Lymphatic Filariasis and the Role of Nursing Interventions

Clinical REVIEW

Lymphatic filariasis and the role of nursing interventions

Rebecca Penzer

Lymphoedema in the resource rich countries of the world is usually associated with cancer or venous disease. In the developing world, however, large numbers of people (1.2 billion) (Dean, 2001) are at risk of developing lympoedema because they live in areas where the infected mosquitos take frequent blood meals from humans. This article seeks to explore the relationship between mosquitos, lymphatic filariasis and the associated lymphoedema and to discuss the relevant nursing interventions which can have a positive impact on literally millions of individuals.

blood meal from a human (which it Once in the blood stream, the Key words does by sticking its probiscus into the parasite make its way to the lymphatic superficial blood supply) it picks up system where it grows: male adult Lymphatic filariasis microfilariae (mf) which are circulating worms growing to 4cm in length and Lymphoedema near the surface of the skin. Once in females up to 10cm (Scott, 2000). The Skin care the mosquito, mf undergo a number worms live tangled together in ‘nests’ Nursing interventions of developmental stages which take in the lymphatics, these can be seen place in the flight muscles of the pulsating on an ultrasound scan. At mosquito. Having undergone these adulthood, the worms mate and the stages, the mf migrate back to the female releases further microfilariae mouth parts of the mosquito. On the into the lymphatics. These immature Lymphatic filariasis and the mosquito parasites migrate to the superficial In the tropical countries of Africa, blood vessels where the mosquito Central America and Asia, mosquitos Dermatolymphang- picks them up on taking a blood meal are the vector for parasites which ioadenitis, often referred and, thus, the disease is transmitted. At cause extreme suffering and ill- to as ‘acute attacks’ cause night time the density of microfilariae health. Most people know of the an individual to suffer pain, in the superficial blood supply is higher relationship between malaria and nausea and fever. These than during the day. It seems that the the mosquito, fewer are aware that inflammatory episodes mf ‘know’ that this is the time when mosquitos also carry the parasite trigger the release of the mosquitos are most likely to bite that causes lymphatic filariasis and, therefore, they are most likely to (LF) leading to lymphoedema and cytokines and growth get picked up and transmitted. eventually elephantiasis. Ninety-one factors into the epidermis, per cent of LF cases are caused by these stimulate the Effect of the lymphatic filariasis parasite the genus Wuchereria Bancrofti, while growth of fibrotic tissue As the adult worms grow within the remaining 9% of cases can be and fat. the lymphatic system, the vessels attributed to Brugia Malayi and Brugia become dilated through mechanisms Timori. not entirely understood (Addiss and next blood meal that the mosquito Brady, 2007). What is clear is that The life cycle of the LF parasite takes, it deposits the parasite onto this dilatation makes the lymphatic is partly in the mosquito and partly the skin of the human where it has to vessels less effective (Vaqas and in humans. As the mosquito takes a make its way through the puncture Ryan, 2003). The progressive nature wound into the blood supply. This of lymphoedema can be explained transmission is not very efficient by considering the frequent (Kazura, 2000) and many mosquito inflammatory episodes experienced. bites are required before the parasites A failing lymphatic system is unable Rebecca Penzer is an Independent Nurse Consultant in skin are effectively established within the to cope with bacterial invasion, which health and Editor of Dermatological Nursing human (McCarthy, 2000). penetrate through any lesions in the

