1. LYMPHATIC FILARIASIS A MAJOR PUBLIC HEALTH CHALLENGE IN THE 21ST CENTURY
Carol Jones-Williams, Ph.D. Student, Epidemiology
Walden University
PUBH
Instructor: Dr. Robert Marino
Spring 2010

2. Agenda Introduction Understanding neglected tropical diseases
Overview of Lymphatic Filariasis
Modeling of successful programs
Good Morning Ladies and Gentlemen:
My name is Carol Jones-Williams, and I’m a Ph.D. student in Epidemiology at Walden University. Today, it is my pleasure to present you with an overview of Lymphatic Filariasis, one of several neglected tropical diseases in the world, and a major public health challenge for endemic countries. The purpose of this presentation is to increase awareness about the global burden of lymphatic filariasis; to increase your understanding of its epidemiology and etiology; and what is currently being done to eliminate or eradicate this disease. Global migration into the United States and other countries continues to rise, opening the pathway of exposure for many diseases. It is important for you as public health professionals, teachers, and community health educators who are in this audience today, to be more knowledgeable about diseases that are not common in this country so that we could help vulnerable populations who may cross our pathways at some time or the other. However, I trust that at the end of this presentation, everyone here will leave with a better understanding of the plight of people who live with lymphatic filariasis, and be willing to share your ideas on ways in which public health could improve the quality of life for these individuals.

3. Learning Objectives
Understand the global impact of lymphatic filariasis
Discuss the epidemiology and etiology of lymphatic filariasis
Identify stages of lymphatic filariasis
Describe and provide examples of the treatment and prevention methods used for lymphatic filariasis
Identify issues of morbidity control and quality of life among individuals with lymphatic filariasis
Understand the burden of lymphatic filariasis on a global scale
Provide examples of control strategies to eliminate and/or eradicate lymphatic filariasis
By the end of this presentation you will be able to: (read out learning objectives)
I would be happy to answer any questions you have at the end of this presentation.
First, I would like to briefly discuss the synopsis of neglected tropical diseases before moving on to our main discussion about lymphatic filariasis.

4. LYMPHATIC FILARIASIS (A NEGLECTED TROPICAL DISEASE)
Affect more than 1 billion people
They cluster geographically and overlap; individuals often afflicted with more than one parasite or infection:
149 countries and territories are affected by at least one neglected tropical disease
more than 70% of them are affected by two or more diseases
28 countries are afflicted by more than six diseases simultaneously
Share some common features with other diseases:
Chagas disease
Dengue
Lymphatic filariasis
Infections caused by unsafe water, poor housing conditions and poor sanitation
Most neglected tropical diseases are endemic in rural areas of sub-Saharan Africa and in poor urban settings of low-income countries in Asia and Latin America. They affect more than 1 billion people, primarily those from impoverished populations in the developing world. These diseases tend to cluster geographically and overlap because they share some common features, such as for example, insect vectors which spread Chagas disease, dengue, lymphatic filariasis, leishmaniasis, and onchoerciasis. Individuals are often afflicted with more than one parasite or infection countries and territories are affected by at least one neglected tropical disease; more than 70% of them are affected by two or more diseases; and 28 countries are afflicted by more than six diseases simultaneously, most of them being from low-income economies experiencing humanitarian emergencies. Infections are attributable to unsafe water, poor housing conditions and poor sanitation.
Leishmaniasis
Onchoerciasis
Retrieved from:

