LYMPHATIC FILARIASIS

I.INTRODUCTION Lymphatic filariasis is a parasitic and infectious tropical disease caused by infection with nematodes of the family Filariodidea: 90% of infections are caused by Wuchereria bancrofti (causes Bancroftian filariasis) and most of the remainder by Brugia malayi. Lymphatic filariasis is found throughout the tropics and subtropics. Worldwide prevalence is more than 90 million. The World Health Organization (WHO) initiated a program in 1997 to eliminate lymphatic filariasis globally as a public health priority. Humans are the exclusive host of infection with W. bancrofti. Although certain strains of B. malayi can also infect some animal species (felines and monkeys), the life-cycles in humans and in these animals generally remain epidemiologically distinct. The major vectors of W. bancrofti are mosquitoes of the genus Culex (in urban and semi-urban areas), Anopheles (in rural areas of Africa and elsewhere) and Aedes (in endemic islands of the Pacific). The parasites of B. malayi are transmitted by various species of the genus Mansonia; in some areas, anopheline mosquitoes are responsible for transmitting infection. Brugian parasites are confined to areas of east and south Asia, notably India, Indonesia, Malaysia and the Philippines. It is also called elephantiasis, a disease that is characterized by the thickening of the skin and underlying tissues, especially in the legs, male genitals and female breasts. It is the most spectacular symptom of the disease. Filarial diseases are rarely fatal, but the consequences of infection can cause significant personal and socioeconomic hardship for those who are infected. It is idebtified as the second leading cause (after leprosy) of permanent and long-term disability in the world by the World Health Organization (WHO). Morbidity of human filariasis is due mainly to the host reaction to microfilariae or to developing adult worms in different areas of the body.

FACTS ABOUT FILARIASIS IN THE PHILIPPINES:

➢ Bancroftian filariasis is endemic to southern Luzon, Mindanao, Mindoro, Palawan, Samar, Leyte, Sorsogon and Bohol. ➢ 43 of 63 provinces were endemic n 1960; 45 of 77 provinces as of 1996 4; 290 municipalities as of 2001; 351 of 1,566 municipalities as of 2003; 39 of 79 provinces as of 2004. ➢ Both forms of filariasis (W. bancrofti and B. malayi) coexist in only four provinces: Davao Oriental, Palawan, Eastern and Northern Samar 6 and Surigao del Sur. ➢ In 1984, 20 million persons were considered at risk for filariasis (both W. bancrofti and B. malayi) in the Philippines; 23.5 million in 2002; 15,034,765 in 2006; 21,882,581 in 2007. ➢ Only two provinces (Marinduque and Sulu) were considered ‘high prevalence’ areas (>10%) as of 1993. ➢ Disease in the Philippines is nocturnally periodic. ➢ 37% of males and 17% of females in a village on Cataduanes (microfilaremia, 1978 publication) ➢ 13% in Bayanan and 3.4% in Manganan (Mindoro, microfilaremia, 2004 publication) ➢ The local vectors are Anopheles minimus flavirostris, Aedes poicilius , Culex quinquefasciatus and Ochlerotatus (Finlaya) niveus. ➢ Brugia malayi infection is endemic to southwestern Palawan, Sulu, Agusan and Samar. ➢ Brugia malayi was first confirmed in the Philippines in 1964 – in Palawan (33.1% local prevalence at the time). ➢ Mass treatment with diethylcarbamazine and albendazole was administered to 1,945,121 persons during 2001. ➢ 9,881,124 persons received mass treatment in 2005 ; 10,174,936 in 2006; 13,627,661 in 2007

I.TRANSMISSION AND PATHOGENESIS
• • • • • • • • • •

Filariasis is transmitted from an infected human to a mosquito. The parasite develops in a mosquito for one to three weeks. The female worm releases embryos that develop into motile larvae, microfilariae. Larvae then go through a biological development in the thoracic muscles of vector. Migrate to the proboscis of the mosquito to be released during feeding. The larvae are then transmitted to another human by the infected mosquito vector. Female worms then release live microfilariae larvae, which travel through the blood, lymph and to the skin. In the lymph nodes and tissue they become trapped and develop to maturity in six to twelve months. Larvae only travel at night in the blood, which coincides with the mosquito's nocturnal feeding habits. The larvae are then picked up by another mosquito.

I. CLINICAL MANIFESTATION Symptoms of bancroftian filariasis may be acute or chronic in nature. Symptoms of lymphatic filariasis usually don't appear until after the adult worms die. Clinical Course:
1. Incubation Period – starts from entry of microfilariae larvae to the onset of symptoms – variable from 8 to 16 months 1. Asymptomatic Stage – Presence of microfilariae in blood – No clinical signs & symptoms – May progress to acute & chronic stage – Men have higher microfilariae rate than women 1. Acute Stage – Recurrent fever – Lymphadenitis – Lymphagitis – Funiculitis, Epididymitis, Orchitis 1. Chronic Stage – Develop 5 – 15 years after death of adult filarial parasites – Microfilarae usually absent in the blood – Hydrocele (swellinfg of the scrotum) – Lymphedema (temporary swelling of the upper & lower extremities) – Elephantiasis (enlargement and thickening of the skin) – Chyluria – presence of milkish urine

I.DIAGNOSIS • Physical examination is done in the main health center or during the scheduled survey bites in the community ➢ History taking ➢ Observation of the major and minor signs and symptoms • Laboratory Examinations: ➢ Nocturnal Blood Examination (NBE) – traditional diagnostic method to demonstrate microfilariae in the peripheral blood ➢ Immunochromatographic Test (ICT) – A commercial kit used to detect filarial antigen – a rapid assessment method I.TREATMENT

Medical Care: ➢ For those with Asymptomatic microfilaremia – oral diethylcarbamazine (DEC) therapy ➢ for those with chronic filariasis and adenolymphangitis (ADL) – requires in patient care:  antihistamines  corticosteroids  pain relief  intravenous antibiotics for secondary infections ➢ For those with large hydroceles, scrotal elephantiasis & chyluria – surgical treatment – correction of gross limb elephantiasis with surgery is less successful and may require multiple procedures and skin grafting Diet ➢ Fatty foods are restricted in those with proven chyluria associated with lymphatic filariasis. Activity ➢ In patients with chronic lymphatic filariasis, mobilization of the affected limb is encouraged with compression bandage support. Drugs used for treatment: ➢ Antihelminthics ○ ivermectin - considered as the drug of choice
➢ alternative are antibiotics such as doxycycline ○ ○ diethylcarbamazine (DEC) albendazole

Nursing Care: – instruct patient to comply the treatment regimen – Bed rest, limb elevation, and compression bandages have traditionally for those with chronic lymphedema – Instruct patient to wash the affected area with soap & water at least 2x a day – Pre-op & post-op care for patient that will undergo surgery – Restriction of fatty foods to those with chyluria – Prevention to other infections due to possible secondary infections

I. PREVENTION CONTROL

A. Measures aimed to control the vector: a. Environmental sanitation such as proper drainage and cleanliness of the surroundings b. Spraying with insecticides (not so recommended because of harmful effects) B. Measures aimed to protect families and individuals in endemic areas: a. Use of mosquito nets b. Use of long sleeves, long pants and socks c. Application of insect repellants d. Screening of houses e. Health education f. Taking of yearly prophylactic drugs disseminated by the health center

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