LYMPHATIC FILARIASIS A MAJOR PUBLIC HEALTH CHALLENGE IN THE 21ST CENTURY

LYMPHATIC FILARIASISLYMPHATIC FILARIASISA MAJOR PUBLIC HEALTH CHALLENGE A MAJOR PUBLIC HEALTH CHALLENGE IN THE 21ST CENTURYIN THE 21ST CENTURY

Carol Jones-Williams, Ph.D. Student, Epidemiology

Walden University

PUBH 8165-10

Instructor: Dr. Robert Marino

Spring 2010

AgendaAgenda

IntroductionIntroduction

Understanding neglected tropical diseases

Overview of Lymphatic FOverview of Lymphatic Filariasis

Modeling of successful programsModeling of successful programs

Learning ObjectivesLearning 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

LYMPHATIC FILARIASISLYMPHATIC FILARIASIS(A NEGLECTED TROPICAL DISEASE)(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

Retrieved from: http://www.whqlibdoc.who.int/publications/2009/9789241598705_eng.pdf

Leishmaniasis Onchoerciasis

IMPACT OF NEGLECTED IMPACT OF NEGLECTED TROPICAL DISEASES 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

Retrieved from: http://www.whqlibdoc.who.int/publications/2009/9789241598705_eng.pdf;World Health Organization (2009)

Adverse pregnancy outcomes Reduced economic productivity

LYMPHATIC FILARIASIS LYMPHATIC FILARIASIS Lymphatic filariasis (LF) is also known as ElephantiasisLymphatic filariasis (LF) is also known as Elephantiasis

Infected by filarial worms - Wuchereria Bancrofti, Brugia malayi or B. timoriInfected by filarial worms - Wuchereria Bancrofti, Brugia malayi or B. timori

≥ ≥ a billion people in more than 80 countries at riska billion people in more than 80 countries at risk

120 million have already been affected120 million have already been affected

40 million seriously incapacitated and disfigured by the disease40 million seriously incapacitated and disfigured by the disease

Located in sub-Saharan Africa, Egypt, Southern Asia, Western Pacific Located in sub-Saharan Africa, Egypt, Southern Asia, Western Pacific Islands, northeastern coast of Brazil, Guyana, Haiti, and Dominican Islands, northeastern coast of Brazil, Guyana, Haiti, and Dominican RepublicRepublic

1/3 of infected people live in India and Africa; remainder live in South Asia, 1/3 of infected people live in India and Africa; remainder live in South Asia, the Pacific and the Americasthe Pacific and the Americas

Fox (2010); World Health Organization (2000)

LYMPHATIC FILARIASISLYMPHATIC FILARIASIS

FeaturesFeatures

Swelling of the limbs and breasts (lymphoedema)Swelling of the limbs and breasts (lymphoedema)

Swollen limbs with thickened, hard, rough and fissured skin Swollen limbs with thickened, hard, rough and fissured skin (elephantiasis)(elephantiasis)

Swelling of scrotum or vulva (hydrocele)Swelling of scrotum or vulva (hydrocele)

Cause internal damage to the kidneys and lymphatic system Cause internal damage to the kidneys and lymphatic system

Present with nocturnal cough, wheezing and feverPresent with nocturnal cough, wheezing and fever

Retrieved from: http://www.cdc.gov/healthywater/hygiene/disease/lymphatic_filariasis.html;Fox (2010)

LYMPHATIC FILARIASISLYMPHATIC FILARIASIS

Lymphoedema of the armWorld Health Organization (WHO), 2009. Online image. April 5, 2010

Figure 1 (a) Retrieved from: http://www.searo.who.int/EN/Section10/Section2096_10583.htm

LYMPHATIC FILARIASIS LYMPHATIC FILARIASIS

Lymphatic filariasis causes gross disfigurement of the lower limbsPhoto provided by Dr. Tilaka Liyange, Sri LankaWorld Health Organization (WHO), 2009. Online image. April 5,

2010 Figure 1 (b)

Retrieved from: http://whqlibdoc.who.int/publications/2009/9789241598705_eng.pdf

LYMPHATIC FILARIASIS

Elephantiasis of the right leg and swelling in the

left

Elephantiasis of the leg

Figure 1 (c)Retrieved from: http://www.searo.who.int/EN/Section10/Section2096_10583.htm

World Health Organization (WHO), 2009. Online image. April 5, 2010

LYMPHATIC FILARIASISBelow 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 surgerySpringer-Verlag 2008. Online image. April 5, 2010

