Historical Overview

The University of Notre Dame (South Bend, Indiana) has had a functioning LF initiative in Léogâne at Hospital St. Croix since 1997. The original clinic was funded by multiple sources including the Gates Foundation—LF patients from 10 regions in Haiti and four other neighboring countries were treated. Until 2009, the clinical program was available for genital and extremity LF. The clinic was forced to scale back operations only offering limited care in 2009 due to loss of funding, loss of trained clinical LF therapists, and an absence of international lymphatic and academic awareness or support.

Pathophysiology of Lymphatic Filariasis

Eight main species of nematodes (roundworms) can cause filariasis; however, the most common is Wucheria Bancrofti, followed by Brugia organisms. The nematodes can live for several years in the lymphatic vessels and lymph nodes. The female worms produce microfilariae, which circulate in the blood. The microfilariae infect biting mosquitoes. 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. Their normal life cycle is 5-6 years. 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 swelling of the limbs and breasts results in lymphedema and/or if it affects the genitals, hydrocele ensues. Lymphatic Filariasis has 7 stages of severity from minimal/reversible edema to massive elephantiasis leading to significant functional impairments and skin dysfunction. Since LF does not always result in clinical symptoms (may take years to develop), 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 LF traditionally has depended on the laboratory examination of the blood taken between 10pm and 2am when microfilaria are most common in peripheral blood. During the day, the microfilaria reside in the deep vasculature of the lungs; it is proposed this may be due to oxygen tension or temperature. They circulate during the night in the peripheral vascular system where they can be picked up by mosquitos via a blood meal. The strategy for interrupting transmission is an annual single co-administration of two drugs for at least five years; massive drug administration (MDA). Diethylcarbamazine (DEC) and Albendazol are the drugs of choice. Additionally, the production and distribution of DEC-fortified salt to all Haitian citizens is also provided to maintain coverage through food consumption. Haiti has been given MDA since 2000 and over 8 million of the 10.5 million people have been dosed. MDA kills the parasite but does not cure damage to the lymphatics caused by the parasites.

Renewed Initiative

Beginning in 2009, the clinic was able to offer only limited clinical services but hopes were made that in the near future additional services would again be available. In spite of excellent MDA coverage, it is estimated that today, in the Léogâne environs, patients with LF number greater than 12,000. Comparable numbers exist in other endemic areas throughout Haiti. The University of Notre Dame (ND) continues with a strong MDA and vector research program. Notre Dame has welcomed the renewed efforts, since 2012, of Hospital Bernard Mevs Project Medishare, Port-au-Prince (HBMPM), Nova Southeastern University, Ft Lauderdale, Fl. (NSU), and The International Lymphedema & Wound Care Training Institute (ILWTI) to re-establish a functioning clinic. The Haitian Ministry of Health supports this initiative. Training of local Haitian clinicians began in December of 2013 through efforts by the Brazilian embassy.  Heather Hettrick, PT, PhD, CWS, CLT, CLWT (Nova Southeastern University) and Robyn Bjork, PT, CLWT, CLT-LANA, CWS, WCC (International Lymphedema & Wound Care Training Institute) provided follow-up training in modified CDT techniques in Jan 2014. The foundation for a functioning program with stocked startup supplies was established through generous grants and donations from the World Alliance for Wound and Lymphedema Care (WAWLC—Geneva, Switzerland), and travel support through medi for Help. In July 2014, Hettrick, Bjork, and Robyn (Redd) Smith, M.Ed., COTA/L, CLWT (Life Rehabilitation, ILWTI, Inc.) traveled back to Haiti to establish logistics for the official opening of an advanced LF lymphedema treatment center for morbidity management. Through a collaborative vision of providing advanced education in wound and lymphedema care, and the "train the trainer" module worldwide through the International Lymphedema & Wound Care Training Institute (ILWTI) and the World Alliance for Wound & Lymphedema Care, ILWTI Medical Missions (now an established 501C3) was quickly born. Advanced LF lymphedema treatment for morbidity management, using modified CDT, officially "opened" Sept. 1, 2014, under the cover of ILWTI Medical Missions, it's newly formed Board of Directors and Program Director Heather Hettrick. The fully trained Haitian Master Clinicians were hired to provide ongoing treatment and education in the annex for Lymphatic Filariasis at the Hopital St. Croix in leogane, Haiti. In October, 2014, Robyn Bjork and Robyn (Redd) Smith, M.Ed., COTA/L, CLWT (Life Rehabilitation, ILWTI, Inc.) led the first volunteer team from Salt Lake City, Utah where 178 separate treatments were given to patients suffering from LF. An effective, modified CDT approach to manage LF morbidity in Haiti has been developed. The program in Haiti is destined to be a unique “Center of Excellence” for the study and treatment of a most serious neglected tropical disease (NTD) --Lymphatic Filariasis. No program globally will have the academic, industrial and cooperative multi-national potential. It is intended that the clinical and research work documented in Haiti over the next 4 years will verify, support and build upon the historic documented progress for LF. Léogâne will be a center for international training of LF therapists; specifically trained to treat in resource poor nations with the associated conditions. Opportunities for volunteers, research, and a unique international dual certification in lymphedema and wound care is available.