A Study on Morbidity Management among Lymphatic Filariasis Patients in Udupi district, Karnataka, India

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1 Int J Med. Public Helth. 2017; 7(2):91-95 A Multifceted Peer Reviewed Journl in the field of Medicine nd Public Helth Originl Article A Study on Morbidity Mngement mong Lymphtic Filrisis Ptients in Udupi district, Krntk, Indi Ktrki Bsvrj, 1 Shetty K Bhrtesh, 2b Dhr Murli, 3c Kmth Rmchndr, 4 Mlmrdi Sowmy 5 Ktrki Bsvrj, 1 Shetty K Bhrtesh, 2b Dhr Murli, 3c Kmth Rmchndr, 4 Mlmrdi Sowmy 5 1 Current Affilition: Regionl Coordintor Krntk, DNRT, Ntionl AIDS Control Orgnistion, Ministry of Helth nd Fmily Welfre, Govt. of Indi. Dept. of Public Helth, Mnipl University, Mnipl, Krntk, Indi. 2 Current Affilition: Additionl Project Director, Krntk Helth Promotion Trust, Bengluru, Indi. b Lecturer, Melk Mnipl Medicl College, Mnipl University, Mnipl, Krntk, Indi. 3 Current Affilition: Associte Professor, Deprtment of Popultion Policies & Progrmmes, Interntionl Institute for Popultion Sciences, Govndi Sttion Rod, Deonr, Mumbi , Indi c Affilition where the work ws primrily crried out: Associte Professor, Deprtment of Sttistics, Mnipl University, Mnipl, Krntk, Indi. 4 Current Affilition: Associte Professor, Dept. of Community Medicine, Melk Mnipl Medicl College, Mnipl University, Mnipl, Krntk, Indi. Affilition where the work ws primrily crried out: Hed of Dept, Dept. of Public Helth, Mnipl University, Mnipl, Krntk, Indi. 5 Current Affilition: Senior Project Consultnt, Ernst & Young, Gurgon, Indi. Dept. of Public Helth, Mnipl University, Mnipl, Krntk, Indi. 1 Current Affilition: Regionl Coordintor Krntk, DNRT, Ntionl AIDS Control Orgnistion, Ministry of Helth nd Fmily Welfre, Govt. of Indi. Correspondence Dr Bsvrj Ktrki 1872, 22nd A Min, Sector 2, HSR Lyout, Bengluru, Krntk, Indi Mobile no: Emil: bsvrj.ktrki@gmil.com History Submission Dte: Revised Dte: Accepted Dte: DOI : /ijmedph Article Avilble online Copyright 2017 Phcog.Net. This is n openccess rticle distributed under the terms of the Cretive Commons Attribution 4.0 Interntionl license. ABSTRACT Context: Morbidity mngement is one of the key spects in the life of Lymphtic Filrisis (LF) ptients. Ntionl Vector Borne Disese Control Progrmme (NVBDCP) is giving more emphsis by conducting morbidity mngement trining cmps every yer since 2004 to help LF ptients to mnge nd cope-up with the existing morbidity. Aim: To study the morbidity mngement mong LF ptients in Udupi district, Krntk. Study Setting nd Design: The study ws conducted in Udupi district, Krntk, Indi in The design ws strtified rndom smpling with proportionl lloction method. Mterils nd Methods: Community bsed cross sectionl study, 178 subjects suffering from LF were selected using strtified rndom smpling with proportionl lloction method. An interview bsed method ws used to collect the dt. Lympoedem Morbidity Mngement Questionnire were designed bsed on the guidelines provided by Ntionl Vector Borne Disese Control Progrmme (NVBDCP). Results: Among 178 LF ptients only bout 34% hd knowledge bout the disese custion. About 98.3% hd good hygiene prctice towrds ffected re but only 30% of them regulrly prcticed one or the other exercise s recommended. Conclusion: The study clerly indictes the outrech focus on LF ptients needs to be enhnced by grss root level helth workers. The progrm hs to ensure tht ll the LF ptients will undergo morbidity mngement trining nd know how to tke cre of lymphoedem. Key words: Morbidity Mngement, Lymphtic Filrisis, Mss Drug Administrtion. INTRODUCTION Lymphtic filrisis (LF), mosquito-borne disese, is cused by the prsitic filril nemtodes (roundworms) Wuchereri bncrofti (W. bncrofti), Brugi mlyi (B. mlyi), or Brugi timori (B. timori). Becuse the burden of the disese is determined by the intensity nd the durtion of the infection, the gretest impct of LF is on older ge groups. 