5. IMPACT OF NEGLECTED TROPICAL DISEASES
Social stigma and prejudice
May lead to:
Long-term disability
Disfigurement
Impaired childhood growth
Vulnerable populations - women, children and ethnic minorities
Kill an estimated 534,000 people worldwide every year
Financial burden – cost of drugs
US$ 0.02 – 1.50
1.1. billion people live on less than US$ 1 /day
2.7 billion people live on less than US$ 2/day
Adverse pregnancy outcomes
Reduced economic productivity
In addition, neglected tropical diseases such as leprosy, lymphatic filariasis, and leishmaniasis are a strong source of social stigma and prejudice and as a result, are often concealed, poorly documented and not spoken about. These diseases do not travel easily and cause no immediate threat to the Western world. However, it is also important to note that these diseases are generally not major killers but can cause long-term disability, disfigurement, impaired childhood growth, adverse pregnancy outcomes, and reduced economic productivity which adds up to billions of lost dollars annually, and keep low-income countries in poverty. Women, children, and ethnic minorities, especially those living in remote areas with restricted access to services are most at risk of infection. Neglected tropical diseases kill an estimated 534,000 people worldwide every year. However, many of these neglected tropical diseases can be prevented, eliminated, or eradicated with drugs that cost as little as US$ 0.02 – In spite of this low price, it can pose financial hardships for many people who earn less that US$ 1 per day, and for those who cannot afford to purchase them, thus, putting them at increased risk of neglected tropical diseases.
Just to give you a global picture of this financial burden, the World Health Organization reported that 1.1 billion people live on less than US$ 1 a day and more than 2.7 billion live on less than US$ 2 a day. Calculating the math, one can actually visualize the devastating impact of both economic and financial burden these neglected tropical diseases have on impoverished populations.
Now let’s move on to Lymphatic Filariasis.
Retrieved from:
World Health Organization (2009)

6. LYMPHATIC FILARIASIS
Lymphatic filariasis (LF) is also known as Elephantiasis
Infected by filarial worms - Wuchereria Bancrofti, Brugia malayi or B. timori
≥ a billion people in more than 80 countries at risk
120 million have already been affected
40 million seriously incapacitated and disfigured by the disease
Located in sub-Saharan Africa, Egypt, Southern Asia, Western Pacific Islands, northeastern coast of Brazil, Guyana, Haiti, and Dominican Republic
1/3 of infected people live in India and Africa; remainder live in South Asia, the Pacific and the Americas
Lymphatic filariasis (LF) or elephantiasis (a painful, disfiguring swelling of the legs and genital organs, a classic sign of late-stage disease) is an infection with the filarial worm, Wuchereria bancrofti, Brugia malayi or B. timori, and is one of the most debilitating and disfiguring afflictions among all diseases. Globally, LF affects 120 million people in 80 countries, and is the second leading cause of permanent or long-term disability worldwide. LF is found in sub-Saharan Africa, Egypt, Southern Asia, Western Pacific Islands, northeastern coast of Brazil, Guyana, Haiti, and the Dominican Republic. In tropical and subtropical areas where LF is well-established, the prevalence of infection continues to increase as a result of the rapid and unplanned growth of cities, which creates numerous breeding sites for the mosquitoes that transmit the disease.
Fox (2010); World Health Organization (2000)

7. LYMPHATIC FILARIASIS Features
Swelling of the limbs and breasts (lymphoedema)
Swollen limbs with thickened, hard, rough and fissured skin (elephantiasis)
Swelling of scrotum or vulva (hydrocele)
Cause internal damage to the kidneys and lymphatic system
Present with nocturnal cough, wheezing and fever
Most infections are asymptomatic and oftentimes go unrecognized. In its most noticeable manifestations, the adult worms can cause permanent damage to the human lymphatic system, resulting in swelling of the limbs and breasts (referred to as lymphoedema) as seen here in Figure 1 (a) and (b) on the slide; swollen limbs with severely thickened, hard, rough and fissured skin (known as elephantiasis), and as seen here in Figure 1 (c) on the slide; or swelling of the scrotum (referred to as hydrocele). Figure 1 (d) shows elephantiasis of a vulva in a 40 year-old Nigerian woman; and Figure 1 (e) shows a transverse section of filarial nodule in the breast of a 40 year old woman who had painless mass in the breast for 1 month. Presence of microfilaria and adult work in the breast is considered a rarity, and only a few such cases have been documented according to the Association of Surgeons of India. Therefore, for medical practitioners overall, LF should not be ruled out when dealing with a breast lump. Although these pictures you have seen are graphic, at least it gives you some sense of how devastating and debilitating this disease can be. In endemic communities, 10-50% of men and up to 10% of women can be affected. Additionally, LF can also cause tropical pulmonary eosinophilia which is a potentially serious progressive lung disease that presents with nocturnal cough, wheezing, and fever, due to immune hyper- responsiveness to microfilariae in the pulmonary capillaries.
Retrieved from:
Fox (2010)

