Introduction

Could early detection and intervention turn the tide against elephantiasis in children and Adolescents? What if a simple health check at school could stop a lifelong disease in its tracks? Elephantiasis, also known as Lymphatic filariasis (LF), is an infectious disease that causes thickening of the skin and disfigurement, such as enlargement of the limbs, causing pain, severe disability and social stigma.^1,2 It is described as an infection that is endemic in 83 countries and a neglected tropical disease, with more than 1,2 billion people at risk and 210 million already infected. According to a study, since 1998, the Global Programme to eliminate Lymphatic Filariasis has targeted the elimination of LF by 2020. The World Health Organisation (WHO), highlighted that in 2019, 51 million people were infected, which meant that there was a decline by 74% due to the Global Programme. Children and adolescents are usually vulnerable to this infection as it is typically acquired in childhood and causes hidden damage to the lymphatic system.^2,3

Background and overview

Cause and transmission

Elephantiasis is spread by mosquitoes. The mosquitoes take on the vector role by transmitting the disease to another person. Elephantiasis can happen when a person has filariasis, which is a parasitic infection caused by a type of roundworm.¹ There are several types, such as:

• Wechereria bancrofti
• Brugia malayi
• Brugia timori

It is spread when a mosquito bites someone who has these worms. The mosquito will be infected by the worms in the bloodstream. In results, when the infected mosquito bites another person, the worm then transfers into another person’s bloodstream. To get the condition, a person has to be bitten multiple times over time. Sometimes it can occur over years.¹

Pathophysiology

When someone gets Elephantiasis, the parasitic worms infect the lymphatic system, which is a group of organs, vessels and tissues that protect you from infections and keep a healthy balance of fluids throughout the body. The parasites will block the capillaries in the lymphatic system, causing fluid to accumulate. This causes:

• Inflammation
• Swelling
• Fever^1,4

Burden of disease in youth

Elephantiasis typically begins in childhood; however, symptoms are visible when the person is an adult.³ Studies show that up to one-third of children under five may already be infected, but their symptoms may appear many years later. In addition, surveys reveal that in endemic regions, almost half of children may carry microfilariae (a worm) without clinical signs.^5,6 The commonness rises as the person ages, with men peaking aged 15 – 44 and girls 10 – 15 with disability burdens.⁷ Children and Young people tend to be overlooked because the infection appears difficult to recognise, which in result causes more clinical symptoms to appear, such as lymphoedema or hydrocele, which are associated with people who have Elephantiasis long term, typically adults. This causes the underestimation of infection rates in children.⁸

Clinical features in children and adolescents

Early symptoms

It is confirmed that 2 in 3 people with the condition do not experience severe symptoms. However, there are common symptoms that occur. They include:

• Inflammation
• Lymphedema (mild to severe swelling of the limbs, breast or genitals)
• Hardening or thickening of the skin
• Hydrocele (swelling and fluid buildup in the scrotum, which occurs in men)
• Bacterial infections of the skin
• Oedema (fluid buildup in the body)^1,13

Progression

Clinical symptoms are grouped into three categories: acute attacks, lymphoedema/elephantiasis and hydrocele.

The filarial worms cause inflammation of the lymphatic system, leading to the damage of lymphatic vessels and lymphatic dysfunction, which puts the lower limbs at risk of recurring bacterial infection. The bacterial infections will, in turn, trigger “acute attacks”, which are the usual local pain, severe swelling with fever and chills. Elephantiasis may also progress towards a hydrocele. In addition, Elephantiasis can lead to permanent disabilities later in adulthood.^3,9

Psychosocial impact

People who have this condition tend to experience negative social experiences. This is dependent on how visible and severe the symptoms are; for example, if the swelling is extreme, they could experience social stigmas. In adults, this may impact work.¹

Importance of early detection

It is important to detect symptoms early for Elephantiasis and be provided with a diagnosis as soon as possible, in order to receive treatment for existing lymphoedema. This is because early treatment can prevent further damage to the lymphatic system and prevent the disease from affecting the quality of life of those affected.¹⁰

Diagnostic tools

There are three diagnostic tools that help healthcare providers diagnose elephantiasis.

