BANCROFTIAN FILARIASIS

Rumala Morel Department of Parasitology Peradeniya Y3S2

South East Asia - the global burden

OBJECTIVES - Bancroftian filariasis

1.Describe the geographical distribution in SL

2.Describe the pathogenesis & clinical features

3.Evaluate the laboratory methods of diagnosis

4.Name the antifilarial drug(s) used in Sri Lanka

5.State the principles underlying the prevention and control

6.Describe the preventive and control measures used in the National Filariasis Control Programme in Sri Lanka

Distribution of Bancroftian filariasis in Sri Lanka

Confined to urbanized coastal belt: 3 provinces - 9.5 million (50% of SL population) exposed inland foci: Gampaha, Warakapola Veyangoda

life span 7-16 yrs

Revision of Life Cycle

Immunopathogenesis:
as yet unclear, associated with

location of adult worms in lymphatics

Basic lesion Dilatation of lymphatics = Lymphangiectasia

Granuloma (host inflammatory reaction) Not due to blockage by adult worm

PATHOLOGY

Adult worms induce endothelial cell proliferation lymphatic dilatation Death of adult worms antigen leakage formation of granulomatous nodules activation of host inflammatory responses Obliterative peri/endolymphangitis in dilated lymphatics Episodes of ACUTE FILARIAL LYMPHANGITIS [AFL]
Lymphangiectasia = dilated lymphatics Impairs lymphatic function Predisposes to bacterial & fungal infections ACUTE DERMATOLYMPHANGIOADENITIS [ADLA] leads to CHRONIC LYMPHOEDEMA

Pathogenesis of lympoedema Death of adult worms

Obstruction & Dilatation of lymphatics

Acute Filarial Lymphangitis [AFL] Granuloma No mechanical blockage by worms Lymphoedema Pitting [Grade 1] 11ry bacterial & fungal infections Acute Dermatolymphangioadenitis [ADLA] Non pitting [Grade 2]
Repeated attacks of ADLA Elephantiasis [Grade 3]

Death of adult worm causes granuloma formation Obliterative peri/endolymphangitis in dilated lymphatics

Clinical ACUTE FILARIASIS

1. Acute Filarial Lymphangitis [AFL] Due to death of adult worms Mild Residual lymphoedema - rare 2. Acute Dermatolymphangioadenitis [ADLA] Due to 11ry bacterial infections in limbs with compromised lymphatics 2-6 attacks / year Diffuse subcutaneous inflammation & oedema Males - acute funiculitis - acute epididymo orchitis
Extra lymphatic disease - filarial monoarthritis - KJ - filarial fevers

Clinical CHRONIC FILARIASIS Lymphangiectasia

Due to adult worms

11ry bacterial infections Recurrent ADLA 11ry bacterial & fungal infections lymphoedema elephantiasis

&

Males: hydrocoele

Lymphoedema

Pitting oedema [Grade 1]

Non pitting [Grade 2]

Elephantiasis [Grade 3]

Clinical manifestations of lymphoedema depend on site of obstruction

Common sites limbs genitalia breast lympoedema Grade 1- pitting Grade 2- non pitting Grade 3- elephantiasis

lymph leakage into urinary tractchyluria (obstruction in cisterna chyli) lymph leakage into peritoneal cavity chylous peritonitis

Kidney damage: proteinuria & /or haematuria

CLINICAL MANIFESTATIONS IN MALE GENITALIA - acute funiculitis - acute epididymo orchitis - hydrocoele -Scrotal elephantiasis, -lymph scrotum (skin vesicles)

Tropical Pulmonary Eosinophilia - TPE

OCCULT FILARIASIS common in India, Sri Lanka
Pathogenesis: immune destruction of mf in lungs due to host response to human mf / mf of animal filaria

Eosinophilic granulocytes in lung

Diagnostic criteria for TPE

Clinical Syndrome: cough, bronchospasm (worse at night) With eosinophila >3000/l & history of exposure to lymphatic filariasis Xraybroncho vascular markings

serum IgE levels (> 1000 kU/L) filarial Ag/Ab+ peripheral blood mf - ve and clinical response to diethylcarbamazine
Bilaterally diffuse bronchopneumonia. Early treatment can prevent interstitial fibrosis

