A review of Lymphatic Filariasis and Its Repercussions in Libya

Prepared by the researche : Namat Saleh Almarymi

Democratic Arabic Center

Journal of Progressive Medical Sciences : First issue – May 2025

A Periodical International Journal published by the “Democratic Arab Center” Germany – Berlin

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Abstract

The lymphatic filariasis is endemic or suspected in several countries, lymphatic filariasis is considered a public health problem, an effort to interrupt transmission and eliminate LF certainly depends on studies pointing out the estimated numbers of lymphatic filariasis cases. countries that have never been endemic with on record or history for lymphatic filariasis, the initial assessment in will be to validate the lymphatic filariasis-free status in the country

The review of existing information on lymphatic filariasis in Libya should be made by investigating and collecting information through an established integrated disease surveillance system., to develop more robust estimates of the lymphatic filariasis

Introduction:

Filariasis is a disease caused by parasitic worms called filariae. Filariae are microscopic roundworms that live in the blood circular and tissues of humans. The most important filarial disease for humans is lymphatic filariasis, in which adult worms are found in the lymphatic system(Chandy et al., 2011b).

The lymphatic form of filariasis will be the site’s focus (lymphatic) also referred to sometimes as elephantiasis. Elephantiasis is an extreme clinical feature of filariasis, that is a neglected tropical disease, the major form of human filarial nematode infections that may lead to severe pathology, lymphatic filariasis (LF) is classified into four types based on the species of microorganisms, vectors, etc. it is caused by infection with parasites classified as nematodes (roundworms) of the family Filariodidea, nematode parasites causing LF are  Wuchereria bancrofti, which is responsible for 90% of the cases and Brugia spp., which causes most of the remainder of the cases, and onchocerciasis caused by Onchocerca volvulus (Pani et al., 2005). Elephantiasis is inscribed in early Indian, Egyptian, and Persian writings, and the epidemiologic association of elephantiasis with hydrocele, chylocele, and chyluria was established by the middle of the 19th century(Chandy et al., 2011a). Their common etiology, however, remained a mystery until discoveries were made of microfilariae in hydrocele fluid (Demarquay, 1863), urine (Wucherer, 1868) and blood (Lewis, 1872), and of the adult worm in a lymphatic abscess (Bancroft, 1877). Patrick Manson first described the uptake of microfilaria by Culex mosquitoes and their maturation to infective forms (1875–89). This was the first description of the mosquito as a vector for parasitic diseases and paved the way for his discovery of malaria transmission. Manson also associated endemic microfilaremia with elephantiasis and other lymphatic diseases.

The nematodes live in human lymphatics resulting in lymphatic damage and dysfunction that leads to recurrent swelling and disfigurement of the limbs (elephantiasis), genitalia (hydroceles) in men and sometimes breasts in women,

the male-to-female ratio is 10:1. (for women, who are over 10 times more

likely to have elephantiasis of the leg than men) This may be because women’s mode of dress is more covered, about 50% of the patients are in their 3rd or 4th decades of life, and the highest prevalence of positive LF was observed in the >50 years old (Senkwe et al., 2022), though no age is exempt.

Occasionally, infected individuals may develop retrograde lymphadenitis and lymphangitis. Symptomatic infection may occur and may last for life, acute manifestations of lymphatic filariasis are episodic attacks of lymphadenitis (inflammation of the lymph glands) and lymphangitis (inflammation of the lymph channels) (fever, pain in the affected part, tender red streaks) along with fever and malaise and subsequent swelling of the limbs or scrotum (lymphedema), these symptoms are typically accompanied by pulmonary eosinophilia which mostly an incorrect diagnosis at presentation (most often asthma-like attacks) (Boggild et al, 2004, and Cairo,2022), over 90% of cases with chronic manifestations will give a history of acute attacks.

Although their clinical manifestations are not often fatal, they lead to the ranking of LF as one of the world’s leading causes of permanent and long-term disability, the disfigurement resulting from lymphatic filariasis can have substantial economic and psychosocial consequences, particularly among individuals whose livelihoods depend on physical labor. LF is a public health problem because the infection damages the lymphatic system, the disease burden for a population is calculated as the years of life lost because of disability as compared with a population living without disease and disability increasing the risk for secondary infections and complications. An estimated 36 million people globally have clinically significant manifestations of LF predominantly lymphoedema and hydrocele (WHO, 2021).

