Running Head: Lymphatic Filariasis
Promoting Health and Well-Being: Lymphatic Filariasis
Natasha L Antonakis
University of Wisconsin La Crosse
HCA 780
10/22/2020
Lymphatic Filariasis
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Abstract:
The CDC and WHO have attempted to control the spread and combat the effects of
communicable disease through mandatory reporting efforts, infection control recommendations,
global programs, and published studies and goals for disease eradication. Lymphatic Filariasis
affects over 100 million people in the tropical and sub-tropical regions of the world. As part of
the UN Sustainable Development Goals for 2030, efforts to curtail transmission and morbidity
from LF are underway. Five strategies to combat the disease are detailed through evaluation of
studies qualified by location and the presence of filarial vectors. Collective results indicate that
near eradication of Lymphatic Filariasis is possible through diligent efforts involving drug
administration, hygiene, vector control, veterinary medicine, and effective oversight of
implemented programs.
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Introduction
Edemkong, Kopparapu, and Huang define communicable diseases as “illnesses caused by
viruses or bacteria that people spread to one another through contact with contaminated surfaces,
bodily fluids, blood products, insect bites, or through the air” (2020). Many forms of spread
occur through oral feces route, sexual contact, insects, contaminated surfaces(fomites), skin to
skin contact, or droplet contamination. An outbreak or epidemic occurs when and agent is
present and able to be conveyed to susceptible hosts in large numbers.
Epidemics and infectious disease have existed since the beginning of time. Charged with
notable deaths, political unrest, and even the collapse of an empire, communicable disease has
shaped the history of mankind. From early on, man has tried to understand disease; how it is
transmitted and ways to combat its effects. As knowledge and technology evolve, so does the
understanding of disease pathology and etiology. While it was always understood that diseases
were contagious, knowledge of modes of transmission and susceptibility was lacking leading to
failed efforts to control transmission.
Most recognizable of the current focus on communicable disease are HIV/AIDS, Measles,
Tuberculosis, Malaria, Hepatitis, West Nile Virus, Zika, and most recently COVID-19. Much
research, testing, and planning has surrounded these diseases and the affected populations. As
such, the UN Sustainable Development Goal number 3; By 2030, end the epidemics of AIDS,
tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne
diseases and other communicable diseases, is testament to the detriment communicable disease
has on world populations. As of 2017, WHO through the Strategic and Technical Advisory
Lymphatic Filariasis
Group for Neglected Tropical Diseases updated the list of NTD to include 20 diseases/disease
categories. Included are

Buruli ulcer

Chagas disease

Dengue and Chikungunya

Dracunculiasis (guinea-worm disease)

Echinococcosis

Foodborne trematodiases

Human African trypanosomiasis (sleeping sickness)

Leishmaniasis

Leprosy (Hansen's disease)

Lymphatic filariasis

Mycetoma, chromoblastomycosis and other deep mycoses

Onchocerciasis (river blindness)