Tropical Pulmonary Eosinophilia- TPE OCCULT FILARIASIS

ANTI-FILARIAL TREATMENT Diethylcarbamazine 6mg/kg tds 3 weeks

Bilaterally diffuse milliary nodules

Clinical manifestations in endemic areas

Asymptomatic mf +
subclinical lymphangiectasia but non reversible 40% kidney damage

Symptomatic mf +/AFD-filarial fevers lymphangitis lymphadenitis CFD-chronic obstructive mf -

TPE
mf - ve
Filarial Ag +/Ab + Occult filariasis

AFD = Acute Filarial Disease CFD = Chronic Filarial Disease

Laboratory Diagnosis of Filariasis:

Direct- detection of microfilaria in blood Thick film- 10pm-2 am (20-60l) wet mount/ stain Giemsa Not sensitive! ConcentrationKnotts method (old) Membrane filtration- pore size 5m Detection of adults in biopsy- rare

Indirect 1. Circulating Filarial Antigen [CFA] - BEST daytime 2. Filarial Specific Antibody wont differentiate from past infection

Detection of filarial antibodies in serum

Useful in occult filariasis - TPE Indirect immunofluorescent test- IFA/FAT ELISA (enzyme linked immunosorbent assay)

Disadvantage: Cant diagnose acute lymphatic disease. Antibodies long lasting. May be past infection.

Now WHO recommends :www. who.int. lymphatic_filariasis/epidemiology

Antigen detection Immunochromatographic [ICT] card test

high sensitivity [100% sensitive in mf +ves ] high specificity 100 l of fingerprick blood drawn at any time, day or night. simple, no equipment required quick results <15 min

Antigen detection strip (card) tests- RDTs

polyclonal Ab + colloidal gold Mab W bancrofti absorbent pad

Sample origin T C (whole blood test control serum/plasma) Immunochromatographic [ICT] card test Detects specific circulating W bancrofti Ag in serum/whole blood using monoclonal antibody

Imaging techniques
A. Ultrasound scan scrotum filarial dance sign

B. Radionucleotide lymphoscintigraphy - assessment of lymphatic damage

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) - 2000 --

Global Alliance to Eliminate Lymphatic Filariasis - 2000

public-private partnership WHO & national Ministries of Health, Private drug companies donating albendazole & ivermectin (Mectizan) NGOs

1 billion at risk population > 120 million people are already infected > 40 million incapacitated or disfigured

>60%

RAGFIL: Rapid Assesment of Geographical distribution of bancroftian FILariasis. - Map endemic foci of lymphatic filariasis - to decide on mass treatment programs.

Filariasis in Sri Lanka1937-39: Brugia malayi predominant 1947: Anti Filariasis Campaign 1960s: Brugian filariasis eradicated control of larval breeding residual action of DDT on adults treatment with DEC Bancroftian filariasis is the ONLY lymphatic filariasis in SL now

Filariasis control in Sri Lanka

by Anti Filariasis Campaign

Vector control: prevent mosquito breeding

clear drains, cess pits, sealing of septic tanks larviciding with insecticides, larvivorous fish

Selective treatment of mf + cases

2-weeks diethylcarbamazine [DEC] (6 mg/kg)

Mass Drug Administration- eradicate parasite by

killing mf and disrupting transmission - continued for 4-5 years MOST EFFECTIVE

Morbidity control disability management training

Mass Drug AdministrationTreat all persons in endemic areas with Diethylcabamazine [DEC] +albendazole annually
started in Oct/1999 in SL covering endemic area-3 provinces. In 2004 - coverage 80% compliance 71% (WHO) Exclude infants & pregnant females

Pregnancy- treat 1 month after delivery

Mf + and clinical filariasis treated with full course DEC Effect on intestinal geohelminths Gunawardena NK et al - Ceylon Med J. 2008 Mar;53(1):13-6

WHO morbidity control strategy Community Home Based Care by Filariasis Morbidity Control Clinics
Motivate & train pts & care givers on :washing elevation preventing & treating entry lesions -topical antibiotics & antifungals using proper footwear

Washing with soap

Proper footwear

MCQ
1. Regarding lymphatic filariasis A. Adult worms block lymphatics B. Wucheraria bancrofti microfilaria show nocturnal periodicity C. Immunochromatographic card test is used to detect circulating filarial antigens D. Secondary bacterial infections are important co-factors in pathogenesis E. Treatment is with diethylcarbamazine [DEC]

True BCDE