Figure 1 (d)Archives of Gynecology & Obstetrics (2008). Retrieved from: http://www.searo.who.int/EN/Section10/Section2096_10583.htm


Photomicrograph showing transverse section of adult filarial worm with granuloma (H&E, ﾗ 400) in a breast

noduleAssociation of Surgeons of India, 2009. Online image. April 4, 2010

Figure 1 (e) Indian Journal of Surgery (2009). Retrieved from: http://web.ebscohost.com.ezp.waldenulibrary.org


Cause

Thread-like, parasitic filarial worms that live in humansThread-like, parasitic filarial worms that live in humans

Worms lodge in the lymphatic systemWorms lodge in the lymphatic system

They live for 4 - 6 years, producing millions of immature They live for 4 - 6 years, producing millions of immature microfilariae (minute larvae)microfilariae (minute larvae)

World Health Organization (2000)


Life cycle of parasite occurs in the mosquito and in humansLife cycle of parasite occurs in the mosquito and in humans

When a mosquito bites a human, it picks up microfilariae (MF) which undergoes a When a mosquito bites a human, it picks up microfilariae (MF) which undergoes a number of developmental stages number of developmental stages

MF travels back to the mouth of the mosquito, and when the mosquito bites 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 another human, it deposits the parasite into the skin of human which travels to lymphatic systemlymphatic system

Parasite grows to adulthood. Worms mate and the female releases more MF into 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 lymphatic system where it is picked up by the mosquito which then transmits the diseasethe disease

Infective stage takes about 7 – 21 daysInfective stage takes about 7 – 21 days

Infection is acquired during childhood causing damage to the lymphatic system and Infection is acquired during childhood causing damage to the lymphatic system and kidneyskidneys

Penzer (2007); Streit, T. & Lafontant, J. G. (2008); World Health Organization (2000)

Transmission

TRANSMISSION OF LYMPHATIC FILARIASIS

Life cycle of Wuchereria bancroftiWorld Health Organization (WHO), 2009. Online image. April 5, 2010

Figure 2

Retrieved from: http://www.searo.who.int/EN/Section10/Section2096_10583.htm

LYMPHATIC FILARIASISSigns and Symptoms

Disease takes many years to manifest itselfDisease takes many years to manifest itself

Absence of outward clinical manifestations of symptoms Absence of outward clinical manifestations of symptoms

Worst symptoms of chronic disease occur more often in men than Worst symptoms of chronic disease occur more often in men than womenwomen

10-50% of men suffer from genital damage10-50% of men suffer from genital damage

Elephantiasis affect up to 10% men and womenElephantiasis affect up to 10% men and women

Chronic and acute manifestations develop more often in Chronic and acute manifestations develop more often in refugees/newcomers refugees/newcomers

Lymphoedema may develop within six months and elephantiasis about Lymphoedema may develop within six months and elephantiasis about a year after arrivala year after arrival



Diagnosis

Difficult to diagnose in the past; easier now with new Difficult to diagnose in the past; easier now with new technology technology

Diagnostic tests includeDiagnostic tests include

➢➢ card test which detects circulating parasite antigens without card test which detects circulating parasite antigens without need for laboratory facilitiesneed for laboratory facilities

➢➢ serum antifilarial immunoglobulin (IgG)serum antifilarial immunoglobulin (IgG)

Easier identification of occurrence of infectionEasier identification of occurrence of infection

Better monitoring of treatment and control programsBetter monitoring of treatment and control programsWorld Health Organization (2000)

LYMPHATIC FILARIASISStages of Lymphatic filariasis (Dreyer staging)

British Journal of Dermatology (2006)

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 left leg of Guyanese female

Dreyer stage 6 British Association of Dermatologists, 2006. Online image. April 4, 2010British Journal of Dermatology (2006). Retrieved from:

http://web.ebscohost.com.ezp.waldenulibrary.org


Macerated interdigital lesion and dystrophic nails in left foot with lymphoedema

Dreyer stage 3British Association of Dermatologists, 2006. Online Image. April 4, 2010

British Journal of Dermatology (2006). Retrieved from: http://web.ebscohost.com.ezp.waldenulibrary.org


Advanced skin changes in an adult with lymphoedema in TanzaniaSara Burr. Online image. April 5, 2010

Journal of Lymphoedema (2007). Retrieved from: http://www.lymphormation.org/journal/content/0202_filariasis.pdf


