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LYMPHATIC FILARIASIS A MAJOR PUBLIC HEALTH CHALLENGE IN THE 21ST CENTURY. Carol Jones-Williams, Ph.D. Student, Epidemiology Walden University PUBH 8165-10 Instructor: Dr. Robert Marino Spring 2010. Agenda. Introduction Understanding neglected tropical diseases - PowerPoint PPT Presentation
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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. Infected by filarial worms - Wuchereria Bancrofti, Brugia malayi or B. timoritimori
≥ ≥ 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 1/3 of infected people live in India and Africa; remainder live in South Asia, the Pacific and the AmericasAsia, the 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 arm
World 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 limbs
Photo 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
LYMPHATIC FILARIASIS
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
LYMPHATIC FILARIASIS
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)
LYMPHATIC FILARIASIS
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 When a mosquito bites a human, it picks up microfilariae (MF) which undergoes a number of developmental stages a 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 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 into the lymphatic system where it is picked up by the mosquito which then transmits the diseasetransmits the 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 Infection is acquired during childhood causing damage to the lymphatic system and kidneysand kidneys
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 Lymphoedema may develop within six months and elephantiasis about a year after arrivalabout a year after arrival
World Health Organization (2000)
LYMPHATIC FILARIASIS
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 programs
World 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
LYMPHATIC FILARIASIS
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
LYMPHATIC FILARIASIS
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
LYMPHATIC FILARIASIS
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
LYMPHATIC FILARIASIS
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 albendazole- ivermectin 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)
LYMPHATIC FILARIASIS
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 Health education messages should be straightforward and aimed at whole communitiesat whole 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 Implement community-wide mass treatment programs to treat entire at-risk populations entire 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
Journal of Lymphoedema (2007). Retrieved from: http://www.lymphormation.org/journal/content/0202_filariasis.pdf
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
Journal of Lymphoedema (2007). Retrieved from: http://www.lymphormation.org/journal/content/0202_filariasis.pdf
LYMPHATIC FILARIASIS
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
World Health Organization (2000)
LYMPHATIC FILARIASIS
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 Secondary and tertiary prevention of patients’ morbidity associated with
the disease:the 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 Difficulty achieving and maintaining high coverage levels for 5 or more
yearsyears➢➢ 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 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, Dermatologists, 2006. Online image. http://web.ebscohost.com.ezp.waldenulibrary.org. April 4, 2010.2010.
““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 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. entry points.” Online image. http://www.lymphormation.org/journal/content/0202_filariasis.pdf. April 5, 2010.April 5, 2010.
Sara Burr. “How to look after big foot.” Educational Resource Developed by the International Skin Sara Burr. “How to look after big foot.” Educational Resource Developed by the International Skin Care Nursing Group in Tanzania. Online image. Care 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