8. World Health Organization (WHO), 2009. Online image. April 5, 2010
LYMPHATIC FILARIASIS
Lymphoedema of the arm
World Health Organization (WHO), Online image. April 5, 2010
Figure 1 (a)
Retrieved from:

9. Photo provided by Dr. Tilaka Liyange, Sri Lanka
LYMPHATIC FILARIASIS
Lymphatic filariasis causes gross disfigurement of the lower limbs
Photo provided by Dr. Tilaka Liyange, Sri Lanka
World Health Organization (WHO), Online image. April 5, 2010
Figure 1 (b)
Retrieved from:

10. Elephantiasis of the right leg and swelling in the left
LYMPHATIC FILARIASIS
Elephantiasis of the right leg and swelling in the left
Elephantiasis of the leg
Figure 1 (c)
World Health Organization (WHO), Online image. April 5, 2010
Retrieved from:

11. LYMPHATIC FILARIASIS
Below is a graphic illustration of elephantiasis of the vulva in a 40 year-old woman with 8-year history of progressive elephantoid vulva swelling.
Elephantoid lesion before surgery
Springer-Verlag Online image. April 5, 2010
Figure 1 (d)
Archives of Gynecology & Obstetrics (2008). Retrieved from:

12. Association of Surgeons of India, 2009. Online image. April 4, 2010
LYMPHATIC FILARIASIS
Photomicrograph showing transverse section of adult filarial worm with granuloma (H&E, ﾗ400) in a breast nodule
Association of Surgeons of India, Online image. April 4, 2010
Figure 1 (e)
Indian Journal of Surgery (2009). Retrieved from:

13. LYMPHATIC FILARIASIS Cause
Thread-like, parasitic filarial worms that live in humans
Worms lodge in the lymphatic system
They live for years, producing millions of immature microfilariae (minute larvae)
LF is caused by the filarial nematodes Wuchereria bancrofti and Brugia malayi, parasitic filarial worms that live almost exclusively in humans. These worms lodge in the lymphatic system which is the network of nodes and vessels that maintain the delicate fluid balance between the tissues and blood, and are essential components for the body’s immune defense system. These worms can live for 4-6 years, producing millions of immature microfilariae (minute larvae) that circulate in the blood.
World Health Organization (2000)

14. LYMPHATIC FILARIASIS Transmission
Life cycle of parasite occurs in the mosquito and in humans
When a mosquito bites a human, it picks up microfilariae (MF) which undergoes a number of developmental stages
MF travels back to the mouth of the mosquito, and when the mosquito bites another human, it deposits the parasite into the skin of human which travels to lymphatic system
Parasite grows to adulthood. Worms mate and the female releases more MF into the lymphatic system where it is picked up by the mosquito which then transmits the disease
Infective stage takes about 7 – 21 days
Infection is acquired during childhood causing damage to the lymphatic system and kidneys
The life cycle of the LF parasite is partly in the mosquito and partly in humans. As the mosquito takes a blood meal from a human, it picks up microfilariae (MF) which circulates near the surface of the skin. Once in the mosquito, MF undergoes a series of developmental stages which take place in the flight muscles of the mosquito. Subsequently, MF migrates back to the mouth parts of the mosquito, and on the next blood meal that the mosquito takes, it deposits the parasite into the skin of the human via the puncture wound and into the blood stream. Once in the blood stream, the parasite then makes its way to the lymphatic system where it grows. Then at adulthood, the worms mate and the females release further microfilariae into the lymphatics. The life cycle is then completed and the disease is transmitted when the immature parasites migrate to the superficial blood vessels where the mosquitoes pick them up on taking a blood meal. The
infection stage usually takes 7 – 21 days. Figure 2 depicts a picture of the life cycle of the worm, Wuchereria bancrofti. Infection is oftentimes acquired during childhood, and damage to the lymphatic system and kidneys may begin at this time. For those persons who show more serious clinical manifestations, these are most commonly caused by pathology related to, for example, the adult parasite secretions, inflammatory reactions associated with the death of adult worms; secondary infections; or failure of lymphatic vessels for those who live long.
Penzer (2007); Streit, T. & Lafontant, J. G. (2008); World Health Organization (2000)