Treatment: CommunitiesTreatment: Communities

Primary goal is to eliminate microfilariae from the blood of Primary goal is to eliminate microfilariae from the blood of infected individualsinfected individuals

➢➢ Annual treatment involve using combination of anti-filarial Annual treatment involve using combination of anti-filarial drugs:drugs:

- diethylcarbamazine citrate (DEC) with albendazolediethylcarbamazine citrate (DEC) with albendazoleivermectin and albendazoleivermectin and albendazole- regular use of DEC fortified saltregular use of DEC fortified salt

➢➢ Single dose treatment must be carried out for 4 – 6 yearsSingle dose treatment must be carried out for 4 – 6 years

World Health Organization (2000); Centers for Disease Control and Prevention (2010)


Treatment: IndividualTreatment: Individual

➢➢ Albendazole and DEC effective in killing adult-stage Albendazole and DEC effective in killing adult-stage filarial parasites (necessary for complete cure of filarial parasites (necessary for complete cure of infection)infection)

➢➢ Rigorous hygiene to affected limbRigorous hygiene to affected limb

➢➢ Care of skin and exercise to increase lymphatic Care of skin and exercise to increase lymphatic drainage in lymphoedemadrainage in lymphoedema

World Health Organization (2000); Fox (2010)

LYMPHATIC FILARIASISMorbidity Intervention StrategiesMorbidity Intervention Strategies

Health education messages should be straightforward and aimed at Health education messages should be straightforward and aimed at whole communitieswhole communities

Messages should address basic skin care and exercise Messages should address basic skin care and exercise

Identify endemic areasIdentify endemic areas

Implement community-wide mass treatment programs to treat entire Implement community-wide mass treatment programs to treat entire at-risk populations at-risk populations

Implement community education programs to raise awareness in Implement community education programs to raise awareness in affected patientsaffected patients

Partnerships with private, public, and international organizationsPartnerships with private, public, and international organizations

Penzer (2007)

Encouraging self-care — person washing their own limb.

Checking between toes for entry points.

SKIN CARE


Sara Burr. Online image. April 5, 2010

Educational Resource Developed by the International Skin Care Nursing Group in Tanzania. Online image. April 5, 2010

HOW TO LOOK AFTER BIG FOOT



Economic and Social ImpactEconomic and Social Impact

Disease has increased over the years because of expansion Disease has increased over the years because of expansion of slum areas and povertyof slum areas and poverty

Disease prevents patients from having a normal working lifeDisease prevents patients from having a normal working life

Disease exerts a heavy social burden due to concealment of Disease exerts a heavy social burden due to concealment of disease and social stigmatizationdisease and social stigmatization

Marriage, in many instances is often impossibleMarriage, in many instances is often impossible



In the tropics the most degraded environments are often linked with poverty, and with lymphatic filariasis

British Association of Dermatologists, 2006. Online image. April 4, 2010

Streit, T. & Lafontant, J. G. (2008). Retrieved from: http://web.ebscohost.com.ezp.waldenulibrary.org

WHAT’S NEXT? Global Elimination of Lymphatic FilariasisGlobal Elimination of Lymphatic Filariasis

➢ ➢ Primary prevention of new cases using mass drug administrationPrimary prevention of new cases using mass drug administration➢➢ Secondary and tertiary prevention of patients’ morbidity associated with the Secondary and tertiary prevention of patients’ morbidity associated with the

disease:disease:–– access to healthcareaccess to healthcare–– educationeducation

Barriers to implementing filariasis elimination programs:Barriers to implementing filariasis elimination programs:

➢➢ FinancingFinancing➢➢ Developing infrastructure capable of distribution of drugs to at-risk Developing infrastructure capable of distribution of drugs to at-risk

populationspopulations➢➢ Difficulty achieving and maintaining high coverage levels for 5 or more yearsDifficulty achieving and maintaining high coverage levels for 5 or more years➢➢ Diminished ComplianceDiminished Compliance

Modeling other successful programs:Modeling other successful programs:

➢➢ Guyana ExperienceGuyana Experience➢➢ China ExperienceChina Experience

Lammie, Milner & Houston (2007)

THE ENDTHE END

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. 1-7. DOI: 10.1317/journal.pntd.00000414. (AN 47507254).

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. 140-143. DOI: 10.1046/j.1365-3156.2003.01001.x. (AN 9079322).