The responsible factors for the transmission of lymphatic filariasis are mosquitoes of the genera Aedes, Anopheles, and Culex, which are the intermediate hosts and vectors that feed on infected subjects of lymphatic filariasis, in addition to ecological conditions linked to migration can contribute to increasing the spread of the disease (Utzinger and Keiser, 2006). Culex pipiens plays the main role in LF transmission in Libya (Vermeil, 1953)(Cairo, 2022), A mosquito species composition study was conducted at Souq Al- jum’aa / Libya, during the period June to December 2016, determining seven species representing three genera of Aedes, Culex, Culiseta were Aedes detritus, Aedes caspius, Aedes dorsalis, Culex perexiguus, Culex pipiens, Culex laticinctus, and Culiseta longiareolate. (Aqeehal et al., 2022)

This review’s objectives were tentative explanations of the problems associated with nationwide lymphatic filariasis and Its repercussions in Libya. This was carried out by looking for scientific articles. Also, the study is enrolled by coordination interview meetings with medical staff from the Department of Cardiovascular in Tripoli Medical Center and International Cardiovascular Center Ben Ashour Tripoli to determine the estimated numbers of lymphatic filariasis cases.

 Review

Lymphatic Filariasis parasites( LF), the second most common vector-borne parasitic disease after malaria is a major cause of clinical morbidity, According to WHO, LF is the second most common cause of long-term disability after mental illness and a significant impediment to socioeconomic development in tropical and subtropical where the disease is well- established, Currently an estimated 1.34 billion people are living in endemic areas where they are at risk of infection, with over 120 million people in 73 countries of Africa, Asia, the western pacific and parts of Americas are affected either disease or infection (microfilaria carriers) in 2018, there are 24 Countries and entities of the Americas listed by the World Health Organization as being positive for lymphatic filariasis(Senkwe et al., 2022).  Almost half (49.2%) of the 120 million estimated cases are in the South East Asian region and another 34.1% are in the African region. (One-third of people infected with LF live in India, a third live in Africa and the remainder live in the Americas, the Pacific Islands, Papua New Guinea, and South-East Asia). In 2021, 882.5 million people in 44 countries were living in areas that require preventive chemotherapy to stop the spread of infection. lymphatic filariasis is estimated to be endemic in over 80 countries and territories putting around one-fifth of the world’s population at risk of contracting the disease (Ottesen et al/., 1997; WHO, 1994b; WHO, 1997c; WHO, 2006b; Zagaria and Savioli, 2002), The 120 million cases of LF include 83.63 million instances of microfilaria carriers, 16.02 million cases of lymphoedema and 26.79 million cases of hydrocele; which clearly shows that the burden of genital manifestations of filariasis in terms of hydrocele is higher compared to lymphoedema, Lymphatic filariasis comprises most of the world’s filarial infection. Due to its alarmingly high prevalence in developing countries, lymphatic filariasis remains one of the most important infectious diseases worldwide.

Cumulative data reported to WHO between 2007 and 2022 refer to the number of LF endemic countries in Africa in 34 countries, while the Western Pacific in 22 countries, and South-East Asia in 9 countries, considered Africa’s highest prevalence endemic area (Programme, Global Filariasis, Eliminate Lymphatic Programme, Le 2023)

Although 80 countries are known to be endemic areas, about 70% of infected cases are in India, Nigeria, Bangladesh, and Indonesia, considered lymphatic filariasis is endemic in 32 of the world’s 38 least-developed countries. Usually, it takes several months to develop filariasis. People who live or stay in endemic tropical or sub-tropical areas for a long time are at the greatest risk. These regions include central Africa, the Nile Delta, Madagascar, Turkey, the Middle East, India, Myanmar, Thailand, Malaysia, Vietnam, South Korea, and Indonesia (Setouhy, 2005).

table 1: summarizing the global distribution of lymphatic filariasis, including regions, the estimated total number of infected cases, and the percentage of individuals with clinical manifestations. The data are based on the latest available information from sources like the World Health Organization (WHO) and other relevant research:

• Total Number of Infected Cases: Estimates are rounded and based on data from the World Health Organization and recent studies.
• Total Out-of-Case Percentage: Represents the proportion of individuals with clinical manifestations such as elephantiasis or hydrocele.