15. TRANSMISSION OF LYMPHATIC FILARIASIS
Life cycle of Wuchereria bancrofti
World Health Organization (WHO), Online image. April 5, 2010
Figure 2
Retrieved from:

16. LYMPHATIC FILARIASIS Signs and Symptoms
Disease takes many years to manifest itself
Absence of outward clinical manifestations of symptoms
Worst symptoms of chronic disease occur more often in men than women
10-50% of men suffer from genital damage
Elephantiasis affect up to 10% men and women
Chronic and acute manifestations develop more often in refugees/newcomers
Lymphoedema may develop within six months and elephantiasis about a year after arrival
The disease may take many years before it manifests itself. Although people may never acquire outward clinical manifestations of their infections, they may have hidden lymphatic pathology and kidney damage. The asymptomatic form of infection is most often characterized by the presence of thousands or millions of larval parasites (microfilariae) and adult worms found in the blood of the lymphatic system. The worst symptoms of the chronic disease usually appear more often in men than in women. Symptoms of LF such as lymphoedema and accompanying secondary infections occur when the germs enter the body through cracks in the skin and between the toes, and can be managed by practicing simple hygiene, exercise and treatment of wounds. Some of these infections are caused by the body’s immune response to the parasite, but most generally result from bacterial infection of the skin where normal defenses have been partially lost due to underlying lymphatic damage. In endemic areas, chronic and acute manifestations of filariasis tend to develop more often and sooner in refugees or newcomers than in local populations who are continually exposed to infection. Lymphoedema may develop within six months and elephantiasis can develop as quickly as a year after arrival in the country.
World Health Organization (2000)

17. LYMPHATIC FILARIASIS Diagnosis
Difficult to diagnose in the past; easier now with new technology
Diagnostic tests include
➢ card test which detects circulating parasite antigens without need for laboratory facilities
➢ serum antifilarial immunoglobulin (IgG)
Easier identification of occurrence of infection
Better monitoring of treatment and control programs
Until very recently, diagnosing lymphatic filariasis had been extremely difficult, since parasites had to be detected microscopically in the blood, and in most parts of the world, parasites have a "nocturnal period" that restricts their appearance in the blood to only the hours around midnight. The new development of a very sensitive and very specific simple "card test" to detect circulating parasite antigens without the need for laboratory facilities, using only finger-prick blood droplets taken anytime of the day has completely transformed the approach to diagnosing LF.
LF is diagnosed via microscopic detection of microfilariae on a thick blood film. In most endemic areas, for example, the highest concentration of microfilariae in the peripheral blood occurs at night; therefore collection of blood specimens is recommended between 10 pm and 2 am. Serum antifilarial immunoglobulin (IgG) is also another diagnostic test used and is available through the Parasitic Diseases Laboratory at the National Institutes of Health (NIH) or through CDC’s Division of Parasitic Diseases. With this and other new diagnostic tools, it will now be possible to improve both our understanding of where the infection actually occurs and to easily monitor the effectiveness of treatment and control programs.
World Health Organization (2000)

18. LYMPHATIC FILARIASIS Stages of Lymphatic filariasis (Dreyer staging) 1
Dreyer Stage
Characteristic Clinical Features 1
Swelling is reversible (goes away) overnight 2
Swelling is not reversible (does not go away) overnight 3
Presence of shallow skin folds (base of fold can be seen with movement of leg) 4
Presence of skin knobs 5
Presence of deep skin folds (base of fold can only be seen if opened up) 6
Presence of “mossy lesions”. Warty-looking epidermal skin lesions 7
Unable to care for self or perform daily activities
Lymphoedema of the leg affects an estimated 15 million persons in LF-endemic areas worldwide. Acute dermatolymphangioadenitis (ADLA) in people with LF causes acute morbidity and increasingly severe lymphoedema. Evidence suggests that episodes of ADLA are believed to be caused by bacteria, and that entry lesions in the skin play a causative role. A study on the severity of lymphoedema disease was conducted in Guyana, South America, one of LF’s endemic areas, using the Dreyer’s seven stage criteria which assessed the progression of the disease from inception of diagnosis to the more severe forms of lymphoedema and elephantiasis. The pictures on the slide will give you an idea of what stage 3 looks like as compared to stage 6. Coming back to this study in Guyana, findings indicate entry lesions situated between the toes are risk factors for episodes of ADLA in people with LF and cause acute morbidity, as well as increasingly severe lymphoedema.
British Journal of Dermatology (2006)

