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 48 Journal of Lymphoedema, 2007, Vol 2, No 2 PenzerC.indd 14 16/9/07 14:21:05 Clinical REVIEW 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. Journal of Lymphoedema, 2007, Vol 2, No 2 49 PenzerC.indd 15 16/9/07 14:21:06 Clinical REVIEW 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.