A significant proportion of the public health problem represented by lymphatic filariasis is due to impairment and disability related to lymphoedema (also known as elephantiasis), hydrocoele and ADL (acute attacks). Therefore, national programmes must focus on managing morbidity and preventing disability. Such activities will assist patients with chronic morbidity as a result of lymphatic filariasis and also improve preventive drug distribution coverage.
Management of morbidity and prevention of disability in lymphatic filariasis require a broad strategy involving both secondary and tertiary prevention. Secondary prevention includes simple hygiene measures, such as basic skin care, to prevent ADL and progression of lymphoedema to advanced/severe stages. For management of hydrocoele, surgery may be appropriate. Tertiary prevention includes psychological and socioeconomic support for people with disabling conditions to ensure that they have equal access to rehabilitation services and opportunities for health, education and income.
Activities beyond medical care and rehabilitation are also required. These may include promoting positive attitudes towards people with disabilities, preventing the causes of disabilities, providing education and training, supporting local initiatives, such as self-help groups and micro- and macro-income-generating schemes. The activities can also include education of families and communities, to help patients with lchronic disease to fulfil their roles in society. Thus, vocational training and appropriate psychological support may be necessary for overcoming the depression and economic loss associated with the disease.
Morbidity Management and Disability Prevention (MMDP)/Disease Management and Disability Inclusion (DMDI) must be continued in endemic communities even after mass drug administration has stopped and after surveillance and verification of interruption of transmission, as chronically affected patients are likely to remain in these communities and may face the challenges of chronic disease for decades.
Further information can be found in the WHO publication – Lymphatic Filariasis; Managing Morbidity and Preventing Disability
Supportive Clinical Care
Adult worms and the bacteria they carry elicit immune responses that cause damage to the lymphatic system. Lymphoedema occurs following recurrent episodes of bacterial infection in the affected limb or when the damage becomes irreversible. However, lymphoedema symptoms can be managed and reducing the frequency of acute attacks will prevent the disease from worsening. Patients can easily learn hygiene measures that are effective in minimizing bacterial infection and promoting lymph flow. These simple measureswhich can be undertaken by the patients themselves or with the assistance of a carer in severe cases include:
- Washing the affected limbs twice daily with soap and clean, cool water, and careful drying.
- Raising the affected limb at night
- Exercising the limb regularly
- Keeping the nails and spaces between the toes clean
- Wearing comfortable shoes
- Using medicated creams or antibiotics to treat small wounds or abrasions
These same measures can also decrease the frequency of recurrent bacterial infection episodes in patients with lymphoedema of the penis or scrotum
Unfortunately, principles of management have not yet been fully developed for successfully reversing the anatomic distortions in the lymphoedematous limb but through these methods, even the worst case of elephantiasis can be improved.
For most hydrocele patients, surgery is the treatment of choice and can be curative. The prognosis is good and corrective surgery for early hydrocele can even be undertaken even with local anaesthetic. Quality pre- and post-operative care are important components that help make this surgery successful. For other genital damage, more complicated surgery is often required. For example, lymphoedema of scrotal skin elephantiasis may require complex reconstructive surgery with skin grafts for real improvement. Unfortunately, however, hydrocele surgery is still often too expensive for those afflicted with LF.
Patient Education and Counselling
Psychological counselling is also essential to support those patients with LF-induced disability who can suffer from stigma, acute shame, isolation, sexual dysfunction and intense chronic pain and suffering. These can also lead to psychological problems and care of patients with psychosocial issues (the mental health) had often been ignored but is now recognised as a major part of patient care.
The Global Programme to Eliminate Lymphatic Filariasis (GPELF) includes 2 main components:
- interrupting transmission of the parasite that causes lymphatic filariasis by using mass drug administration to deliver annual preventive drug treatment to all people living in endemic areas who are at risk of the disease; and
- managing morbidity and preventing disability among people who have already been affected by the disease through community based education in self-care.
National elimination programmes should focus on implementing morbidity management activities in order preent further disabiiity and achieve the objectives of GPELF, which include providing care to those already affected by lchronic morbidity even after parasite transmission has been interrupted. Patients who experience various clinical and social consequences of the disease have a right to health care and national programmes must make this a reality.
The WHO basic recommended package of care for MMDP/DMDI requires that health facilities in every district with known patients be able to provide treatment and prevention of acute ADL, management of lymphoedema, surgery for hydrocele and give treatment for any remaining LF infection and, where considered needed, include access to psychological counselling. Treatment of acute attacks: include appropriate antibiotic treatment, symptomatic management with anti-pyretic, analgesics and anti-inflammatory medications and supportive treatment. Managing lymphoedema includes limb hygiene measures, skin and wound care, exercise, elevation of the affected limb and wearing comfortable shoes
Prevention of ADL attacks is mainly by hygiene measures of the limbs. This includes washing the affected area thoroughly with soap and water twice a day or at least once before going to bed. Particular attention should be paid to the webs of the toes and deep skin folds and wiping dry with a clean cloth. Clipping the nails at intervals and keeping them clean, preventing or promptly treating any local injuries or infections, applying anti-fungal ointment in the webs of the toes, skin folds and sides of the feet to prevent fungal infections should all be performed routinely.
For MMDP to be successful all health care providers including the health workers, volunteers and patients should be trained in the limb-care programme to prevent ADL attacks and thereby preventing progression of disease. There should be 100% geographical coverage of these activities in the areas with known patients in all endemic countries. The MMDP activities need to be integrated into the primary health care system of the endemic area in order to be sustainable in the long term.
Activities to manage morbidity and prevent disability will not only meet the needs of those with the disease but will also enhance compliance with mass drug administration, and thereby contribute to efforts to interrupt transmission of the parasite and prevent new infections.
The MMDP activities could be integrated with other disease specific programmes especially neglected tropical diseases (NTDs) like leprosy and buruli ulcer, other infectious diseases such as infection with the human immuno-deficiency virus (HIV) and acquired immuno-deficiency syndrome (AIDS) or with foot-care for diabetes.
Patients with lymphoedema usually will not have adult worms or microfilariae and so they do not require treatment with anti filarial drugs
To view the WHO position statement 'Managing morbidity and preventing dsability in the Global Programme to Eliminate Lymphatic Filariasis' click here
For further information on the activities of morbidity management and disability prevention click here