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epidermis to create what is known as How big is the problem? is possible to reduce the level of the an acute dermatolymphadenopathy As already mentioned, 1.2 billion circulating parasite to such an extent (Mortimer, 2000). Dermatolymphang- people live in parts of the world that it no longer poses a public health ioadenitis, often referred to as where they are at risk of contracting problem (Ottesen, 1998). In 1997, ‘acute attacks’, cause an individual to LF; this equates to one-fifth of the the World Health Assembly passed a suffer pain, nausea and fever. These world’s population all living in the motion making the elimination of LF a inflammatory episodes trigger the poorest parts of the world. LF is public health priority. release of cytokines and growth most definitely a disease of poverty. factors into the epidermis, these 120 million people have been The programme to eliminate LF as stimulate the growth of fibrotic infected with the LF parasite, and a public health problem has two pillars. tissue and fat. The result of these while many of these people will The first is to treat every individual inflammatory changes is that the remain asymptomatic, around 10% who lives within an endemic area with swelling is less and less caused by will go on to develop elephantiasis drugs that will kill the LF microfilariae. fluid accumulation and more caused either of the leg, arm, breast or This requires each individual to take by fibrotic tissue and fat. genitals (World Health Organization drugs once a year for 5–10 years. [WHO], 2000; www.who.int). The effect of this is to gradually As the above description suggests, decrease the level of circulating lymphoedema caused by LF is staged. Elephantiasis describes the microfilariae in the blood of individuals, Initially, the lymphoedema is reversible stage of the disease where there thus making it harder and harder with swelling going down following is huge swelling and skin changes for the disease to be transmitted elevation. There will be few, if any, often accompanied by pain, smell, (i.e. when the mosquito bites there skin changes. However, if the limb immobility, social exclusion and is an ever decreasing chance of it is not cared for (see section below economic hardship. While this article picking up the mf). The drugs are on skin care), there are repeated focuses on the problem of limb given in tablet form, distributed bacterial infections and the skin will lymphoedema, LF is also associated by the public health services. The gradually change, with deep skin folds, with hydrocoele and scrotal precise drugs given depends on the nodules and knobs and mossy lesions lymphoedema in men, and vulval and location, however, they consist of (Figure 1). The limb will gradually breast lymphoedema in women. either diethylcarbamazine (DEC) become bigger and bigger. Eventually in conjunction with ivermectin or elephantiasis may result. How is lymphoedema in lymphatic albendazole (Ottesen et al, 1997). filariasis managed? In some communities, the DEC is The impact on the individual is WHO have identified LF as an given through fortified salt rather significant. Acute bacterial infection eliminatable disease, in other words, it than as tablets (e.g. in Guyana). introduced through small skin breaks (e.g. small wounds or interdigital maceration) make the individual feel unwell, with significant pyrexia, nausea and pain. This can last for a few days and severely impact on the economic stability of a household, particularly if the sufferer is the main income generator. The long- term effects of lymphoedema and eventual elephantiasis are physical, social and psychological. There is a general discomfort (and often pain) and mobility may be significantly decreased. The individual may feel rejected by society and struggle in work and social situations (Wijesinghe et al, 2007). There is often a social stigma associated with swollen disfigured limbs which goes beyond the physical appearance. The society may believe that the altered limb is caused by witchcraft and/or a curse, thus isolating the individual even further (Coreil et al, 1998). Figure 1. Advanced skin changes in an adult with lymphoedema in Tanzania.

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While this population-based ‘mass 1. Wash the skin carefully on a daily 4. Check between toes and in drug administration’ approach will basis using soap and clean water, skin folds for breaks in the skin eventually eliminate the disease, there always rinse the skin carefully and fungal infections (Figure 3) will still be a significant burden of (Figure 2). — treat with an appropriate disease, i.e. people will continue to 2. Dry the skin thoroughly but gently antifungal or antibacterial product. suffer from the effects of the disease with a clean towel or soft cloth. 5. Wear comfortable shoes to for years to come. Consequently, a 3. Apply an emollient to the skin if protect the skin from traumatic programme to manage the effects of the skin is cracked or dry. damage. the disease (largely lymphoedema and skin changes) forms the second pillar of the elimination programme. It is this second pillar that the remainder of this article refers.

Morbidity management and disability prevention In 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: 8 Looking after the skin Figure 2. Encouraging self-care — person washing their own limb. 8 Elevation 8 Movement.

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 (McPherson, 2003).

Skin care messages Various skin care messages have been developed with colleagues throughout the world (in particular, Dr Gerusa Dreyer from Brazil) (Dreyer et al, 2002). These include: Figure 3. Checking between toes for entry points.