1 LF is one the Neglected Tropicl Diseses (NTDs). In 1997 World Helth Orgnistion (WHO) declred LF s erdicble or potentilly erdicble nd in 2000 the Globl Progrmme to Eliminte LF ws lunched. 2 Mss Drug Administrtion s one of the key strtegy to eliminte LF nd disbility mngement is the other key component. The progrmme hs coverge of more thn 500 million implemented in 27 countries. 3 According to World Helth Orgniztion (2011) n estimted 120 million people in 73 countries re currently infected with filrisis. It is one of the second leding cuse of disbility worldwide. 4 About 15 million people re hving lymphoedem (Elephntisis) nd 25 million with urogenitl swelling especilly the scrotl hydrocele. Around 65% of those t risk reside in WHO s South Est Asi Region. Indi, Indonesi, Nigeri, nd Bngldesh contribute bout 70% of infection worldwide. 5 LF is disfiguring nd disbling disese which is usully cquired in childhood nd mnifesttions re usully seen in dulthood. Lymphoedem is common with frequent ttcks of infection cusing swollen limbs, severe pin nd fever. The disese is minly trnsmitted by mosquito species Culex quinquefscitus, Aedes egypti nd Mnsoni nnulifer/ M. uniformis. 4,5,6 Culex species is min vector for W. Bncrofti nd Mnsoni is the vector for B. Mlyi. Most of the time the disese is symptomtic nd the individul my crry millions of lrvl prsites clled microfilrie in the blood nd dult worms minly in the lymphtic system. 7 These dult worms get blocked in lymphtic system cusing lymphoedem like lymphoedem of legs, scortum, brests nd rms. 8 In Indi bout 600 million people re considered t risk of developing the disese like LF. Indigenous LF is reported from 20 sttes including the union territories. An verge of 250 districts hve been identified to be endemic for filrisis. In Indi the filrisis is minly cused by two species Wuchereri bncrofti nd Brugi mlyi. It is estimted Cite this rticle : Bsvrj K, Bhrtesh SK, Murli D, Rmchndr K, Sowmy M. A Study on Morbidity Mngement mong Lymphtic Filrisis Ptients in Udupi district, Krntk, Indi. Int J Med. Public Helth. 2017; 7(2): Interntionl Journl of Medicine nd Public Helth, Vol 7, Issue 2, Apr-Jun,

2 tht 99.4% of the cses re cused by Wuchereri bncrofti nd 0.6% by Brugi mlyi. 9 In Krntk there re 8 endemic districts for filrisis nd Udupi is one mong them. The min im ws to study the morbidity mngement mong LF ptients nd the objective ws to know the knowledge nd prctices for morbidity mngement of lymphoedem. MATERIALS AND METHODS A community bsed cross-sectionl study ws conducted in Udupi district which is dministrtively divided into three tluks, nmely Udupi, Kundpur, nd Krkl, between the months Februry nd July All the subjects confirmed positive for LF were included in the study nd who re bedridden nd unble to spek were excluded from the study. Among the totl 800 LF ptients (District Vector Borne Disese Control (DVBDC), Udupi, 2012) in Udupi district, smple of 224 ptients ws included in the study nd out of which 178 greed to prticipte in the study. A strtified rndom smpling with proportionl