FILARIASIS

Dr Sanjay Kini

Associate Professor
Community Medicine
KMC Manipal
FRAME WORK
Introduction
Problem Statement
Epidemiology
Life Cycle of Parasite
Clinical Manifestations
Investigations
Management
Control measures and
NFCP
INTRODUCTION
Filariasis- common term for a group of diseases

 Caused by parasitic nematodes of superfamily Filarioidea

LF: Filariasis by nematodes that live in the human lymph

system

Wuchereria Bancrofti

Brugia Malayi

Brugia Timori

Transmitted by bite of mosquitoes

Problem statement
>1.3 billion-areas where there is risk

120 million are infected & in need of Rx

15 million-Lymphoedema

25 million-Urogenital swelling

Appr. 66% of those at risk of infection live in

South-East Asia Region
GLOBAL DISTRIBUTION MAP
 INDIA
 Public health problem next to malaria

 Recorded in India- 6th century BC by susruta

 In 1709,Clarke- elephantoid legs in Cochin as Malabar legs

 Microfilaria in PB-Lewis in 1872 in Calcutta

 Presently,60million-at risk in 250 endemic dst

 8 lac-Lymphoedema cases

 4 lac-Hydrocele cases

 Microfilaria Rate-0.33%
 Andhra Pradesh
 Assam
 Bihar
 Chhattisgarh
 Goa
 Jharkhand
 Karnataka
 Gujarat
 Kerala
 Madhya Pradesh
 Maharashtra
 Orissa
 Tamil Nadu
 Uttar Pradesh
 West Bengal
 Andaman & Nicobar
Islands
 Daman & Diu
 Dadra & Nagar Haveli
 Lakshadweep.
AGENT FACTORS
LYMPHATIC FILARIASIS NON-LYMPHATIC FILARIASIS

W.BANCROFTI ONCHOCERCA VOLVULUS

B.MALAYI MANSONELLA OZZARDI

B.TIMORI T.PERSTANS

T.STREPTOCERCA
HOST FACTORS
Man – Natural Host

Age – All age , Max: 20-30 years

Sex – Higher in men

Migration – leading to extension of infection to

non-endemic areas

Immunity – may develop after long year of

exposure (Basis of immunity-not known)
SOCIAL & ENVIRONMENTAL FACTORS
 Urbanization, Poverty, Industrialization,
Illiteracy and Poor sanitation

 Climate: The breeding of mosquito

 Longevity (Optimum temperature 20-300C

& Humidity 70%)

 Sanitation, Town planning, Sewage &

Drainage.
MOSQUITO VECTOR
Main vectors in India

Culex Quinquefasciatus-Bancroftian filarisis

Mansonia(Annulifers & Uniformis)-Brugian filariasis

In different areas of world

Culex,Anopheles & Aedes-W.Bancrofti

Mansonia,Anopheles & Coquillettidia-Brugia species

Clinical IP:8-16 mths

DIFFERENT STAGES OF LARVA IN
MOSQUITO
LIFECYCLE
DISEASE SPECTRUM
Asymptomatic Parasite Carrier State

Acute Disease

 Acute dermato-adeno-lymphangitis (ADLA)

 Acute filarial lymphangitis (AFL)

 Acute epididymo-orchitis and funiculitis

ACUTE FILARIAL LYMPHANGITIS
Caused by death of adult worms

Tender nodes - scrotum or along the

lymphatics of the limbs

Not assoc. with fever, toxaemia or sec.

bacterial infection

Mild clinical course

Rarely causes Lymphoedema

 ACUTE DERMATO-ADENO-
LYMPHANGITIS(ADLA)
 Associated with fever and chills

 It is more frequent in higher grades of lymphoedema

 Extremities are painful, warm,red, swollen and tender

 The draining lymph nodes in the groin or axilla become

swollen and tender

There may be lymphangitis, lymphadenitis, cellulitis or

abscess

 Entry of bacteria through lesions responsible for the

acute episodes.
CHRONIC DISEASE
Main consequences of chronic bancroftian filariasis

Lymphoedema

 Elephantiasis

Hydrocele and

 Chyluria
GENITAL MANIFESTATIONS
Hydrocele-Accumulation of fluid in the tunica vaginalis

