FILARIASIS

Definition

Filiariasis is the name for a group of tropical diseases caused by various thread-like parasitic round worms (nematodes) and their larvae. The larvae transmit the disease to humans through a mosquito bite. Filariasis is characterized by fever, chills, headache, and skin lesions in the early stages and, if untreated, can progress to include gross enlargement of the limbs and genitalia in a condition called elephantiasis.

Causative Organisms
Wuchereria bancrofti- a parasitic filarial nematode (roundworm) spread by a mosquito vector. It is one of the three parasites that cause lymphatic filariasis, an infection of the lymphatic system by filarial worms. It affects over 120 million people, primarily in Africa, South America, and other tropical and subtropical countries. If the infection is left untreated, it can develop into a chronic disease called elephantiasis. Limited treatment modalities exist and no vaccines have been developed.

Brugia Malayi- a nematode (roundworm), one of the three causative agents of lymphatic filariasis in humans. B. malayi is transmitted by mosquitoes and is restricted to South and South East Asia. It is one of the tropical diseases targeted for elimination by the year 2020 by the World Health Organization.

Brugia timori- is a human nematode (roundworm) which causes the disease "Timor Filariasis." While this disease was first described in 1965, the identity of Brugia timori as the causative agent was not known until 1977. In that same year, Anopheles barbirostris was shown to be its primary vector.

Mode of Transmision
The parasites that cause lymphatic filariasis are transmitted from human to human through the bites of Culex and Anopheles mosquitoes. The female mosquitoes take the microscopic forms of the parasitic worm (microfilaria) from an infected person during a blood meal. The microfilaria develop into larvae, and when the mosquito feeds on another person, the larvae enter the skin punctured by the mosquito bite. The larvae travel via the lymphatic vessels, where they develop into adult worms all over the body. After mating, the females lay millions of eggs which develop into microfilaria, completing the lifecycle.

Pathology
Developing and adult worms of the human lymphatic filarial parasites (Wuchereria bancrofti,Brugia malayi, and Brugia timori) are located mainly in the lymphatic system and occasionally in aberrant sites like subcutaneous and conjunctival cysts. Lymphatic pathology ranging from dilatation of lymphatic channels and lymphangiectasia are detected on ultrasonography in apparently healthy, amicrofilaraemic, but filarial antigen positive individuals in endemic areas. Microfilariae are distributed in various organs and may be associated with immune mediated pathology at these sites; tropical pulmonary eosinophilia is characterized by intense immune mediated destruction of microfilariae in the lung parenchyma. In the spleen and other sites, nodular granulomatous lesions can occur where microfilariae are trapped and destroyed. The finding of Wolbachiaendosymbionts in all stages of lymphatic filarial parasites has provided new insight on the adverse reactions associated with anti-filarial chemotherapy.

 Inflammatory molecules mainly lipopolysaccharide (LPS)-like molecules released from endosymbionts on death of the parasites are largely responsible for the adverse reactions encountered during anti-filarial chemotherapy. Prenatal tolerance or sensitization to parasite derived molecules can immune-modulate and contribute to both pathology and susceptibility/resistance to infection. Pathological responses thus depend not only on exposure to filarial antigens/infection, but also on host-parasiteendosymbiont factors and to intervention with antifilarial treatment. Treatment induced or host mediated death of parasites are associated with various grades of inflammatory response, in which eosinophils and LPS from endosymbionts play prominent roles, leading to death of the parasite, granulomatous formation, organization and fibrosis. The non-human primate (Presbytis spp.) model of Brugia malayi developed for the tertiary screening of anti-filarial compounds has provided unique opportunities for the longitudinal study of the pathology associated with lymphatic filariasis. The pathology in this non-human primate model closely follows that seen in human lymphatic filarial infections and correlates with clinical evidence of lymphatic pathology as detected with ultrasonography. These studies also show that successful treatment as detected by loss of motility and calcification of worms on ultrasonography is associated with reversal of early dilatations of lymphatic channels.

Signs & Symptoms

The most spectacular symptom of lymphatic filariasis is elephantiasisedema with thickening of the skin and underlying tissueswhich was the first disease discovered to be transmitted by mosquito bites. Elephantiasis results when the parasites lodge in the lymphatic system.

Elephantiasis affects mainly the lower extremities, while the ears, mucus membranes, and amputation stumps are affected less frequently. However, different species of filarial worms tend to affect different parts of the body: ''Wuchereria bancrofti'' can affect the legs, arms, vulva, and breasts, while ''Brugia timori'' rarely affects the genitals. Interestingly, those who develop the chronic stages of elephantiasis are usually amicrofilaraemic, and often have adverse immunlogical reactions to the microfilaria as well as the adult worm.