lloction technique ws used s smpling technique. Number of ptients needed for the study, were selected ccording to urbn nd rurl setting. Then proportionlly llocted to ll the three tluks (Udupi, Krkl nd Kundpur) by rndomizing the list of prticipnts from the line list of LF ptients given in the Udupi District (DVBDC, Udupi, 2012) in which nme nd ddresses of the ptients re mentioned. The rndomly selected ptients were included in the study. The smple size of 224 for the study ws clculted bsed on the prevlence study which ws found in the literture review nd clculted using Prevlence (P) = 30%, Confidence Intervl of 95%, Reltive precision (ε) = 20% of p. SPSS version 15 (SPSS Inc., Chicgo, IL) ws used to nlyse the dt. Sttisticl nlysis ws done with ctegoricl vribles expressed s frequencies nd percentges. Continuous vribles were mesured using men nd stndrd devition. Ethicl pprovl The ethicl clernce ws obtined from the Institutionl Ethics Committee of Ksturb Hospitl, Mnipl Univesity; nd mesures were un- dertken to mintin ptient confidentility throughout the study nd during nlysis of dt. Written informed consent ws obtined from ech prticipnt. Tools Included the socio-demogrphic detils followed by lympoedem morbidity mngement questionnire 10 which ws designed bsed on the guidelines provided by NVBDCP for morbidity mngement mong lymphtic filrisis ptients. This tool included knowledge bout nil hygiene, wshing of the ffected prt, exercises s recommended. RESULTS A totl of 178 prticipnts were covered in the study. Mjority of the prticipnts were from Udupi tluk (67.4%) nd mong the three tluks, mximum prticipnts were from rurl (78%) (Tble 1). In this study mjority of the prticipnts were femles ptients (66.3%), 88.8% were Hindu nd close to 61% were bove 56 yers, 75% mle nd 52% femle respondents were mrried. About 30% of mle nd 31% of femle respondents were educted up to primry nd 15% of mle nd 34% of femle were illiterte. Regrding occuption 73% femle were housewives nd mong men 28% were unskilled workers (Tble 2). Grding of lymphoedem showed tht 52.2% hd grde I stging, 31% hd grde II stging nd 13% hd grde III (elephntisis) stging. Single leg morbidity ws high mong the respondents, 33% men hd lymphoedem of left leg, nd 25% hd on right leg. Among women 44.07% hd lymphoedem of left leg nd 37.29% of right leg. In men 33% hd scrotl swelling (Hydrocele). Knowledge of how the disese is cused ws responded by 34%. Women (32%) were more wre bout the disese thn men (22%). For morbidity mngement, 58% were wre bout nil hygiene nd 94.4% hd the knowledge of Mss Drug Administrtion (MDA). Regrding recommended prctices for morbidity mngement, 98% ptients sid they wsh the ffected body prt dily with sop. Regrding frequency of clening ffected prt, 62% wsh twice dily nd 17% wsh during morning nd evening time. Among 178 ptients inter- Tble 1: Distribution of cses ccording to Tluks. Tluks Urbn n (%) Rurl n (%) Totl (%) Udupi 21 (11.79) 99 (55.62) 120 (67.4) Kundpur 12 (6.74) 26 (14.61) 38 (21.35) Krkl 6 (3.37) 14 (7.87) 20 (11.24) Totl 39 (21.9) 139 (78) 178 Figure 1: Exercises prcticed for morbidity mngement (n=152) Figure 2: Protective Mesures Used by Ptients 92 Interntionl Journl of Medicine nd Public Helth, Vol 7, Issue 2, Apr-Jun, 2017

