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Assessment of knowledge and practice of morbidity management among lymphatic filariasis patients.

Introduction

Lymphatic filariasis (LF), a neglected tropical disease, is the second leading cause of chronic disability worldwide. An estimated 120 million people are infected worldwide and 1.3 billion are at risk. [1] The disease alters the lymphatic system leading to wide spectrum of clinical manifestations such as lymphedema, hydrocele, chyluria, elephantiasis, and others. [2,3] The clinical manifestations of the disease appear many years after initial infection. The chronic disability associated with LF leads not only to physical suffering, but also emotional problems, social stigmatization, and economic problems for the affected individual and socioeconomic problems for the family members. [4-6] The strategies of Global Programme to Eliminate Lymphatic Filariasis (GPELF) focus on interruption of LF parasite transmission and morbidity management to reduce the disability. [37] Painful acute attacks in the form of acute filarial lymphangitis (AFL) or acute dermatolymphangioadenitis (ADLA) are common among LF patients. These acute attacks occur either due to immune response to the adult worms or bacterial infections. Recurrent acute attacks cause further damage to the already affected lymph vessels leading to progression of lymphedema. [8-10] ADLA results from secondary bacterial infection and is favored by entry lesions in the skin. Hygiene and skin care are important in the management of lymphedema. [11-13] Lymphedema management focuses on limb hygiene which would prevent the secondary bacterial infections, prevention and cure of entry lesions, exercises and limb elevation to increase lymph flow, and wearing appropriate footwear. [14-16] Self-care by the patients plays a major role in morbidity management thereby reducing disability. Evaluating the patient's knowledge and their practice of morbidity management is important for the success of disability limitation. This study was conducted with the objectives to study the sociodemographic profile of LF patients and to assess their level of knowledge and practice regarding management of lymphedema.

Materials and Methods

This community-based cross-sectional study was conducted among 66 LF patients selected from the Filariasis Morbidity Control Clinic at Woraiyur, Tiruchirappalli. A total of 125 patients were availing the services in the clinic, of which 66 patients who were residing in Woraiyur were selected for the study. The study was carried out between May and June 2015. The study was approved by the Institute Ethics Committee. After obtaining informed consent each individual patient was interviewed in their home using a pretested, structured questionnaire. The questionnaire included sociodemographic details, knowledge and practice about limb hygiene, identification and treatment of entry lesions, limb elevation and exercise, wearing appropriate footwear, and management of acute attacks. The questionnaire was developed based on the learners guide for treatment and prevention of problems associated with Lymphatic by World Health Organization (WHO)[18] and manual on LF morbidity management by National Vector Borne Diseases Control Programme (NVBDCP). [17] The results were analyzed using Statistical Package for Social Sciences version 20. The results are presented in the form of mean and proportion.

Result

Of the 66 patients interviewed 39 (59%) were males and 27 (41%) were females. Mean age was 56.38 and 53.33 among males and females, respectively. Table 1 shows the sociodemographic details of the patients. None of them had family history of LF. The mean duration of disease was 17.2 years in the study group. Table 2 shows the clinical profile of the patients and classification of lymphedema. Lymphedema is classified according to the Fifth WHO Expert Committee on Filariasis. [16]

Knowledge about Lymphedema Management

Among the interviewed patients 63 (95%) were aware of the importance of limb hygiene. Importance of early identification and treatment of skin infections was known to 23 (35%) patients. 56 (85%) patients were aware of the importance of limb elevation and limb exercise in reducing edema. The source of information was health workers for 53 (80%) patients, doctors were the source of information for 30 (45.4%) patients, 14 (21.2%) patients gained knowledge from posters, and 10 (15%) patients received advice from the LF patients already receiving treatment from the clinic. Almost 50% (34 patients) considered wearing appropriate footwear was important.

Practice of Lymphedema Management

Sixty three (95%) patients practiced at least one morbidity management measure. Regular washing of limbs with soap and water was practiced once daily by 46 (69%) and twice daily by 4 (6%) patients. Only 4 (6%) patients regularly checked for the presence of entry lesions. Limb elevation was practiced regularly by 33 (50%) patients and all the 33 practiced limb elevation while lying. None of them practiced limb elevation while sitting or during household activities and work-related activities. Limb exercise at least once a day was practiced only by 14 (22%) patients. Footwear was used regularly by 56 (85%) patients and only 14 patients (22%) used footwear even while they were indoor. 15% (10 patients) did not use footwear either indoor or outdoor. Only 4 (6%) patients were using specially made footwear. Chart I shows the gap between knowledge and practice of lymphedema management.

Eleven (16%) patients had at least one attack of ADLA in the past 6 months. Except for one patient who had taken self-treatment, all others consulted either a health worker or medical practitioner for treatment of ADLA. Almost 50% of those who had an attack of ADLA visited a private practitioner for treatment. Cost of treatment ranged from Rs 300 to Rs 5000 for an attack with average cost of Rs 1020 per attack.