Scrotum skin may be covered with vesicles distended

with lymph-‘lymph scrotum’

Prone for ADLA attacks involving the skin of genitalia

Chronic epididymitis

 Funiculitis (swelling of the spermatic cord)

Lymphoedematous thickening of the scrotal skin

OTHER MANIFESTATIONS
 Chyluria- excretion of chyle in the urinary tract

 Block of the retroperitoneal lymph nodes

 Reflux and flow of the intestinal lymph into the renal

lymphatics

 Which may rupture & permit flow of chyle into the urinary
tract-Milky urine

 Hematuria & Protienuria

 Immune complex on the basement memb. of renal glomeruli

OCCULT FILARIASIS
 No clinical manifestations, no mf in blood but found in tissues

 Tropical Pulmonary Eosinophilia (TPE)

 Severe cough and wheezing (night)

 Blood eosinophilia > 2500 cells /μl

 Extreme elevation of IgE

 Elevation of anti-filarial antibodies

 Diffuse miliary lesions radiologically

 Clinical improvement in response to specific antifilarial

chemotherapy(DEC).
LABORATORY DIAGNOSIS
Demonstration of mf in peripheral blood

Thick blood smear: collected b/w 8.30 pm-12 am

Membrane filtration method: 1-2 ml venous blood

filtered through 3µm membrane filter

DEC Provocation test: After consuming DEC

100mg

 mf enters into the peripheral blood in day time

within 30 - 45 minutes
IMMUNOCHROMATOGRAPHY(ICT)
Antigen detection assay: done by Card test
and through ELISA

 Circulating Filarial Antigen detection

Sensitivity is greater than all other parasite

detection assays

 Will detect antigen in amicrofilaraemic as

well as with clinical manifestations
 Clinical Survey

 When blood is collected, pt.s are examined for clinical

manifestations

 Detection of Antibodies to mf: Immunofluorescent &

complement fixing techniques

 Xenodiagnosis: Mosquitoes are allowed to feed on pt.

 Dissected 2 weeks later

 Entomological Survey: Collection of mosquito from

houses

 Female species dissected for detection of infective forms of

larvae
ULTRASONOGRAPHY
Ultrasonography using a 7.5 MHz or 10 MHz
probe

 Locate and visualize the movements of living

adult worms of W.b. in the scrotal lymphatics
of asymptomatic males with microfilaraemia

 The constant thrashing movements

described as “Filaria dance sign” can be
visualized
LYMPHOSCINTIGRAPHY

The structure and function of the lymphatics of

the involved limbs can be assessed

 By injecting radio-labelled albumin or dextran in

the web space of the toes

changes can be imaged using a Gamma camera

Lymphatic dilation & obstruction can be directly

demonstrated even in early clinically
asymptomatic stage
MANAGEMENT OF LYMPHATIC FILARIASIS
 Treating the infection

 Treatment and prevention of Acute ADL

attacks

 Treatment and prevention of

Lymphoedema
CHEMOTHERAPY
 Drugs effective against filarial parasites

 Diethyl Carbomazine citrate (DEC)

 Ivermectin

 Albendazole

 Treatment of microfilaraemic patients may prevent chronic

obstructive disease

 Repeated every 6 months till mf and/or symptoms

disappears
DI ETHYL CARBAMAZINE

 Very effective against mf (Microfilariacidal)