3 Tble 2: Socio Demogrphic Detils of Ptients. N=178 Mle Femle Vribles Ctegory N % N % Gender Religion Hindu Muslim Christin Age (yrs) < to to to to > Mritl sttus Mrried Unmrried Widow Widower Single Eductionl sttus Primry Higher primry High school Pre University Grdute Post grdute Illiterte Occuptionl sttus Professionl/ white collr Business Skilled Unskilled Housewife Retired Right now not working Unemployed Tble 3: Describes the knowledge nd prctices for morbidity mngement mong LF ptients. Chrcteristic N (%) Chrcteristic N (%) Knowledge How the disese is cused About MDA Yes 60(33.7) Yes 168(94.4) No 118(66.7) No 10 (5.6) Nil Hygiene Yes 102 (57.3) No 76 (42.7) Morbidity mngement Sites ffected Mles n=60 Femles n=118 Rt rm 1(1.6) 3(2.5) Lt rm 2(3.3) 1(0.8) Rt Leg 15(25) 44(36.7) Interntionl Journl of Medicine nd Public Helth, Vol 7, Issue 2, Apr-Jun,

4 Lt leg 20(33.3) 54(45.0) Both Legs 3(5.2) 18(15.0) Scortum 19(31.6) Grding of Lymphoedem Dily wshing of ffected body re GRADE 1 93(52.2) Yes 175(98.3%) GRADE 2 55(30.9) No 3(1.7%) GRADE 3 23(12.9) Didn t hd ny edem 7(3.9) Time of wshing their ffected prt Prctices of using customized footwer n=152 Morning time Both morning nd evening time No specific time Both morning nd night before going to sleep 51(2.7%) Yes 148(97.4) 30(16.7%) No 4(2.6) 21(11.8%) 76(42.7%) viewed, 152 hd lymphoedem of leg. Dily leg exercise is necessry for the morbidity mngement s recommended by the NVBDCP progrm. It ws found tht only 30% of them prcticed one or the other exercise regulrly (Figure 1). Elevtion of the leg ws prcticed by 45% ptients, Up on toe exercise by 30%, Toe pointing exercise by 31%, circle exercise by 25 %. Wering of customized footwer ws prcticed by only 2.6% (Tble 3). Attendnce to morbidity mngement cmp ws very less i.e 28%. For protection ginst mosquitoes, 48% used mosquito repellent coils nd only 6% used bed nets (Figure 2). DISCUSSION Globl Progrmme to Eliminte LF (GPELF) focuses on two mjor components 1. Interrupting trnsmission, 2. Mnging morbidity nd preventing disbility. 2 Present study focused on the second mjor component of the GPELF. One of the study conducted in tertiry cre centre Kerl, % (82) hd in the ge group of yers which ws lmost similr to our study were most of the ptients were bove ge of 56 yers 60.7 % (108). Other similr study conducted in Srilnk 12 hd mle ptients 33.3% (22) nd femle ptients 66.7% (44), both legs ffected ptients were 9% (6). 45.5% (30) were in Grde 1 stge nd 16.7% (11) were in Grde 3 stge, which ws similr to our study s femle ptients were 66.3% (118) nd mle ptients 33.7% (60). Both legs ptients were 21 (11.8%), 52.2% (93) were in Grde 1 stge nd 12.9% (23) were in Grde 3 stge. Knowledge of nil hygiene ws lower in present study (57.3%) compred to the bove study in which it ws bove 80%. A study conducted in northestern Brzil 13 showed tht the ptients who were not using bed nets t night were t two times high risk of developing infection thn those who were using the bed nets t night (OR=1.87; 95CI: ). As present study did not focus on the risk fctors, rther use of protective mesures ws studied. Only 6.2% of the ptients used bed nets nd 4.5% used both bed nets nd coils, 41% did not use ny form of protective mesure ginst mosquitoes. CONCLUSION The progrm hs to ensure tht ll the LF ptients will undergo morbidity mngement trining nd know how to tke cre of lymphoedem. A totl of 178 people were interviewed in the study mong them most of the ptients i.e. 60.7% were bove 55 yers nd women were more (66.3%) thn men (33.7%). The litercy rte mong subjects ws firly good, 31% hd up to primry level 27% of them up to secondry level. Regrding knowledge on how filrisis is cused, women (32%) hd better knowledge thn men (22%). Regrding MDA both men nd women hd good knowledge nd 95% of men nd 84% women hd received drugs during recent MDA. The lymphoedem of leg ws found both in men nd women. More thn 50% of them hd grde I stge lymphoedem followed by grde II (31%). In morbidity mngement, wshing ws prcticed by 98.3% mong which mjority (42.7%) sid tht they wshed both morning nd night before going to sleep. Recommended exercises for morbidity mngement were not prcticed by most of the ptients. Limittions Due to the cross sectionl study design, temporl ssocition cnnot be mde. Moreover, lesser durtion of the study nd in depth perception of the ptients regrding morbidity mngement ws not possible. ACKNOWLEDGEMENT I m gretly indebted to ll Medicl officers (PHCs/CHCs/UHCs) ASHA workers nd Mle helth workers of concerned PHCs/CHCs/UHCs of Udupi District for shring their vluble time nd helping me for fcilitting the dt collection process t the field level. CONFLICT OF INTEREST None ABBREVIATIONS USED GPELF: Globl Progrmme to Eliminte LF; LF: Lymphtic Filrisis; MDA: Mss Drug Administrtion; NVBDCP: Ntionl Vector Borne Disese Control Progrmme; NTD: Neglected Tropicl Diseses; WHO: World Helth Orgniztion. REFERENCES 1. Svioli L, Dumerie D. Sustining the drive to overcome the globl impct of neglected tropicl diseses: second WHO report on neglected tropicl diseses. 1st ed. Genev. WHO press; Lymphtic filrisis progrmme [Internet] The Globl Progrmme to Eliminte Lymphtic Filrisis. [cited 2012 Oct 15]. Avilble from: lymphtic_filrisis/disese/en/ 3. Eric et l [Internet]. Progrmme to Eliminte Lymphtic Filrisis MDA Progress. [cited 2012 Oct 15]. Avilble from: 4. Weekly epidemiologicl record [Internet]. World Helth Orgniztion. No. 37, 2012, 87, [cited 2012 Oct 17]. Avilble from: 5. Filrisis Control in Indi nd its Elimintion. Ntionl Vector Borne Disese Control Progrmme. Chpter 1: p 6-7. [cited 2012 Oct 17]. Avilble from: nvbdcp.gov.in/filrisis.html 6. Microfilri of Wuchereri bncrofti nd Brugi mlyi (CDC Photo; DPDx) [In- 94 Interntionl Journl of Medicine nd Public Helth, Vol 7, Issue 2, Apr-Jun, 2017

5 ternet]. [cited 2012 Oct 19]. Avilble from: 7. Clinicl Mnifesttions of lymphtic filrisis [Internet]. [cited 2012 Oct 15]. Avilble from: 8. Chronic mnifesttions of lymphtic filrisis [Internet]. [cited 2012 Oct 15]. Avilble from: 9. Lymphtic filrisis: Country indictors [Internet]. World Helth Orgniztion. [cited 2012 Oct 19]. Avilble from: preventive_chemotherpy/lf/db/index.html?units=miniml&region=ll&country =ind&countries=ind&yer= Morbidity Mngement mong lymphtic filrisis ptients [Internet]. [cited 2012 Nov 03]. Avilble form: Sushm K, Aswthy S, Snjeev S, Pniker N, Kvit D, Shmsul K. Morbidity trends in Lymphtic Filrisis: Anlysis from tertiry cre centre in Kerl, Southern Indi. G J Med Ph. 2012;1(2). 12. Nilmini TGAC, Rnjn P, Silv DN. Lymphoedem mngement knowledge nd prctices mong ptients ttending filrisis morbidity control clinics in Gmph District, Sri Lnk. Filri journl 2004, 3:6. Avilble from: ; PMid: PMCid:PMC Ftim A, Muro M, Ricrdo X, Cinti B, Silv MM, Andre F. Bncroftin Filrisis in two urbn res of Recife, Brsil: The role of individul risk fctors. Rev. Inst Med Trop. 1995;37(3): Cite this rticle : Bsvrj K, Bhrtesh SK, Murli D, Rmchndr K, Sowmy M. A Study on Morbidity Mngement mong Lymphtic Filrisis Ptients in Udupi district, Krntk, Indi. Int J Med. Public Helth. 2017; 7(2): Interntionl Journl of Medicine nd Public Helth, Vol 7, Issue 2, Apr-Jun,