Rabies

Scabies and other ectoparasites

Schistosomiasis

Soil-transmitted helminthiases

Snakebite envenoming

Taeniasis/Cysticercosis

Trachoma

Yaws (Endemic treponematoses)
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These are the less spoken of communicable diseases and are prevalent in tropical and
subtropical conditions in 149 countries. Those who live under adverse conditions such as
poverty, poor sanitary conditions, and amongst plentiful vectors are the most affected. NTD has
become a topic of concern as their impact on the economy, health, and overall quality of life of
the affected population is better understood. As such, the United Nations has recognized the
seriousness of these diseases and has put ending the epidemic of NTD on the list of Sustainable
Development Goals to be realized by 2030.
Lymphatic Filariasis is a parasitic communicable disease caused by 3 species of round
worms: Wuchereria bancrofti, Brugia malayi, and Brugia timori. The worms are spread through
vector transmission by mosquito bites. The microfilaria, or microscopic worms are transmitted
from the blood of an infected person to the mosquito and then to an uninfected host through the
bite of that same mosquito. The microfilaria travel through the lymph system and are stored in
the lymph nodes where they become adult worms. Effects of the parasite include lymphedema,
swelling of the lymph system that may include swollen, cracked, and infected limbs and scrotum
in men. The strain on the lymphatic system creates an environment where the body may struggle
to fight off further sources of infection. Even after treatment for Lymphatic Filariasis, the
damage to the lymphatic system remains and the affected individual must follow a strict limb
care regimen to prevent further infections. While many affected individuals are asymptomatic,
those that have visible symptoms struggle with disability, mental health issues from social
stigma, and an overall decreased quality of life.
The World Health Organization determined that Lymphatic Filariasis, a NTD, is an
important public health concern and upon development of diagnostic tools and drugs for
treatment, launched the Global Programme to Eliminate LF (GPELF) in 2000 and identified 5
Lymphatic Filariasis
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strategies to combat NTD. With implementation of identified strategies beginning in the year
2000, we should be near total eradication of new cases of Lymphatic Filariasis by the year 2030.
The five strategies recommended by GPELF are as follows:
* Preventive chemotherapy of population at risk/infected
Mass Drug Administration (MDA)
* Intensified case-finding and management
* Integrated vector control/management
* Provision of safe water, sanitation, and hygiene
* Veterinary public health.
Detailed steps can be taken under each of these five categories to work towards
control and eventual eradication of Lymphatic Filariasis.
\Methods
Google, Google Scholar, and the UW systems library were utilized to search the topics of
Lymphatic Filariasis and communicable disease. Sources were chosen that indicated scientific
study of LF with numeric findings, global program effectiveness, and evaluation of causes,
treatments, and morbidity from the disease. Studies published from varied journals were utilized
to avoid any type of bias. While some literature sources were reviews in and of themselves, the
information provided was deemed pertinent and beneficial to the topic of combating Lymphatic
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Filariasis and was therefore included for review. Data was collected via survey, sampling,
through procedure and medication trials and scientific testing methods. Information from WHO
and the CDC supplemented study findings as confirmation of dissention to findings for this
Literature Review.
The information was organized by strategy and studies of the strategy were summarized
by topic. When applicable, information obtained from the CDC and WHO supplemented
reported findings. Scientific fact and human opinion and thought were obtained and recorded
through the reviewed trials. As such, findings vary between simplified data and stated thoughts
and ideas (as reported by study subjects) on the topics under each strategy.
Body
Mass Drug Administration
The goal of MDA is to reduce the density of parasites circulating in the blood of infected
persons and prevalence of infection in communities to levels where transmission is no longer
sustainable by the mosquito vector (Gyapoung, et al., 2018).
A qualitative study by Ahoulr et al.,aimed to determine community acceptance through
participation and ingestion of choice drugs for elimination of LF; Ivermectin (IVM) in
combination with Diethylcarbamazine (DEC) or Albendazole (ALB),and to gather information
to promote intervention strategies in hotspot areas (Ahorlu et al., 2018). Findings suggest that
there are multiple barriers to medication regimen compliance that span from personal to health
system related. Residents were aware of the program and the treatment plan, but compliance
varied (Ahorlu et al., 2018). Reasons for noncompliance given from respondents was as follows:
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Fear of side effects
Patients thought they were not susceptible (those that were infected but did not have visible
signs/symptoms)
Personal dislike for medicine
Distrust of/dishonest program facilitators
Healthcare facility request for payment prior to medication dispensing
Findings suggest that any program must be compatible with its intended recipients and
environment for success. The reasons for noncompliance can be utilized to gear the program
towards successful interruption of LF transmission in hotspot areas by customizing the approach
towards the affected populations.
Types of Medication, Dosage, and Effectiveness
Treatment consisting of a single dose of a three-drug regimen of ivermectin plus
diethylcarbamazine plus albendazole was tested against a single dose of a two-drug regimen of
diethylcarbamazine plus albendazole (King et al., 2018). The testing involved a randomized
controlled trial from villages in New Guinea of patients who had not received any PF treatment
prior to the study.
Results of the study found that a single dose of a three-drug regimen of ivermectin plus
