poverty, 46%. This number is alarming not only because it is such a large number but also since the GDP has been growing for the past 14 years, while the poverty line has only decreased 2%. Another statistic that is alarming if Nigeria is to become a developed nation is their unemployment rates. Nigeria has over a fifth of their population unemployed. One major factor with this statistic might be the amount of people that have become disabled from infectious diseases. It is estimated that nearly 600 million Nigerian are living with a disease, of which nearly 20 million are affected by elephantiasis, a symptom of Lymphatic Filariasis (Zaggi). This disease is the most deforming disease in the entire world, yet is very highly neglected throughout the world. A possible reason for this neglect is because the disease is located in tropical regions and countries with high poverty rates, which is why the disease has been classified as one of the diseases of poverty. Now as of recent years there has been an effort from many different organizations to eradicate this disease. The volunteers and donations that are given in aid are crucial to the eventual goal of 2020, where the disease will be eradicated. Mapping countries and their possible endemic areas costs anywhere from $20,000 - $40,000. To map out the areas they get a sample of the population and test them. If over 1% of the population is infected than it is considered endemic (The Way Ahead). After the mapping is done if the area is considered endemic then they will receive medication for prevention of the disease. This is a two medicine process of albendazole and Mectizan with diethylcaramazine (DEC). The albendazole and Mectizan has been pledged by Merck & Co Inc. and GlaxoSmithKlien until the disease has been completely eradicated at an estimated cost of 1 billion dollars. The only drug that is required to still be purchased for the elimination is the DEC, which is able to be purchased at cost, and on a global scale costs $1 million annually (The Way Ahead). With this aid and donations the actual cost to eliminate this disease is extremely low for the benefits that it will provide. This will help in the workforce as individuals will not be left disabled from this disease or others as the medicine will help also get rid of other diseases such as river blindness and malaria. http://hilltop.corban.edu/news/ christian-massacre-in-nigeria

http://data.worldbank.org/country/nigeria

Interventions

of reengineering mosquitoes to prevent the spread of disease(Parry). Some organizations have made support groups like one called Hope Group. This group allows those with disfiguring elephantiasis to talk to others and learn how to cope with the disease and alleviate symptoms (VOA). The Bill and Melinda Gates foundation enacted a program in 2012 called the Nigeria Immunization Challenge. The challenge called for the 36 state governments of Nigeria to sign up for it and it awarded any government that met the threshold criteria a grant of $500,000 to support health priorities. The program was designed to actively engage the local governors in the health programs and to stay on track in the fights against health problems (Bill and Melinda Gates Foundation).

There are several different interventions set in place by different organizations. The first is the WHO, or World Health organization. Their response is targeted toward the elimination of lymphatic filariasis in the entire world, rather than just Nigeria. It is known as the Global Programme to Eliminate Lymphatic Filariasis, or GPELF for short. The final goal of the WHO is to have this disease eradicated by the year 2020. To do this, they have split up their objectives into two obtainable goals. One is stopping transmission, and two is alleviating the suffering of those already infected (WHO). Now to prevent the spread of infection, people at risk are given one dose of two medicines that kill the young worms that cause lymphatic filariasis, but have limited destructive properties on the adult worm. These medicines are called albendazole with ivermectin or diethylcarbamazine citrate[DEC]. Due to these actions, so far, the at-risk population has dropped 43%.They have also believed that the use of insecticide-treated nettings over beds, and indoor residual spray may help to deter and kill infected mosquitoes, preventing the infection from ever reaching a human host(WHO). The second part of their intervention is to alleviate the suffering of those already affected. This is done by morbidity management and disability prevention. GPELFs goal is to provide each person presenting with a minimum package of care in order to help better their way of life. There are also surgeries for those with extreme elephantiasis and other helpful small things such as simply elevating the affected appendage and keeping it clean(WHO). These tactics are both need and capacity based. The prevention of disease with medicine is need based, meaning the services are provided to the people. Teaching the population how to care for an affected limb is capacity based, meaning the population is taught how to take care of themselves(WHO). The Carter Center is a group that is focused on eliminating the spread in Nigeria, as well as Ethiopia. Their intervention strategy is very similar to the strategy of the WHO. They raise awareness in areas where lymphatic filariasis is prevalent, teaching that it is the bite of an infected mosquito that causes the disease. They believe in preventing the disease with medicines as well. Their method is to use Mectizan and albendazole. They also teach about and provide long lasting insecticidal bed nets [LLINs] (Carter center). There is also talk

LLIN
These are two children playing under a long lasting insecticidal mosquito net. It repels mosquitoes so that the children will not be bitten at night when insects are most active. http://www.unmultimedia.org/radio/english/2013/05/ugandalaunches-largest-malaria-prevention-campaign/

WHO
The World Health Organization is on the forefront of many health issues that affect the population of the world. Their main goal is to combat the infections of the world in accordance with the Millennium Development Goal 6. These also include malaria, HIV, and AIDS. http://smartforlife.com/tag/world-health-organization/

The Carter Center

Sources
As stated in their logo, The Carter Center is about Waging Peace. Fighting Disease. Building Hope. Like the WHO, the also help out with other diseases like River Blindness. http://www.cabellbrandcenter.org/Cooperating-Orgs.html

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"New Strategy Aims to Eradicate Elephantiasis." VOA. N.p., n.d. Web. 14 Apr. 2014.
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