To understand the repercussions of LF on Libya should be highlighted neighboring countries that have Lymphatic filariasis endemic, especially those that have migrants in Libya, the disease is endemic or suspected in several countries of the Eastern Mediterranean Region. Ramzy and Al Kubati (2020) reported the Eastern Mediterranean countries that have medical records estimated the risky population to be 12.6 million people, accounting for about 1% of the global disease, the disease is known to be focally endemic in 3 countries, Egypt, Sudan, and the Republic of Yemen. In contrast, the LF situation in Djibouti, Oman, Pakistan, Saudi Arabia, and Somalia is currently suspected. However, clinical cases have been reported in Oman, Pakistan, Saudi Arabia, and Somalia Lymphatic filariasis, in Egypt and sub-Saharan Africa representing one-third of all cases worldwide with about 50 million people.

In Egypt, nocturnally periodic LF infection has been endemic in rural areas for a long (WHO,2021). The disease has a focal distribution, causing a major public health problem in 6 governorates in the Nile Delta and in Giza and Assiut governorates in Upper Egypt(Setouhy, 2005).                                    

Lymphatic filariasis is endemic in Sudan based on previously published and unpublished data from scattered spot surveys and hospital records (lymphoedema and/or hydrocele). Of the 26 Sudanese states, 12 states are considered LF-endemic areas. In addition, 5 more states are suspected to be endemic for LF, and certain areas cannot be accessed for epidemiological surveys (Setouhy, 2005, Ramzy and Al Kubati, 2020)).

The WHO records of 2021 declared Libya, Morocco, Tunisia, and Algeria non-endemic, (World Health Organization, 2021b, Riches et al., 2020, Lammie et al., 2021) level strategies need to consider both endemic districts and adjacent non-endemic districts and \or countries (cross border) to account for changing demographics and morbidity over time.

In Libya, the status of lymphatic filariasis is not well defined as well as in some countries of the Eastern Mediterranean region. The information is scarce due to the absence of formal systemic collection and report information on the presence and distribution of cases of lymphatic filariasis, as well as distribution and potential mosquito vectors.

In Libya, the health system lacks data collection and reporting tools which include a patient database, there is currently no methodology for estimating the number of patients (it has not been established), It can therefore be decided to determine the estimated numbers through organized meeting with the medical staff of the cardiovascular department in Tripoli Medical Center and International cardiovascular center Ben Ashour to an optimal number of the patient by estimating the numbers approximately found the number estimated about three to five case per month in Tripoli university hospital, this number is close to the existing case in medical center that were about three to five case per week.

General Discussion

Lymphatic filariasis (LF) represents a major public health problem worldwide. The disease is endemic or suspected in several countries. Recent advances in diagnosis and therapy led the World Health Assembly to pass a resolution in in1997, calling for the elimination of lymphatic filariasis as a public health problem, the elimination program is based on two main components: stopping the spread of LF infection through mass drug administration (MDA) of Diethylcarbamazine citrate (DEC) is the effective drug used for treatment (6mg/kg) in combination with albendazole (400 mg), an annual single-dose of combined drug regimens for 5–6 consecutive years (Mbabazi P, WHO, unpublished data, 17 May 2017), reported that no published studies exist that assess the feasibility of biannual albendazole versus annual albendazole, alleviating suffering through morbidity management and disability prevention. Subsequent steps included the formation of a Regional Programmed Review Group to orient national LF control programs towards the concept of elimination (WHO, 2007. Ottesen, 2017)

The Global Program to Eliminate Lymphatic Filariasis is a program that aims to reduce global Lymphatic filariasis infection rates from 120 million individuals in 1997 to 56 million individuals in 2017, thus contributing to eliminating lymphatic filariasis by 2030(Medeiros et al., 2022). The infection rate is estimated 51.4 million people were infected with LF in 2019, down from 199 million in 2000, the World Health Organization lists the current status of all 72 LF-endemic countries, In 2020, 48 countries were considered to require mass drug administration, in Africa the total population requiring mass drug administration in 2020 about 339 170 316, while in Eastern Mediterranean, it is estimated at 10 867 188, In 2021,139,043 hydrocele patients were reported to WHO in Africa, however, some countries has made progress towards eliminating LF, after the launch of the Global Program to eliminate LF, a countrywide mapping of LF distribution was undertaken in several west African countries including Benin, Burkina Faso, Cote d’Ivoire, Ghana, Mali, Niger, Togo. Ofanoa et al. (2019)