diethylcarbamazine plus albendazole was more effective in clearing W. bancrofti microfilariae
from the blood than a single dose of a two-drug regimen of diethylcarbamazine plus
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albendazole(King et al., 2018). The conclusion was that both drug regimens actively reduce
circulating filarial antigen levels with the triple drug treatment also killing adult worms making it
a more effective treatment with less probable disease transmission. Therefore, the three-drug
regimen of ivermectin, diethylcarbamazine, and albendazole was deemed by the authors as a
potential effective treatment for the elimination of lymphatic filariasis.
WHO reports “a single dose of diethylcarbamazine citrate (DEC) has the same long-term
(1 year) effect in decreasing levels of microfilaraemia as the formerly recommended 12-day
regimen of DEC. More importantly, the use of single doses of two drugs administered together
(optimally albendazole with DEC or ivermectin) is 99% effective in removing microfilariae from
the blood for a full year after treatment” (WHO, 2016). This does not contradict study findings
nor does it correlate with the finding that the triple drug treatment is most effective.
Provision of Safe Water, Sanitation and Hygiene
Stocks, Freeman, and Addiss performed a systemic review and meta-analysis of studies
of the effects of hygiene -based lymphedema management in Lymphatic Filariasis endemic
areas. LF creates a condition of swollen limbs that are prone to cracking and infections. Acute
bacterial dermatolymphangioadenitis (ADLA), inflammation of skin, tissue, and lymphatics, has
been demonstrated in several case studies of Lymphatic Filariasis. Per the authors, ADLA further
erodes lymphatic function, stimulates fibrosis, and increases the risk of additional ADLA
episodes which complicate LF (2015).
Lymphedema management programs in the reviewed studies all included a hygiene
element such as washing limbs with soap and water and combinations of other various treatments
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such as lymph fluid drainage, compression bandages, body movement exercises, foot/leg creams,
and education on limb care. Direct findings of the study indicate that “the proportion of
lymphedema patients experiencing at least one ADLA episode in a given time period decreased
from 49.6% at baseline to 16.2% after implementation of hygiene based lymphedema
management (Stocks, Freeman, and Addiss, 2015).
Stocks, Freeman, and Addiss state the evidence strongly supports the effectiveness of
hygiene-based lymphedema management in LF-endemic areas in controlling the morbidity and
disability associated with LF but does not affect the spread of the disease (2015).
WHO recommends rigorous hygiene of the affected areas in combination with a regimen
to promote lymph flow and limit infection, as bacterial and fungal infections promote the
pathology of LF. This correlates with study findings (WHO, 2016).
Intensified Case-Finding and Management
Global elimination of lymphatic filariasis is achieved through treatment of at-risk
populations with annual or bi-annual mass drug administration campaigns. To ensure
effectiveness of MDA, the proper population coverage must be achieved. To do this, surveys
must accurately depict the affected populations and medication administration must be properly
documented.
Maroto-Camino et al., evaluated MDA programs for effectiveness.
The World Health Organization has established that to eliminate Lymphatic Filariasis as
a public health problem, a minimum of five consecutive annual MDA rounds with effective
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coverage; administration of medication to at least 65% of the total population, must be
administered.
WHO has requested that endemic countries conduct household surveys to validate the
reported MDA coverage rate and support action where microfilaremia persists despite reports of
achieved coverage targets (Maroto-Camino et al., 2019).
With Suboptimal MDA coverage persistent parasite transmission is imminent leading to
infection, disease and disability, and the need for even more drug treatments substantially raising
the cost of treatment efforts. To verify effectiveness of MDA coverage, WHO recommends
verification of the campaign’s administrative records using household cluster surveys at least
once every 5-years (Maroto-Camino et al., 2019).
The authors evaluated surveys with suboptimal coverage for QA purposes. These
evaluations addressed reasons for failure of the MDA, residents not taking the medication, places
where the medication was received, information sources, and knowledge about diseases
prevented by the MDA (Maroto-Camino et al., 2019).Their results showed that administrative
records over-estimated treatment area coverage and did not detect implementation and problems
due to errors in numerators and denominators, incorrect reporting, and/or incorrect data (MarotoCamino et al., 2019).
Integrated Vector Control/Management
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Vector control is thought to be a valuable secondary measure to prevent the spread of
Lymphatic Filariasis. There are several species of mosquito that can carry and transmit the
filarial nematodes involved in LF. Lymphatic filariasis is transmitted by many species of
mosquitoes in four principal genera—Anopheles, Culex, Aedes and Mansonia (WHO,2020).
Each species has a different rate of parasite transmission.
For filariasis transmission to be interrupted, vector density or microfilaria intensity needs
to be lowered to ensures no new infection occurs (Bockarie, Pedersen, White, & Michael, 2009).
Two types of eradication thresholds are also most likely to exist for LF; one related to the
infection transmission process (biting humans) from the vectors and the other to worm infection
levels in the human host. The two thresholds exist wherein the level of biting is too low to
facilitate transmission and when the level of worms in the human body is too low to allow for
transmission to the vector(mosquito).
“Vector control is particularly attractive for LF because transmission of the parasite is
inefficient. There is no multiplication of the parasite in the mosquito vector and only continuous
exposure to bites of many infected mosquitoes maintains the infection in humans” (Bockarie,
Pedersen, White, & Michael, 2009, p. 474).