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While these steps seem relatively Ryan note that the breathing taught and take the drugs. While individuals simple to follow, in resource poor to lymphoedema patients in resource cannot be forced to take the environments many issues remain rich countries is similar to that used medication, there is often significant problematic. For example, clean water in some Asian traditional systems of peer pressure to do so. The drugs are may not be available and, even if it is, medicine (Vaqas and Ryan, 2003). In a provided to the individuals within a it may not be plentiful, soap may be recent paper, 112 Indian case studies are community for free. Generally, these unavailable (and/or of a very poor reported which suggests that the use of are then distributed on specific days quality), an individual may not own a Ayuverdic medicines and yoga (including in public venues, for example, a health towel or even a piece of clean cloth to breathing techniques) may be helpful centre. dry with, and emollients are often well in the management of lymphoedema beyond the resources of those who related to LF (Narahari et al, 2007). Messages not included in the public need them. Despite these potential health messages problems, it appears that these simple Other health promotion messages Bandaging and massage skin hygiene measures can make a Communities are also being taught In resource rich environments, difference in terms of reducing the a number of other health messages bandaging and massage form frequency of acute attacks (Kerketta et to reduce the impact of LF on important components of al, 2005). their own health and that of their lymphoedema management. In children (Figure 4). Mosquito nets resource poor environments, these are Elevation are important for preventing the generally not part of the strategy for Elevation is most effective at reducing transmission of all mosquito bourne management. swelling in the early stages of the diseases, and their use is being disease. Low level swelling may be actively encouraged through the LF Bandages are costly and difficult to totally reversed overnight if the leg programme. It has also been noted use effectively in poor environments, is elevated. Ideally, the limb should that it is likely that initial infection which may be dirty and hot with poor be raised to the same height as occurs in childhood (Witt and water supplies. Even where individuals the hip, but the individual must feel Ottesen, 2001), which means that can afford bandaging, the heat and comfortable. The knee should be protection of children is particularly humidity may prohibit their use. The slightly flexed and pressure on the important. The annual mass drug complexity of lymphatic massage ankle/heel should be avoided (Dreyer administration is often heralded as makes it impractical as part of a public et al, 2002). In communities where something of a community event. health message. However, there are furniture is scarce, elevation may be Celebrities and dignatories may be clearly exceptions to this, for example, achieved by rolling a piece of cloth to invited to attend to encourage all bandaging and massage are used to place under a sleeping mat or by using members of the community to come good effect in communities in India. a box padded by a piece of cloth.

Movement Movement and simple 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 flexing it, movement of the whole limb is beneficial. Walking and foot exercises are probably the most effective ways of promoting lymph flow (Vaqas and Ryan, 2003). Breathing exercises have not traditionally formed part of the LF programme, however Vaqas and Figure 4. Teaching skin care messages to a village group.

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How to look after Big Foot

USE A MOSQUITO NET

IF YOU HAVE FEVER / PAIN, SEE YOUR HEALTH CARE WORKER

TAKE TABLETS

WEAR SHOES

Developed by International Skin Care Nursing Group. Funded by a grant from the Gates Foundation. Designed and produced by e.media, University of Southampton, U.K. April 2003

HowHow to to looklook after after BigBig Foot Foot

USE AUSE MOSQUITO A MOSQUITO NET NET

IF YOUIF YOUHAVE HAVE FEVER FEVER / PAIN, / PAIN, SEE YOURSEE YOUR HEALTHHEALTH CARE CARE WORKER WORKER

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Developed byDeveloped International by InternationalSkin Care Nursing Skin Care Group. Nursing Group. Funded by aFunded grant from by athe grant Gates from Foundation. the Gates Foundation. Designed andDesigned produced and by produced e.media, Universityby e.media, of University Southampton, of Southampton, U.K. U.K. April 2003 April 2003

Figure 5. Educational resource developed by the International Skin Care Nursing Group in Tanzania.

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The nursing response lymphoedema, these are largely based The International Skin Care Nursing on the importance of managing the Group (ISNG) has been an active skin and promoting its function and