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. 92-97. BMC Infectious Diseases. DOI: 10.1186/1471-2334-9-2. (AN 43547147).

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. 501-568.

Monge-Maillo, B., Jimenez, B. C. et al. (2009). Imported Infectious Diseases in Mobile Populations, Spain. Emerging Infectious Diseases, Vol. 15(11), p1745-1752. DOI: 10.3201/eid1511.090718. (AN 44983291).

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. 53-63. DOI: 10.1196/annals.1425.036. (AN 32677465).

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. 597-600. DOI: 10.1007/s00404-008-0628-1. (AN 34851598). Retrieved on April 5, 2010 from: http://web.ebscohost.com.ezp.waldenulibrary.org

Fox, L. M. (2010). Chapter 5 – Filariasis, Lymphatic – 2010 Yellow Book. Retrieved on April 5, 2010 from: http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/lymphatic-filariasis.aspx

Hygiene Related Diseases. Retrieved on April 5, 2010 from: http://www.cdc.gov/healthywater/hygiene/disease/lymphatic_filariasis.html

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. 210-212. DOI: 10.1007/s12262-009-0053-0. (AN 44190892). Retrieved on April 4, 2010 from: http://web.ebscohost.com.ezp.waldenulibrary.org

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. 501-568. Retrieved on March 27, 2010 from: http://www.who.int/bulletin/volumes/85/7/06-034108/en

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. 933-941. DOI: 10.1111/j.1365-2133.2005.07081x. (AN 20433221). Retrieved on April 4, 2010 from: http://web.ebscohost.com.ezp.waldenulibrary.org

REFERENCES

REFERENCES

Penzer, R. (2007). Lymphatic filariasis and the role of nursing interventions. Journal of Lymphoedema. Vol. 2(2), p. 48-53. Retrieved on April 5, 2010 from: http://www.lymphormation.org/journal/content/0202_filariasis.pdf

Streit, T. & Lafontant, J. G. (2008). Eliminating filariasis: a view from the fold. Annals of the New York Academy of Sciences. Vol. 1136, p. 53-63. DOI: 10.1196/annals.1425.036. (AN 32677465). Retrieved on April 4, 2010 from: http://web.ebscohost.com.ezp.waldenulibrary.org

World Health Organization (WHO). Communicable Diseases. Lymphatic Filariasis: The disease and its treatment. Retrieved on April 5, 2010 from: http://www.searo.who.int/EN/Section10/Section2096_10583.htm

World Health Organization (WHO). 2000. Lymphatic Filariasis: Fact Sheet No. 102. Retrieved on April 5, 2010 from: http://www.who.int/mediacentre/factsheets/fs102/en

World Health Organization (WHO). 2009. Neglected Tropical Diseases, Hidden Successes, Emerging Opportunities. Retrieved on April 5, 2010 from: http://whqlibdoc.who.int/publications/2009/9789241598705_eng.pdf

““Elephantiasis of the right leg and swollen in the left”; “Elephantiasis of the leg.” World Elephantiasis of the right leg and swollen in the left”; “Elephantiasis of the leg.” World Health Organization (WHO), 2009. Online image. Health Organization (WHO), 2009. Online image. http://www.searo.who.int/EN/Section10/Section2096_10583.htm. April 5, 2010.http://www.searo.who.int/EN/Section10/Section2096_10583.htm. April 5, 2010.

““Elephantoid lesion before surgery.” Springer-Verlag 2008. Online image Elephantoid lesion before surgery.” Springer-Verlag 2008. Online image http://web.ebscohost.com.ezp.waldenulibrary.org. April 5, 2010.http://web.ebscohost.com.ezp.waldenulibrary.org. April 5, 2010.

““Globe.” Online image. http://vvv.presentationpro.com/products/PD Category Globe.” Online image. http://vvv.presentationpro.com/products/PD Category Descriptions.asp. Descriptions.asp. April 5, 2010April 5, 2010

““Globe in grass.” Microsoft Clip Art. Online Image. Globe in grass.” Microsoft Clip Art. Online Image.

http://office.microsoft.com/en-us/clipart. April 5, 2010.http://office.microsoft.com/en-us/clipart. April 5, 2010.

““In the tropics the most degraded environments are often linked with poverty, and with In the tropics the most degraded environments are often linked with poverty, and with lymphatic filariasis”. British Association of Dermatologists, 2006. Online image. lymphatic filariasis”. British Association of Dermatologists, 2006. Online image. http://web.ebscohost.com.ezp.waldenulibrary.org. April 4, 2010.http://web.ebscohost.com.ezp.waldenulibrary.org. April 4, 2010.