 Lowers mf level even in single dose

 Effective against adult worms in 50% of patients

 Dose: 6mg/Kg/12 days

 Recent dosage: 6mg/Kg single dose

 Adverse reactions :destruction of mf-fever, nausea,

myalgia, sore throat, cough, headache

 Drug of choice in the treatment of TPE

IVERMECTIN
Mode of action: Directly acts on mf and no action on
adults

Lowers mf level in single dose of 200µg – 400µg/Kg

BW

No action on TPE

Drug of choice in Co-endemic areas of Onchocerciasis

with LF

Adverse reactions are lesser but similar to that of DEC

Microfilariae reappears faster than DEC

ALBENDAZOLE
This antihelmenthic kills adult worms

No action on microfilariae

Dose: 400mg/twice day /2 weeks

With combination of DEC & Ivermectin, it

enhances the action of the drugs

Induces severe adverse reactions in hydrocele

cases due to the death of adult worms
TREATMENT OF ADLA

 The simple procedures can alleviate the symptoms

 A cloth soaked in water , placed around the leg can relieve

pain/ leg can be soaked in cold water

 The leg should be washed with soap and clean water but
more gently and carefully

 After drying, antiseptic can be applied to the skin

 The patient should drink plenty of water

 PCT can be taken for fever every 6hrs until the fever
subsides

 Oral antibiotics :Amox(1.5g ,3 divided doses/Penicillin)for

8dys
MANAGEMENT OF SEVERE ADLA
IV Benzyl Penicillin:5million units,2times/dy until fever
subsides

IM Procain Benzyl Penicillin

Then Phenoxy methyl Penicillin:750mg-1g,3 times a

day

Total treatment atleast for 8 days

If allergic to penicillin give Erythromycin 1g iv,3 times

a day
MANGEMENT OF LYMPHOEDEMA

 Washing
 Prevention and cure of entry lesions
 Elevation of the foot
Exercise
 Wearing proper footwear
 Management of acute attacks
EXERCISE
SURGICAL TREATMENT
Before any surgical procedure: A course of DEC

Chronic Hydrocele: Excision and Eversion Sac

Scrotal Elephantiasis

Removal of skin & tissue, preserving penis & testicles

Lymphoedema: Excision of redundant tissue, Excision of

subcutaneous and fatty tissue

Postural drainage and physiotherapy

CONTROL MEASURES

 Chemotherapy

 Vector control

 3 main reasons why filariasis never causes

explosive epidemics

 The microfilariae does not multiply in the vector

 Infective larvae do not multiply in man

 Life cycle of the parasite is relatively long

Mass Drug administration
The following drug regimens once a year for
at least 5 years

6 mg/kg of body weight diethylcarbamazine

citrate (DEC) + 400 mg albendazole; or

150 µg/kg of body weight ivermectin + 400

mg albendazole (in areas that are also
endemic for onchocerciasis).

 Use of common table salt or cooking salt

fortified with DEC for a period of one year
MDA
Removal of Pistia Plant: In case of Mansonia
mosquitoes

Herbicides: Phenoxylene 30/shell weed

killerD

Minor Environmental Measures

Filling of ditches,drainage of stagnant water

Maintenance of septic tanks & Soakage pits

Anti Adult measures

Indoor residual spray using DDT, HCH and

Dieldrin

 Pyrethrum as a space spray is also followed

Personal Prophylaxis

Reduction of man mosquito contact by using

mosquito nets, screening of houses, etc.
Vector control involves anti larval measures, anti
adult measures, personal prophylaxis

 An integrated method using all the vector control

measures : sustained vector control

Vector Control: Antilarval Measures

Chemical control

Mosquito larvicidal oil


Pyrosene oil

Organo phosphorous compounds such as Temephos,

Fenthion:Once weekly on all breeding places
NATIONAL FILARIA CONTROL
PROGRAMME(NFCP)
Was launched in the country in 1955- under
NVBDCP

 The current strategy of filariasis control

(Elimination) is

 Interruption of transmission

 Control of Morbidity
REVISED STRATEGY
 Annual MDA with single dose of DEC was taken up as a pilot
project covering 41 m population in 1996-97 and extended
to 74 m population

 This strategy was to be continued for 5 years or more

 Excluding children below two years, pregnant women and

seriously ill persons

 DEC + Albendazole in selected distt& DEC in other distt on

NATIONAL FILARIA DAY, NOVEMBER 11
Morbidity Management

Home based management of lymphoedema

cases

 Up-scaling of hydrocele operations in the

identified CHCs / District hospitals/ medical
colleges
THANK U
REFERENCES
http://www.who.int/lymphatic_filariasis/epidemiology/
treatment_prevention/en/index.html

http://www.filariasis.org/elimination_strategy.html

www.nvbdcp.gov.in/guidelines

MANSON’S TROPICAL DISEASE,Edited by

Gordon.C.Cook and Alimuddin I Zumla, 22nd EDITION

PARK’S TEXT BOOK OF PREVENTIVE AND SOCIAL

MEDICINE, 22ND EDITION