19. Lymphoedema of left leg of Guyanese female
LYMPHATIC FILARIASIS
Lymphoedema of left leg of Guyanese female
Dreyer stage 6
British Association of Dermatologists, Online image. April 4, 2010
British Journal of Dermatology (2006). Retrieved from:

20. LYMPHATIC FILARIASIS
Macerated interdigital lesion and dystrophic nails in left foot with lymphoedema
Dreyer stage 3
British Association of Dermatologists, Online Image. April 4, 2010
British Journal of Dermatology (2006). Retrieved from:

21. Advanced skin changes in an adult with lymphoedema in Tanzania
LYMPHATIC FILARIASIS
This picture is an example of what Dreyer’s stage 6 looks like – presence of “mossy lesions;” warty-looking epidermal skin lesions.
Advanced skin changes in an adult with lymphoedema in Tanzania
Sara Burr. Online image. April 5, 2010
Journal of Lymphoedema (2007). Retrieved from:

22. LYMPHATIC FILARIASIS Treatment: Communities
Primary goal is to eliminate microfilariae from the blood of infected individuals
➢ Annual treatment involve using combination of anti-filarial drugs:
diethylcarbamazine citrate (DEC) with albendazole
ivermectin and albendazole
regular use of DEC fortified salt
➢ Single dose treatment must be carried out for 4 – 6 years
Treatment of LF requires a collaborative effort among communities where the disease is endemic, and treating individuals. The primary goal of treating the affected community is to eliminate microfilariae from the blood of infected individuals so that transmission of the infection by the mosquito is interrupted. Recent studies have shown that single doses of diethylcarbamazine (DEC) day regimens, and also single doses of combined albendazole with DEC or ivermectin is 99% effective in removing microfilariae from the blood for a full year after treatment. It is important that treatments of single doses be carried out for 4-6 years to be effective.
World Health Organization (2000); Centers for Disease Control and Prevention (2010)

23. LYMPHATIC FILARIASIS Treatment: Individual
➢ Albendazole and DEC effective in killing adult-stage filarial parasites (necessary for complete cure of infection)
➢ Rigorous hygiene to affected limb
➢ Care of skin and exercise to increase lymphatic drainage in lymphoedema
On an individual level, anti-parasite treatment can result in improvement of patients’ elephantiasis and hydrocele, especially in the early stages of the disease. Rigorous hygiene to the affected limb, with care and exercise to increase lymphatic drainage in lymphoedema have shown to be effective measures in reducing the frequency of acute episodes of inflammation (filarial fevers), and in improving elelphantiasis.
World Health Organization (2000); Fox (2010)

24. LYMPHATIC FILARIASIS Morbidity Intervention Strategies
Health education messages should be straightforward and aimed at whole communities
Messages should address basic skin care and exercise
Identify endemic areas
Implement community-wide mass treatment programs to treat entire at-risk populations
Implement community education programs to raise awareness in affected patients
Partnerships with private, public, and international organizations
Morbidity relates to the illness caused by lymphoedema and skin changes. Morbidity associated with lymphoedema includes recurrent episodes of acute dermatolymphangioadenitis (ADLA), which are painful and debilitating, and can result in inability to work or perform normal daily activities, thus having a major impact on socioeconomic and quality of life factors. Management of lymphoedema in relation to LF is based on the hypothesis that the progression of the disease can be reduced by using simple strategies that are cost effective. In other words, minimal resources can be used to treat the problem. Since this disease has an impact on a huge population, health education messages need to be straightforward and aimed at whole communities. Basic strategies to reduce lymphoedema can be taught to people; these include basic skin care routine; elevating the foot to reduce pressure in the early stages of the disease; and movement and simple exercise to stimulate lymphatic flow. We also have to remember that we are dealing with poor environments with limited resources, and the issues of clean water, availability of soap, and even a clean piece of cloth may be potential problems that can hinder effective management of LF. Additionally, other health promotion messages should include use of mosquito nets, since children are most vulnerable to getting infections.
We also need to consider implementation of community-wide mass treatment programs where once-yearly administration of diethylcarbamazine (DEC), ivermectin, or DEC is done. Most importantly, we need to partnership with private, public, and international organizations, schools, as well as healthcare companies like SmithKline Beecham and Merck and Co., Inc. (they have been active in donating drugs in the past) for donations of the drugs which can be given out to communities free of charge.
Penzer (2007)