““Life cycle of Wuchereria Bancrofti.” World Health Organization (WHO), 2009. Online Life cycle of Wuchereria Bancrofti.” World Health Organization (WHO), 2009. Online image. http://www.searo.who.int/EN/Section10/Section2096_10583.htm. April 5, 2010.image. http://www.searo.who.int/EN/Section10/Section2096_10583.htm. April 5, 2010.

““Lymphatic filariasis causes gross disfigurement of the lower limbs.” World Health Lymphatic filariasis causes gross disfigurement of the lower limbs.” World Health Organization (WHO), 2009. Online image. Organization (WHO), 2009. Online image. http://whqlibdoc.who.int/publications/2009/9789241598705_eng.pdf. April 5, 2010.http://whqlibdoc.who.int/publications/2009/9789241598705_eng.pdf. April 5, 2010.

““Lymphoedema of the Arm.” World Health Organization (WHO), 2009. Lymphoedema of the Arm.” World Health Organization (WHO), 2009. Online image.http://www.searo.who.int/EN/Section10/Section2096_10583.htm. April 5, Online image.http://www.searo.who.int/EN/Section10/Section2096_10583.htm. April 5, 2010.2010.

CREDITS

““Lymphoedema of left leg of Guyanese female. Dreyer Stage 6.” British Association of Dermatologists, Lymphoedema of left leg of Guyanese female. Dreyer Stage 6.” British Association of Dermatologists, 2006. Online image. http://web.ebscohost.com.ezp.waldenulibrary.org. April 4, 2010.2006. Online image. http://web.ebscohost.com.ezp.waldenulibrary.org. April 4, 2010.

““Macerated interdigital lesion and dystrophic nails in left foot with lymphoedema. Dreyer Stage 3. Macerated interdigital lesion and dystrophic nails in left foot with lymphoedema. Dreyer Stage 3. British Association of Dermatologists, 2006. Online Image. British Association of Dermatologists, 2006. Online Image. http://web.ebscohost.com.ezp.waldenulibrary.org. April 4, 2010.http://web.ebscohost.com.ezp.waldenulibrary.org. April 4, 2010.

““Mosquito.” Microsoft Clip Art. Online Image. http://office.microsoft.com/en-us/clipart. April 5, 2010.Mosquito.” Microsoft Clip Art. Online Image. http://office.microsoft.com/en-us/clipart. April 5, 2010.

““Photomicrograph showing transverse section of adult filarial worm with granuloma (H&E, Photomicrograph showing transverse section of adult filarial worm with granuloma (H&E, ﾗﾗ 400) in a 400) in a breast nodule. Association of Surgeons of India, 2009. Online image. breast nodule. Association of Surgeons of India, 2009. Online image. http://web.ebscohost.com.ezp.waldenulibrary.org. April 4, 2010.http://web.ebscohost.com.ezp.waldenulibrary.org. April 4, 2010.

Sara Burr. “Advanced skin changes in an adult with lymphoedema in Tanzania.” Online image. Sara Burr. “Advanced skin changes in an adult with lymphoedema in Tanzania.” Online image. http://www.lymphormation.org/journal/content/0202_filariasis.pdf. April 5, 2010.http://www.lymphormation.org/journal/content/0202_filariasis.pdf. April 5, 2010.

Sara Burr. “Encouraging self care – person washing their own limb.” “Checking between toes for entry Sara Burr. “Encouraging self care – person washing their own limb.” “Checking between toes for entry points.” Online image. http://www.lymphormation.org/journal/content/0202_filariasis.pdf. April 5, points.” Online image. http://www.lymphormation.org/journal/content/0202_filariasis.pdf. April 5, 2010.2010.

Sara Burr. “How to look after big foot.” Educational Resource Developed by the International Skin Care Sara Burr. “How to look after big foot.” Educational Resource Developed by the International Skin Care Nursing Group in Tanzania. Online image. Nursing Group in Tanzania. Online image. http://www.lymphormation.org/journal/content/0202_filariasis.pdf. April 5, 2010.http://www.lymphormation.org/journal/content/0202_filariasis.pdf. April 5, 2010.

CREDITS

LYMPHATIC FILARIASIS A MAJOR PUBLIC HEALTH CHALLENGE IN THE 21ST CENTURY

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