Discussion

The study results showed that the practice of morbidity management was low compared to the knowledge of the patients in all management methods. At least one morbidity management measure was practiced by 63 (95%) patients. This is similar to a study done in Orissa [18] where most of the patients practiced one or two measures. Though 95% study group knew about the importance of limb hygiene only 69% practiced it regularly. Importance of early identification of skin infections was known to 35% patients but still only 6% regularly checked for entry lesions. Limb hygiene and early identification of entry lesion have been shown as important measures in preventing ADLA attacks. [11-13] Though 50% patients practiced limb elevation, none of them practiced it during daily household activities such as cutting vegetables, watching television, chatting which would help them in reducing edema without allotting specified time in a day. Immobilization of the edematous limb in dependent position causes venous hypertension which results in further lymph stasis. [19] Proportion of patients who were practicing limb exercise (22%) was significantly high compared to a study carried out in India (2%)[181 and Sri Lanka (6%). [20] Importance of regular limb exercise in reducing lymph stasis should be emphasized in the education programs for patients. Simple joint movements either active or passive were shown to reduce edema. [21] Footwear was used regularly by 56 (85%) patients and 6% used specially made footwear. In a study conducted in Orissa, [18] 96% patients were using comfortable footwear and none of the patients used specially made footwear. This study assessed the effect of disability limitation program which is one of the strategies of GPELF.

Since the study included a small sample of patients, the study results cannot be generalized.

Conclusion

It is encouraging to note that majority (95%) patients practice at least one method of morbidity management. But still there is existence of gap between knowledge and practice of lymphedema management. Converting knowledge in to practice has to be emphasized.

DOI:10.5455/ijmsph.2016.04022016428

Acknowledgement

We would like to express our gratitude for the staffs working in the morbidity control clinic for their support throughout the period of data collection in the field. We thank the patients for their cooperation.

References

[1.] WHO. Progress report 2000-2009 and strategic plan 2010-2020 of the global programme to eliminate lymphatic filariasis: halfway towards eliminating lymphatic filariasis. Geneva: World Health Organization 2010. Available at: whqlibdoc.who.int/publications/2010/9789241500722_eng.pdf (last accessed on March 7, 2015).

[2.] Ichimori K, King JD, Engels D, Yajima A, Mikhailov A, Lammie P, et al. Global Programme to Eliminate Lymphatic Filariasis: the processes underlying programme success. PLoS Negl Trop Dis 2014;8(12):e3328.

[3.] Addiss DG, Brady MA. Morbidity management in the Global Programme to Eliminate Lymphatic Filariasis: a review of the scientific literature. Filaria J 2007;6(2):1-19.

[4.] Wynd S, Melrose WD, Durrheim DN, Carron J, Gyapong M. Understanding the community impact of lymphatic filariasis: a review of the sociocultural literature. Bull World Health Organ 2007;85(6):493-8.

[5.] Wijesinghe RS, Wickremasinghe AR, Ekanayake S, Perera MS. Physical disability and psychosocial impact due to chronic filarial lymphoedema in Sri Lanka. Filaria J 2007;6(4):1-8.

[6.] Ramaiah KD, Radhamani MP, John KR, Evans DB, Guyatt H, Joseph A, et al. The impact of lymphatic filariasis on labour inputs in southern India: results of a multi-site study. Ann Trop Med Parasitol 2000;94(4):353-64.

[7.] WHO. Lymphatic Filariasis: A Handbook of Practical Entomology for National Lymphatic Filariasis Elimination Programmes. World Health Organization 2013. Available at: www.who.int/iris/bitstre am/10665/87989/1/9789241505642_eng.pdf. (last accessed on August 8, 2015).

[8.] Dreyer G, Medeiros Z, Netto MJ, Leal NC, de Castro LG, Piessens WF. Acute attacks in the extremities of persons living in an area endemic for bancroftian filariasis: differentiation of two syndromes. Trans R Soc Trop Med Hyg 1999;93(4):413-7.

[9.] WHO. Lymphatic Filariasis Epidemiology, Clinical Manifestations. Available at: http://www.who.int/lymphatic_filariasis/epidemiology/ epidemiology_manifestations/en/. (last accessed on March 7, 2015).

[10.] Pani SP, Yuvaraj J, Vanamaii P, Dhanda V, Michael E, Grenfeli B, et al. Episodic adenolymphangitis and lymphoedema in patients with bancroftian filariasis. Trans R Soc Trop Med Hyg 1995; 89(1):72-4.

[11.] Shenoy RK. Management of disability in lymphatic filariasis: an update. J Commun Dis 2002;34(1):1-14.

[12.] Budge PJ, Little KM, Mues KE, Kennedy ED, Prakash A, Rout J, et al. Impact of community-based lymphedema management on perceived disability among patients with lymphatic filariasis in Orissa State, India. PLoS Negl Trop Dis 2013;7(3):e2100.

