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Bring Hope to Haiti- Establishing a Lymphatic Filariasis Clinic
- 1. This presentation details our efforts to re-establish a Lymphatic Filariasis clinic in Leogane Haiti FOR MORE INFORMATION PLEASE VISIT WWW.BRINGHOPETOHAITI.COM OR EMAIL US AT: INFO@BRINGHOPETOHAITI.COM 1
- 2. Lymphatic Filariasis Clinic at Hospital St. Croix Leogane, Haiti HEATHER HETTRICK PT, PHD, CWS, CLT, CLWT ROBYN BJORK MPT, CWS, WCC, CLT-LANA, CLWT GLOBAL ALLIANCE/US VOLUNTEERISM SYMPOSIUM ON ADVANCES IN WOUND CARE SPRING 2014
- 3. 3
- 4. Stats about Haiti The people ~10.5 million Median age 21 Life expectancy 61 M/64 W 53% literacy rate Health Infant mort: 52/1000 1.9% HIV/AIDS 37% lack clean water 83% lack sanitation Economy Poorest nation in Americas; 54% < $1/day with 80% below poverty line ~41% unemployment Education Half of children do not attend school 1 of 5 attend secondary school Primary language- Creole and French Source: povertyresolutions.org 4
- 5. Lymphatic Filariasis Lymphatic Filariasis (LF) is a parasitic infection spread by mosquitoes that is endemic in 83 countries with over 1.3 billion people at risk of contracting it Worms reside in lymphatic system where they live 4-6 years producing millions of microfilariae Circulate in blood and picked up by mosquitoes Result: swelling of the limbs and breasts (lymphedema), and/or genitals (hydrocele), or swollen limbs with dramatically thickened, hard, rough and fissured skin (elephantiasis) 5
- 8. Stages of LF (Stage I) Swelling reverses at night Skin folds-absent Appearance of skin- smooth, normal 8
- 9. Stages of LF (Stage II) Swelling not reversible at night Skin folds-absent Appearance of skin- smooth, normal 9
- 10. Stages of LF (Stage III) Swelling not reversible at night Skin folds-shallow Appearance of skin-smooth, normal 10
- 11. Stages of LF (Stage IV) Swelling not reversible at night Skin folds-shallow Appearance of skin - Irregular, knobs, nodules 11
- 12. Stages of LF (Stage V) Swelling not reversible at night Skin folds-deep Appearance of skin – smooth or irregular 12
- 13. Stages of LF (Stage VI) Swelling not reversible at night Skin folds-absent, shallow, deep Appearance of skin- mossy lesions on foot or top of the toes 13
- 14. Stages of LF (Stage VII) Swelling not reversible at night Skin folds-deep Appearance of skin- irregular Needs help for daily activities - Walking, bathing, using bathrooms, dependent on family or health care systems 14
- 15. LF Diagnosis Since lymphatic filariasis does not always result in clinical symptoms (may take years), the most accurate way to determine if someone is infected is a blood test. In most parts of the world, the parasites have a "nocturnal periodicity" that restricts their appearance in the blood to only the hours of 10pm - 2am. Therefore, the diagnosis of lymphatic filariasis traditionally has depended on the laboratory examination of blood taken between 10pm and 2am when microfilaria are most common in peripheral blood. 15
- 16. LF Prevention MDA- massive drug administration The strategy for interrupting transmission is an annual single co-administration of two drugs for at least five years. Haiti has been given MDA since 2000 and over 8 million of the 10.5 million people have been dosed. Fortified salt is also provided to maintain coverage through food consumption. MDA kills the parasite but does not cure damage to the lymphatics caused by the parasites. 16
- 17. LF and Haiti Leogane has ~ 200,000 people with ~10% afflicted by LF Original LF clinic at Hospital St. Croix has been closed since 2009 and now only provides ‘social counseling’ Training of local clinicians began in December of 2013 through efforts of Brazilian embassy Follow up training and clinic logistics established January 2014 17
- 18. 18 Special thanks to: -Bandages Plus -Circaid -Project Medishare
- 19. Port-au-Prince, Haiti Hospital Bernard Mevs Wound Clinic John Macdonald, Robyn Bjork, Edaine, Clerge, Heather Hettrick 19
- 20. Haitian Life 20
- 22. LF Lymphedema Training 22
- 24. Cleaning & Prepping LF Clinic 24
- 25. Treating – Calf Reduced 10cm in 2.5 Days 25
- 26. Before & After 2 Days Modified CDT 26
- 27. Sorting & Applying Circaids 27
- 28. Home Visits 28
- 29. LF Clinic Wound Care 29
- 30. Trainees Receive Certificates from teachers Heather Hettrick & Robyn Bjork (ILWTI) 30 Clerge: Master Clinician at LF Clinic Leogane
- 31. The Plan 2014 Ongoing training/support for local clinicians (4-6 trips/year) Anticipated re-opening of clinic March/April 2014 Clinic space, training/dorm facilities, and supplies have been procured Patients have been logged and identified (500-1200 in Leogane alone) Logistics for clinic being developed including modified CDT and wound care Working on funding for sustainability Opportunities for volunteers, research, international dual certification in lymphedema and wound care Goals: eradication of LF by 2020; patient independence with LF management by 2020 31
- 32. Thank you! Together We Can Make a World of Difference 32
Editor's Notes
- Eight main species of nematodes (roundworms) can cause filariasis; however, the most common is W bancrofti (100 X 0.3 mm), followed by Brugia organisms. The nematodes can live for several years in the lymphatic vessels and lymph nodes. The female worms produce microfilariae (200-300 µm), which circulate in the blood. The microfilariae infect biting Culex pipiens mosquitoes (less commonly Anopheles, Aedes, and Mansonella species). It then develops into the infective filariform larvae within 1-2 weeks. During subsequent bites by the mosquito, the larvae infect human hosts and migrate to the lymphatic tissues, where they develop into adult worms within a year. The microfilariae produced by the female worms enter the bloodstream and are ingested by feeding mosquitoes. Once in the mosquito, the juvenile worms pass through 2 larval stages before development halts. Subsequent blood meals taken by the mosquitoes transmit the third-stage larvae into the human dermis. The juvenile worms then migrate to lymphatic tissue in the infected human, where maturation is completed. While the adult female worms can continue to produce microfilariae in the human host, the adult worm burden cannot increase in the absence of the intermediate host. In endemic areas, filarial infection begins in childhood and the adult worm burden increases upon repeated exposures. Acute presentations most commonly occur in the fourth or fifth decade of life. Death of the adult worm causes an inflammatory reaction that manifests as acute filarial lymphangitis (AFL). Granulomatous nodule formation and recurrent episodes of AFL impair lymphatic flow, predisposing the host to secondary bacterial infections, which result in fibrosis, lymphatic obstruction, and lymphedema. High-protein lymphedema causes further inflammation and tissue destruction. Once damage is sufficient to overwhelm the lymphatic system, chronic hydrocele ensues. http://emedicine.medscape.com/article/438525-overview
- Heather and Robyn are developing a modifed CDT approach to manage LF in Haiti. Further, they are developing protocols for each of the seven stages of LF. Patients will need to demonstrate commitment and proficiency with hygiene, diaphragmatic breathing, exercise and self-MLD prior to receiving clinician based MLD and compression. Further, plans are in place to develop a scoring system to rate the stage of lymphedema and skin involvement (based upon the existing staging system) to facilitate outcomes and research opportunities.
- Modified CDT