Many African countries have been able to succeed in eliminating the infection of lymphatic filariasis and among these countries in Africa, Malawi, and Togo, have eliminated LF, where Tonga found that successfully LF elimination is a public health problem, Tonga looks forward to working with stakeholders to eliminate LF transmission and reached zero incidences, four more are under surveillance and Some countries have succeeded in reducing and towards eliminating LF. Zambia is one of the countries that has achieved successful steps, in 2015, over 10.7 million people received medications as part of Zambia’s mass drug administration, and 92.8% of endemic regions were effectively covered Year over year, the number of endemic areas has declined due to this successful campaign, and in 2021, 4.8 million people were treated, and 97.1% of endemic regions were effectively covered (Tropical Medicine and Infectious Disease, 2024, Plos one, 2024).

  On the other hand, Even in areas where LF prevalence has been reduced to less than 1% of the population(Wynd et al., 2007), elimination remains elusive and in some situations, the disease has resurged, (Setouhy, 2005) Medeiros et al., 2022) findings demonstrate that Have argued Disease control program in developing countries often fail to fully meet their objectives because the strategies pursued are inappropriate for the community or challenge local perceptions of an etiology,  the northern savannah and coastal regions of Ghana are endemic for lymphatic filariasis, and disability-adjusted life years have increased from 850,000 in 1997 to 1.3 million in 2017 (Senkwe et al., 2022).

Also, there are three countries in the Eastern Mediterranean region considered endemic countries Egypt, Sudan, and Yamin, which need an intervention program to interrupt the transmission of lymphatic filariasis(Setouhy, 2005).

Al-Kubati et al. (2020) reported that Yemen in 2000 joined WHO global efforts to eliminate lymphatic filariasis as a public health problem by initiating a National LF Elimination Program that was fully integrated with National Leprosy Elimination Program, the Ministry of Public Health and Population. The elimination activities in the Republic of Yemen are still restricted to certain identified endemic regions.

Egypt, in developing a national program to eliminate LF as a public health problem, with the particular aim of reducing microfilaria prevalence rates, Egypt was one of the first countries to join the WHO global effort, it has an active national LF elimination program (Who, 2018).

Despite the efforts that remain the results of many studies reveal that LF transmission is still occurring and is more important as a public health problem than previously thought. (Gyapong et al., 2002). This is accompanied by the realization that an intervention that assumes compliance will not alone ensure a permanent solution in many regions.

Despite the efforts that have been made to confront this disease and the success of some countries in overcoming it, the number of infections with this disease remains high in other regions, as well despite the efforts made, morbidity management remains less widespread and unsuccessful, and less information is available regarding the implementation of programs that aim to address this situation, where found a few prevalence studies that were representative of the population at risk in endemic areas were identified; some studies gave a small estimate of the number of those affected and their significance as a public health problem. Medeiros (2022) reported that the current literature and available information on the burden of filarial morbidity and the implementation of structured services concerning morbidity assistance in the Americas were all found to be scarce. Now that this knowledge gap has been identified, both health services and researchers need to seek the implementation and enhancement of the maintenance of strategies that relate to the morbidity pillar (Medeiros et al., 2022)

Information and data on LF in Libya are scarce, known risk factors for LF include exposure to mosquitoes  (Senkwe et al., 2022), these are compounded by an increased likelihood of extreme climatic events such as floods, high temperatures, and moisture conditions related to the spread of LF, moreover South Libya very vulnerable to the transmission of clustering immigrants that are come aggregated from endemic countries, which may be carriers of the infectious. And anecdotal information suggests that LF may be endemic in Libya. Although these factors are related to the spread of LF in Libya, WHO reports through existing data indicate LF is non-endemic in Libya. The actual observations and LF prevalence across the country remain unknown.

Conclusions

In this review, we sought to analyze publications related to the handling of lymphatic filariasis and also aimed to tentative explanations of the problems associated with nationwide lymphatic filariasis and its repercussions in Libya.  In Libya be estimate of the number of patients with lymphatic filariasis is needed to help plan and estimate the number of patients with LF, this information must be available in the health information system. This information may already be available in the health information system, or it may have to be collected through various patient estimation surveys, this information is useful for designing management, and further studies are needed to better assess the rates of prevalence and implement control programs recommended.

Libya requires concerted efforts and effective policy to interrupt LF transmission with a focus on cross-border coordination and synchronization of LF preventive and control interventions against illegal immigration from sub-Saharan countries as these countries endemic with lymphatic filariasis and establish a public health database.

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