25. SKIN CARE Checking between toes for entry points.
These pictures illustrate basic skin care.
Checking between toes for entry points.
Encouraging self-care — person washing their own limb.
Sara Burr. Online image. April 5, 2010
Journal of Lymphoedema (2007). Retrieved from:

26. HOW TO LOOK AFTER BIG FOOT
These steps on how to look after big foot were developed by the International Skin Care Nursing Group in Tanzania.
Educational Resource Developed by the International Skin Care Nursing Group in Tanzania. Online image. April 5, 2010
Journal of Lymphoedema (2007). Retrieved from:

27. LYMPHATIC FILARIASIS Economic and Social Impact
Disease has increased over the years because of expansion of slum areas and poverty
Disease prevents patients from having a normal working life
Disease exerts a heavy social burden due to concealment of disease and social stigmatization
Marriage, in many instances is often impossible
The fight to eliminate lymphatic filariasis is also a fight against poverty. Lymphatic filariasis is primarily considered a disease of the poor because of its prevalence in remote rural areas, and in disadvantaged peri-urban and urban areas. In recent years, LF showed a steady increase because of growth in urbanization of slum areas, especially in Africa and the Indian sub-continent. Many individuals are physically incapacitated as a result of the disease and are unable to have a normal working life. In addition, the disease puts a social burden on the population especially since chronic complications are oftentimes hidden and are considered shameful. For example, when men are affected by lymphoedema, they are considered undesirable, and when their lower limbs and genital parts are enlarged, they are severely stigmatized. Also, marriage, which is seen as a source of security for many, is often impossible. Similarly, for women, shame and taboos are also associated with the disease.
World Health Organization (2000)

28. LYMPHATIC FILARIASIS
In the tropics the most degraded environments are often linked with poverty, and with lymphatic filariasis
British Association of Dermatologists, Online image. April 4, 2010
Streit, T. & Lafontant, J. G. (2008). Retrieved from:

29. WHAT’S NEXT? Global Elimination of Lymphatic Filariasis
➢ Primary prevention of new cases using mass drug administration
➢ Secondary and tertiary prevention of patients’ morbidity associated with the disease:
– access to healthcare
– education
Barriers to implementing filariasis elimination programs:
➢ Financing
➢ Developing infrastructure capable of distribution of drugs to at-risk populations
➢ Difficulty achieving and maintaining high coverage levels for 5 or more years
➢ Diminished Compliance
Modeling other successful programs:
➢ Guyana Experience
➢ China Experience
The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in 2000 by the World Health Organization with a purpose to eliminate LF as a public health problem by 2020 by protecting the whole at-risk population. LF is one of the only six infectious diseases considered eradicable by the World Health Organization (WHO) with the available tools. Strategies to achieve this objective includes primary prevention of new cases involving mass drug administration to treat the entire at-risk population once a year with two drug combinations of diethylcarbamazine citrate (DEC) fortified salt plus donated albendazole, or albendazole with donated ivermectin to keep the levels of microfilariae in the blood below those necessary to sustain transmission. Secondary and tertiary prevention of patients’ morbidity associated with the disease include access to effective surgery for hydrocele, and education of hygiene and self-care to prevent attacks of acute inflammatory adenolymphangitis. WHO reported that progress has been made to date in accomplishing their objectives: 1013 billion doses of albendazole tablets donated to WHO were supplied to 48 countries, and in 2008, 266 million were distributed to 30 out of 48 countries; 788 million ivermectin tablets were supplied to 16 out of the 29 countries in the African Region and the Eastern Mediterranean Region where LP is co-endemic with onchocerciasis, enabling 304 million treatments; 499 million diethylcarbamazine citrate (DEC) tablets obtained by WHO from prequalified manufacturers were supplied to 13 countries; 610 million people were protected through the mass drug administration in 42 countries, which represents 50% of the at-risk population. Current efforts are being made to provide increased access to hydrocele surgery at district levels, and also lymphoedema management training for community home-based self-care.
Despite these efforts, however, the program is faced with barriers to expanding the elimination programs based on mass drug administration. These barriers include obtaining scarce dollars to finance the programs; difficulty developing an infrastructure capable of distributing drugs to the entire at-risk population; achieving and maintaining high coverage levels for 5 years or more; and diminishing compliance over subsequent cycles of mass drug administration because of adverse reactions associated with the parasite’s death following treatment.
Despite these barriers, WHO, along with other countries who have had successes in eliminating LF, feel that salt fortified with DEC which causes few or no adverse reactions when compared with DEC tablets, is more cost effective than tablet-based programs, and can be used as an alternative treatment to mass drug administration with the potential to overcome the previously mentioned barriers. Guyana has had successes in using DEC-fortified salt in reducing microfilaraemia transmissions mainly through regulatory control of the salt as a food product and not as a pharmaceutical; establishing strong partnerships with salt producers and importers, and social marketing to build consumer demand for DEC-fortified salt. Similarly, China’s success using DEC-fortified salt highlights a model for a safe and effective program. China became the first country declared to have eliminated LF as a public health problem in August 2007, followed by the Republic of Korea in March 2008.
Lammie, Milner & Houston (2007)