[13.] Shenoy RK, Suma TK, Rajan K, Kumaraswami V. Prevention of acute adenolymphangitis in brugian filariasis: comparison of the efficacy of ivermectin and diethylcarbamazine, each combined with local treatment of the affected limb. Ann Trop Med Parasitol 1998;92(5):587-94.

[14.] WHO. Global Programme to Eliminate Lymphatic Filariasis. Managing morbidity and preventing disability in lymphatic filariasis. World Health Organization 2013. Available at: who.int/iris/bitstre am/10665/85347/1/9789241505291_eng.pdf

[15.] WHO. Training Module on Community Home-Based Prevention of Disability due to Lymphatic Filariasis--Learner's Guide. Geneva: World Health Organization, 2003. Available at: http://www.wpro. who.int/southpacific/pacelf/publications/New_Lymphatic_Filariasis_Disability_prevention_guide_Part1.pdf. (last accessed on July 25, 2015).

[16.] WHO. Lymphedema Staff Manual. Treatment and Prevention of Problems Associated with Lymphatic Filariasis-Learners Guide. Geneva. World Health Organization, 2001. Available at: who.int/ iris/bitstream/10665/67224/1/WHO_CDS_CPE_CEE_2001.26a. pdf. (last accessed on July 28, 2015).

[17.] National Vector Borne Diseases Control Programme. Morbidity management in lymphatic filariasis. Delhi: Directorate of National Vector Borne Disease Control Programme, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Available at: http://nvbdcp.gov.in/Doc/LFmorbidity-management.pdf. (last accessed on March 10, 2015).

[18.] Bontha VB, Abhay NN, Anna SK. A survey on foot care practices among filarial lymphoedema patients in Orissa, India. Trop Biomed 2007;24(2):7-14.

[19.] Vaqas B and Ryan TJ. Lymphoedema: pathophysiology and management in resource-poor settings--relevance for lymphatic filariasis control programmes. Filaria J 2003;2(1):4.

[20.] Chandrasena TN, Premaratna R, De Silva NR. Lymphoedema management knowledge and practices among patients attending filariasis morbidity control clinics in Gampaha District, Sri Lanka. Filaria J 2004;3(1):6.

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Hemalatha Kumarasamy (1), Ram Prabhakar (2), Elango Subbiah (1)

(1) Department of Community Medicine, Chennai Medical College Hospital and Research Centre, Tiruchirappalli, Tamilnadu, India.

(2) Department of Community Medicine, Government Theni Medical College, Tamilnadu, India.

Correspondence to: Hemalatha Kumarasamy, E-mail: drkhemalatha@gmail.com

Received February 04, 2016. Accepted March 25, 2016
Table 1: Sociodemographic details of the patients (N = 66)

Characteristics                                            Number (%)

Age group           31-39 years                             6 (9)
                    40-49 years                            25 (37.9)
                    50-59 years                            17 (25.8)
                    [greater than or equal to] 60 years    18 (27.3)
Type of family      Nuclear                                48 (72.7)
                    Joint                                   9 (13.6)
                    Three generation                        9 (13.6)
Housing condition   Pucca                                  40 (60.6)
                    Semipucca                              26 (39.4)
Total                                                      66 (100)

Table 2: Clinical profile of the patients (N = 66)

Clinical manifestation                                    Number (%)

  Lymphedema of lower limb                                65 (98.5)
  Lymphedema of upper limb                                 1 (1.5)
  Hydrocele and lymphedema                                 10 (15)
  Total                                                      76 *
Grades of lymphedema
  I   Pitting edema; spontaneously reversible on            4 (6)
        elevation
  II  Non-pitting edema; not spontaneously reversible     46 (69.7)
        on elevation
  III Gross increase in grade II lymphoedema,             16 (24.3)
        with dermatoscelerosis and
  papillomatous lesions
  Total                                                    66 (100)
Other chronic morbidities
  Diabetes mellitus                                       22 (33.3)
  Hypertension                                            18 (27.3)
  No morbidity                                            26 (39.4)
  Total                                                    66 (100)

* Total exceeds sample size due to multiple clinical manifestations
in few patients.

Figure 1: Knowledge and practice of morbidity management in the
study group.

Lymphedema management

                            Knowledge             Practice

Limb hygiene                  95                     69

Detection of                  35                      6
entry lesion

Limb elevation                85                     50

Limb exercise                 85                     22

Wearing appropriate           50                     22
foot wear

Note: Table made from bar graph.
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Article Details
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Title Annotation:Research Article
Author:Kumarasamy, Hemalatha; Prabhakar, Ram; Subbiah, Elango
Publication:International Journal of Medical Science and Public Health
Article Type:Clinical report
Geographic Code:9INDI
Date:Oct 1, 2016
Words:2246
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