Antigen tests

It is used to measure an individual’s blood sample for the presence of antibodies. Antibodies are proteins that the body creates in response to an infection that may appear in the bloodstream.¹

Ultrasound for live worms

Another way that Elephantiasis is detected is through a general imaging examination or ultrasound. This can detect moving adult worms in lymphatic vessels, which is said to be described as a “filarial dance sign”.¹²

Blood smear

A definite diagnosis for an active infection would be a blood smear/microscopic blood test. This is when a healthcare professional examines the blood sample under a microscope, which enables them to see if there are any worms in the blood. This is usually obtained at “peak micro filariae circulation”, which is at night between 10 PM and 2 AM. This is because filarial worms are active at night (nocturnal).^1,11

Intervention strategies and treatment

A treatment used to combat the spread of the infection is preventive chemotherapy. This is introduced by the WHO in the preventative chemotherapy strategy, called a mass drug administration (MDA). MDA is an annual dose of medicine which is administered to the entire population who is at risk.³ This medicine is used to help limit the effect of adult parasites and reduce the number of worms in the bloodstream, as well as prevent the spread of parasites to mosquitoes.^3,17

Symptom management and disability prevention are also vital for improving overall health. Although surgery can decrease the severity in most cases of hydrocele. Clinical severity and progression of the infection, including acute inflammatory episodes, can be simply reduced by measures of upkeeping:

• Good hygiene (washing limbs every day)
• Skin care and wound care (such as the use of antifungal and antibiotic creams)
• Exercises
• Elevation of affected limbs
• Wearing comfortable and appropriate protective footwear^3,14

Surgery is also an option to get rid of dead worms from the bloodstream.

Prevention

The most effective way to prevent elephantiasis is to avoid mosquito bites, especially in tropical areas. If someone lives or travels to places where filariasis infection is possible, some steps can be followed to prevent bites, such as:

• Sleeping under a mosquito net
• Use insect repellent, especially at night
• Keep windows and doors closed to prevent mosquitoes from coming in
• Sleep in an air-conditioned room
• Wear loose-fitted long pants and long sleeves^1,16

Preventative chemotherapy medication or a specific annual dose of chemotherapy medication, prescribed by the WHO, is another way to prevent infection. In addition, before travelling, it is important to learn the health risks and precautions recommended for the destination.

There are campaigns that focus on eliminating lymphatic filariasis. The Global campaign focuses on slowing down transmission by controlling mosquitoes and providing medicine that kills the worms to affected communities. In addition, those who are already affected by the disease are provided essential care from the global campaign to prevent morbidity and reduce disability.¹⁶

Supporting children and families

Although everyone is different, living with Elephantiasis can be difficult for some children and adolescents, due to not only physical symptoms but also the impact on quality of life, which causes negative emotional consequences. This includes a high risk of depression, anxiety and suicidal thoughts. This is why it is highly important to incorporate psychological support for affected individuals from the time of diagnosis. In addition to providing the education of transmission and treatment of the disease in endemic communities to prevent discrimination and exclusion.^17,18

Advocacy for elephantiasis and mental health is important. WHO notes that by using media, it can further educate the public around stigmatisation. Dealing with stigmatisation can improve the mental health of individuals with this disease, which in turn raises the likelihood of their participation in their own care.¹⁹

According to a study, peer support groups are beneficial. It is highlighted that peer support groups demonstrated the usefulness of providing patient education in group settings where members can share their experiences and offer psychological support to others coping with similar concerns.¹⁸

Finally, seeking support from family members and having a strong support system can provide individuals with the disease the opportunity to express their concerns and receive understanding and empathy.²⁰

Summary

In summary, early detection and intervention for elephantiasis in children and adolescents is important as it provides the chance to end the cycle of disability, stigma and health complications. ^3,14 Early detection, preventative strategies and treatment like MDA and mosquito control provide the opportunity of reducing transmission and long-term disability.^3,14 It is also important that psychological support is implemented for affected individuals through education, advocacy and community support.^17,20 By prioritising early intervention and mental health support, vulnerable populations with Elephantiasis can be protected, stigma reduced and progress made toward the global goal of eliminating lymphatic filariasis for future generations.