The subcutaneous worms present with skin rashes, urticarial papules, and arthritis, as well as hyper- and hypopigmentation macules. ''Onchocerca volvulus'' manifests itself in the eyes causing river blindness" (onchocerciasis), the 2nd leading cause of blindness in the world. Serous cavity filariasis presents with symptoms similar to subcutaneous filariasis, in addition to abdominal pain because these worms are also deep tissue dwellers.

Diagnostic Procedures
Filariasis is usually diagnosed by identifying microfilariae on a Giemsa stained thick blood film. Blood must be drawn at night, since the microfilaria circulate at night(nocturnal periodicity), when their mosquito vector is most likely to bite. Also,decreased peripheral temperature may attract more microfilariae.

Modalities of Treatment
Filariasis treatment can be either diethylcarbamazine or ivermectin with albendazole. Diethylcarbamazine rapidly clears microfilaremia for a long time, but has a slower effect on the adult worms, necessitating repeated doses. Ivermectin used as a single dose reduces microfilarial levels over a long period, although retreatment is required at three to 12 month intervals until the adult worms have been eradicated. Albendazole, though not used for onchocerciasis, may be effective as an adjunct for other filarial infections, due to its effect on the adult worms.

 For lymphatic filariasis treatment, diethylcarbamazine or ivermectin with albendazole may be given as a yearly dose for five years. Doxycycline has also been used to treat Onchocerca volvulus and Wucheria bancrofti, as it may interrupt production of microfilariae by causing sterility in the female nematode or worm. It is used as a daily dose for six weeks. The choice of filariasis treatment will be established by the attending doctor.

Nursing Management
Morbidity management and disability preventionIn this instance, morbidity relates to the illness caused by lymphoedema and skin changes, and disability relates to the consequences of these experiences. Management of lymphoedema in relation to LF is based upon the premise of reducing the progression of the disease by effective and simple strategies that have minimal resource implications. Because the disease and its impacts potentially affect a huge population, health education messages need to be straightforward and aimed at whole communities. These basic messages can be summarised as:

 Looking after the skin- This is an absolutely fundamental part of lymphoedema management in LF endemic parts of the world. These messages are being taught to those who are healthy as a preventive measure, and to those with lymphoedema and skin changes in order to prevent progression of the disease to the more serious stages. McPherson was able to show improved Dermatology Life Quality Index scores in individuals who were taught basic skin care routines by nurses in Guyana

Elevation- Elevation is most effective at reducing swelling in the early stages of the disease. Low level swelling may be totally reversed overnight if the leg is elevated. Ideally, the limb should be raised to the same height as the hip, but the individual must feel comfortable. The knee should be slightly exed and pressure on the ankle/heel should be avoided (Dreyer et al, 2002). In communities where furniture is scarce, elevation may be achieved by rolling a piece of cloth to place under a sleeping mat or by using a box padded by a piece of cloth.

Movement- exercises that stimulate lymphatic flow are effective ways of helping individuals to manage lymphoedema. Once they have been taught, the individual can undertake this form of therapy independently. Over exercising, for example, through vigorous running, can be counter productive and aggravate lymphoedema. Therefore, movement should be gentle yet deliberate and carried out on a regular daily basis. While movement is focused on the foot, for example, circling and exing it, movement of the whole limb is benecial. Walking and foot exercises are probably the most effective ways of promoting lymph ow (Vaqas and Ryan, 2003). Breathing exercises have not traditionally formed part of the LF programme, however Vaqas and Ryan note that the breathing taught to lymphoedema patients in resource rich countries is similar to that used in some Asian traditional systems of medicine (Vaqas and Ryan, 2003).

Prevention And Control

The best way to prevent lymphatic filariasis is to avoid mosquito bites. The mosquitoes that carry the microscopic worms usually bite between the hours of dusk and dawn. If you live in an area with lymphatic filariasis: at night sleep in an air-conditioned room or sleep under a mosquito net between dusk and dawn wear long sleeves and trousers and use mosquito repellent on exposed skin.

Another approach to prevention includes giving entire communities medicine that kills the microscopic worms -- and controlling mosquitoes. Annual mass treatment reduces the level of microfilariae in the blood and thus, diminishes transmission of infection. This is the basis of the global campaign to eliminate lymphatic filariasis. Experts consider that lymphatic filariasis, a Neglected Tropical Disease (NTD), can be eradicated and a global campaign to eliminate lymphatic filariasis as a public health problem is under way. The elimination strategy is based on annual treatment of whole communities with combinations of drugs that kill the microfilariae. As a result of the generous contributions of these drugs by the companies that make them, tens of millions of people are being treated each year. Since these drugs also reduce levels of infection with intestinal worms, benefits of treatment extend beyond lymphatic filariasis. Successful campaigns to eliminate lymphatic filariasis have taken place in China and other countries.