Measures taken to prevent or eliminate the breeding of mosquitoes in their natural or
human-made habitats included closing of wells and eliminating unnecessary bodies of water.
Biological control methods included the release of natural predators such as certain species of
fish in suitable habitats. Application of pesticides and chemical larvicides can also be utilized.
After five years of studied vector control activities, the reported vector density was reduced by
90% (Bockarie, Pedersen, White, & Michael, 2009).
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Successful vector control requires adequate resources and well-trained personnel with
appropriate oversight. The reviewed results show that vector control could serve as a major tool
in combination with MDA for achieving LF elimination in endemic areas.
Veterinary Public Health
The role of animals in the spread of LF is unclear. Humans are considered the main
definitive host of filariasis, but there are several animals that can transmit filarial infections
Mulyaningsih et al., 2019).There have been studies conducted that identify the species Brugia
Malayi, one of the three parasites that cause Lymphatic Filariasis, as present in dogs and other
animals, the notion that the animals are able to spread the parasite to humans is disputed. Two
studies, one on canine filarial infections in India and another on Brugia Malayi in Indonesia
agree that LF from Brugia Malayi is zoonotic, meaning it can be spread from animals to humans.
The articles relay that cats and dogs and monkeys have been determined to host B Malayi,
respectively. Findings by Ravindran et al., did not find evidence to support dog to human
transmission in the current study (2014).
With the above detailed information from the literature review, is total eradication of
Lymphatic Filariasis a possibility and is the 10-year time frame of eradication by the year 2030
feasible?
Discussion
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A successful eradication campaign can be realized based on the scientific findings from
the literature reviewed. The gathered research data and information clearly supports the means to
prevent further spread of microfilaria through vector transmission and to minimize further
complications in those who currently have manifest symptoms. By utilizing the recommended
treatment regimen of a single dose of a three-drug regimen of ivermectin plus
diethylcarbamazine plus albendazole as part of a LF reduction campaign with high oversight and
accurate data maintenance regarding population coverage, the levels of circulating microfilarial
antigens and live worms can be reduced, the first threshold needed for transmission, to a nontransmissible level in hosts. Vector management in the way of pesticide applications and
biological elimination methods, and monitoring breeding grounds has proven to reduce the
vector population by 90% and therefore greatly reducing the vector to human bites, the second
threshold needed for transmission.
Barriers to prevention exist in the human element to the treatment processes. Resistance
and non-compliance on behalf of the affected population and human error, negligence, and lack
of enthusiasm of the public health and community members tasked with record keeping and drug
administration efforts will actively work against the eradication campaign.
Successful efforts will include an education portion to the campaign, addressing the fears
and concerns of the affected population. Benefits of total eradication must be thoroughly
established and discussed through the education and downfalls of non-compliance and associated
disability and mortality clearly outlined. Conscientiousness regarding medication administration,
ingestion, and overall compliance must be made mandatory, but first must be understood by the
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population. The MDA efforts must be subsidized so that all treatment, regardless of ability to
pay, is maximized.
A campaign of trust needs to be fostered between the medical providers, public health,
and community health workers and the treatment population. This must include accurate record
keeping and working with integrity towards LF eradication. The promise of and inclusion of
follow-up care including teaching and provision of hygiene techniques and supplies to prevent
further complication from irreversible disease effects as a philanthropic effort once drug
administration has been completed, will continue to foster trust between the two groups.
In addition to these efforts, generalized sanitation measures and education must be
addressed within the communities. This includes the importance of proper veterinary care from
farm and domesticated animals, and the effects that the state of the environment can have on the
human population regarding the spread of illness and disease.
If the above measures are taken, maintained, and reevaluated annually for effectiveness,
it is my belief that the goal of total eradication by the year 2030 can be realized.
Conclusion
The United Nations Sustainable Development Goal #3; good health and well-being, seeks
to ensure health for all regardless of age, ability, or status. This goal addresses all major health
priorities, the conditions, resources, and knowledge. Specific to this focus is strengthening each
countries ability to identify, reduce, and manage health risk.
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NTD, neglected tropical diseases effect not only physical well-being but also the mental
health of the affected and their caregivers. Addressing the causes and potential treatments and
eradication efforts of the diseases are essential to maintain health across the world. The UN and
WHO address these issues and have increased efforts through global programs to eliminate
communicable disease. Neglected tropical diseases affect the poorest of nations with the weakest
populations. This only intensifies the spread of the diseases and inhibits efforts to control them.
Following recommended guidelines through global programs to eliminate specific NTD, is a step
towards providing health and well-being for inhabitants across the globe. Eradication of
Lymphatic Filariasis is possible with collaboration of the global health initiatives, community
workers, and the affected populations.
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