30. Now that we’ve come to the end of our presentation, ladies and gentlemen, I would like to briefly recap what we’ve discussed. Lymphatic filariasis is associated with poverty in developed countries, and is one of the most debilitating diseases which have affected over 120 million people, putting more than a billion people at risk for the disease. The infection is generally acquired early in childhood and the disease may take many years to manifest itself. LF primarily affects more men than women, and creates immense psychological and social stigma. Rapid and unplanned urbanization is considered a primary cause for the increased transmission of the disease and exacerbates the problems faster than solutions can be implemented. Early diagnosis and treatment are important; as well as community mobilization and education to help interrupt transmission of the disease. Despite barriers relating to financing, difficulty developing an infrastructure to distribute drugs to at-risk populations, and diminishing compliance, efforts are still being made to eliminate LF through mass drug administration and DEC salt-fortified programs, following examples of countries that had successes in the past, like Guyana, China, and Korea.
As a public health problem, LF has the potential of being eradicated once appropriate strategies and interventions are properly enlisted. Therefore continued progress toward global LF elimination will require solutions to potential obstacles in the most challenging and poorest endemic environments.
I’d like to take this opportunity to thank you for your participation and hope that this presentation has been beneficial to you.
THE END

31. THANK YOU FOR
YOUR PARTICIPATION

32. Suggested Readings
Babu, B. V., Mishra, S., & Nayak, A. N. (2009). Marriage, Sex, and Hydrocele: An ethnographic study on the effect of filarial hydrocele on conjugal life and marriageability from Orissa, India. PLoS Neglected Tropical Diseases, Vol. 3(4), p DOI: /journal.pntd (AN ).
Chadee, D. D., Rawlins, S., & Tiwari, T. S. B. (2003). Short communication: concomitant malaria and filariaris infections in Georgetown, Guyana. Tropical Medicine & International Health. Vol. 8(2), p DOI: /j x. (AN ).
Huppatz, C., Capuano, C., et al. (2009). Lessons from the Pacific program to eliminate lymphatic filariasis: a case study of 5 countries. BMC Infectious Diseases, Vol. 9, p BMC Infectious Diseases. DOI: / (AN ).
Lammie, P., Milner, T., & Houston, R. (2007). Unfulfilled potential: using diethylcarbamazine- fortified salt to eliminate lymphatic filariasis. Bulletin of the World Health Organization. Vol. 85(7), p
Mong lo, B., Jimenez, B. C. et al. (2009). Imported Infectious Diseases in Mobile Populations, Spain. Emerging Infectious Diseases, Vol. 15(11), p DOI: /eid (AN ).
Streit, T., & Lafontant, J. G. (2008). Eliminating Lymphatic Filariasis: A view from the field. Annals of the New York Academy of Sciences. Vol. 1136, p DOI: /annals (AN ).