member of the WHO’s efforts integrity. Nurses have a significant Key points to eliminate LF as a global health role to play and the lymphoedema problem. Particularly in the early and dermatology specialists should 8 Lymphatic filariasis is a mosquito 2000s, ISNG had resources to fund enhance their impact by working bourne disease which can a project worker who worked within together. JL lead to lymphoedema and the WHO programme to begin elephantiasis. to mobilise the nursing response The photographs in this article are (although there is no longer a project reproduced by kind permission of 8 As the condition affects millions worker for the ISNG, it still exists as Sara Burr. of people in tropical countries a network supporting nurses who around the world, a public have an interest in skin health). This health approach is needed. involved discussions about curricula, References resource development, field work 8 A public health approach and training. The ISNG also had an Addiss D (2007) Global collaboration is includes providing drugs to the impact on developing the skin care crucial for lymphology and filariology. J whole population to interrupt Lymphoedema 2(1): 89–90 messages related to lymphoedema transmission and simple health management. Figure 5 is a patient Addiss D, Brady M (2007) Morbidity promotion messages to manage education leaflet that was developed management in the Global Programme to the impact of lymphatic changes. for use in Tanzania in conjunction Eliminate Lymphatic Filariasis: a review of the scientific literature. Filaria J 6: 2 with the Tanzanian LF team. The 8 Health promotion messages challenge now is to find ways to work Coreil J, Mayard G, Louis-Charles J, are skin care, elevation and across specialisms to ensure that skin Addiss D (1998) Filarial elephantiasis movement. among Haitian women: social context and care within LF management maintains behavioural factors in treatment. Trop Med a high profile and attracts the Int Health 3(6): 467–73 resources it needs to be successful. Dean M (2001) Lymphatic Filariasis: The J, eds. Lymphoedema. Radcliffe Medical Quest to Eliminate a 4000-Year-Old-Disease. Press, Oxford As Addiss pointed out in his Hollis Publishing, New Hampshire recent article on the global LF Narahari S, Ryan T, Mahadevan P, programme (Addiss, 2007), despite Dreyer G, Addiss D, Dreyer P, Noroes J Bose K, Prasanna K (2007) Integrated (2002) Basic Lymphoedema Management: management of filarial lymphedema for the differences between standards Treatment and Prevention of Problems and approaches to care, some of rural communities. Lymphology 40(1): Associated with Lymphatic Filariasis. Hollis 3–13 the basic elements, i.e. underlying Publishing Company, New Hampshire physiology, protecting barrier Ottesen E (1998) Towards elimination Kazura J (2000) Resistance to infection function through skin care and the of lymphatic filariasis. In: Angelico with lymphatic-dwelling filarial parasites. M, Rocchi G, eds. Infectious Diseases psychosocial impacts are the same In: Nutman T, ed. Lymphatic Filariasis. and Public Health. Balaban Publishers, whatever the underlying disease Imperial College Press, London Philadelphia process causing lymphoedema. Kerketta A, Babu B, Rath K, Jangid P, This should encourage us to work Ottesen E, Duke B, Karam M, Behbehani K Nayak A, Kar S (2005) A randomized (1997) Strategic and tools for the control/ together, regardless of where our clinical trial to compare the efficacy of elimination of lymphatic filariasis. Bull interest in lymphoedema starts. three treatment regimens along with World Health Organization 75(6): 491–503 footcare in the morbidity management of filarial lymphoedema. Trop Med Int Health Scott A (2000) Lympatic-dwelling filariae. Conclusions 10(7): 698–705 In: Nutman T, ed. Lympatic Filariasis. Lymphatic filariasis is a disease of Imperial College Press, London the lymphatic system which causes McCarthy J (2000) Diagnosis of lymphatic lymphoedema and elephantiasis. filarial infections. In: Nutman T, ed. Vaqas B, Ryan T (2003) Lymphoedema: Lymphatic Filariasis. Imperial College pathophysiology and management in A WHO programme has been Press, London resource poor setting — relevance for LF developed to eliminate this parasitic control programmes. Filaria J 2: 4 disease as a public health problem. McPherson T (2003) Impact on the quality of life of lymphoedema patients Wijesinghe R, Wickremasinghe A, However, there will continue to be following introduction of a hygiene Ekanayake S, Perera, M (2007) Physical significant disease burden caused and skin care regimen in a Guyanese disability and psychosocial impact due by ongoing lymphoedema and community endemic for lymphatic to chronic filarial lymphoedema in Sri related health problems. A series of filariasis: A preliminary clinical Lanka. Filaria J 6: 4 intervention study. Filaria J 2: 1 public health messages have been Witt C, Ottesen E (2001) Lymphatic developed to help communities Mortimer P (2000) Acute inflammatory filariasis: an infection of childhood. Trop prevent the problems related to limb episodes. In: Twycross R, Jenns K, Todd Med Int Health 6(8): 582–606

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