33. Adesiyun, A. G. & Samaila, M. O. (2008)
Adesiyun, A. G. & Samaila, M. O. (2008). Huge filarial elephantiasis vulvae in a Nigerian woman with subfertility. Archives of Gynecology & Obstetrics. Vol. 278(6), p DOI: /s (AN ). Retrieved on April 5, 2010 from:
Fox, L. M. (2010). Chapter 5 – Filariasis, Lymphatic – 2010 Yellow Book. Retrieved on April 5, 2010 from:
Hygiene Related Diseases. Retrieved on April 5, 2010 from:
Behera, P. K., Rath, P. K., Panda, R. R., Satpathy, S., & Sarkar, B. K. (2009). Adult filarial work in the tissue section of a breast lump. Indian Journal of Surgery, Vol. 71(4), p DOI: /s (AN ). Retrieved on April 4, 2010 from:
Lammie, P., Milner, T., & Houston, R. (2007). Unfulfilled potential: using diethylcarbamazine-fortified salt to eliminate lymphatic filariasis. Bulletin of the World Health Organization. Vol. 85(7), p Retrieved on March 27, 2010 from:
McPherson, T., Persaud, S., Singh, S., Fay, M. P., Addiss, D., Nutman, T. B., & Hay, R. (2006). Interdigital lesions and frequency of acute dermatolymphangioadenitis in lymphoedema in a filariasis-endemic area. British Journal of Dermatology. Vol. 154(5), p DOI: /j x. (AN ). Retrieved on April 4, 2010 from:
REFERENCES

34. REFERENCES
Penzer, R. (2007). Lymphatic filariasis and the role of nursing interventions. Journal of Lymphoedema. Vol. 2(2), p Retrieved on April 5, 2010 from:
Streit, T. & Lafontant, J. G. (2008). Eliminating filariasis: a view from the fold. Annals of the New York Academy of Sciences. Vol. 1136, p DOI: /annals (AN ). Retrieved on April 4, 2010 from:
World Health Organization (WHO). Communicable Diseases. Lymphatic Filariasis: The disease and its treatment. Retrieved on April 5, 2010 from:
World Health Organization (WHO) Lymphatic Filariasis: Fact Sheet No Retrieved
on April 5, 2010 from:
World Health Organization (WHO) Neglected Tropical Diseases, Hidden Successes, Emerging Opportunities. Retrieved on April 5, 2010 from:

35. CREDITS
“Elephantiasis of the right leg and swollen in the left”; “Elephantiasis of the leg.” World
Health Organization (WHO), Online image. April 5, 2010.
“Elephantoid lesion before surgery.” Springer-Verlag Online image April 5, 2010.
“Globe.” Online image. Category Descriptions.asp.
April 5, 2010
“Globe in grass.” Microsoft Clip Art. Online Image. April 5, 2010.
“In the tropics the most degraded environments are often linked with poverty, and with lymphatic filariasis”. British Association of Dermatologists, Online image. April 4, 2010.
“Life cycle of Wuchereria Bancrofti.” World Health Organization (WHO), Online image. April 5, 2010.
“Lymphatic filariasis causes gross disfigurement of the lower limbs.” World Health Organization (WHO), Online image. April 5, 2010.
“Lymphoedema of the Arm.” World Health Organization (WHO), 2009.
Online image. April 5, 2010.

36. CREDITS
“Lymphoedema of left leg of Guyanese female. Dreyer Stage 6.” British Association of Dermatologists, Online image. April 4, 2010.
“Macerated interdigital lesion and dystrophic nails in left foot with lymphoedema. Dreyer Stage 3. British Association of Dermatologists, Online Image. April 4, 2010.
“Mosquito.” Microsoft Clip Art. Online Image. April 5, 2010.
“Photomicrograph showing transverse section of adult filarial worm with granuloma (H&E, ﾗ400) in a breast nodule. Association of Surgeons of India, Online image. April 4, 2010.
Sara Burr. “Advanced skin changes in an adult with lymphoedema in Tanzania.” Online image. April 5, 2010.
Sara Burr. “Encouraging self care – person washing their own limb.” “Checking between toes for entry points.” Online image. April 5, 2010.
Sara Burr. “How to look after big foot.” Educational Resource Developed by the International Skin Care Nursing Group in Tanzania. Online image. April 5, 2010.