Treatment

Diethylcarbamazine (DEC) tablet @ 6 mg. /kg. body weight for 12 days is administered for mf. carrier cases present in circulating peripheral blood which can be detected only during night blood survey.

DEC tablets @ 6 mg./kg/ body weight for 7 days in a month is administered.

Foot hygiene, foot care and physical exercise is suggested.

DEC Dosage Schedule

DEC is now supplied to all MDA districts as 100 mg tablets. The drug has been in use in India for more than five decades. It is a very safe drug at the recommended dose. The single dose of 6 mg DEC per kg body weight has to be adjusted and age-wise streamlined dosage is given below:

Drug Dosage Schedule

Note: (i). The advantage of streamlined DEC dosage is that the number of tablets are less and the three doses can easily be remembered by the peripheral drug administrator.

GUIDELINES ON MORBIDITY MANAGEMENT FOR PREVENTION AND CONTROL OF DISABILITY

Filaria patients with damaged lymphatic vessels often have more bacteria on the skin than usual. The large number of bacteria on the skin, multiple skin lesions, slow lymph fluid movement and the reduced ability of the lymph nodes to filter the bacteria cause inflammation characteristic of an acute attack. Repeated bacterial infections precipitate frequent acute attacks, which further damage the tiny lymphatic vessels in the skin, reducing their ability to drain fluid. This vicious cycle continues, aggravating the condition of the patient.

Good hygine and treatment of entry leisions are important measures for managing lymphoedema. The patients should be encouraged to practise skin care and hygine and to use proper footwear. The reduction in the frequency of the acute attacks is an indication that the patient's condition is improving. Effective, simple and cheap techniques have now been available to minimize the suffering caused by the acute and chronic manifestations of the disease.

A Hygine - Washing

1. Supplies needed

(i) Clean water at room temperature,

(ii) Soap (least expensive soap without perfume is usually the best),

(iii) Basin,

(iv) Chair or Stool,

(v) Towel,

(vi)Footwear within easy reach.

2. Check skin for (i) Entry lesions, including very small lesions between the toes that can hardly be seen, (ii) Entry lesions between the toes may cause itching. Scratching can further damage the skin and can provoke an acute attack; tell patients to avoid scratching, (iii) Toenails should be trimmed in such a way that the skin is not injured. Do not try to clean under the nails with sharp objects as these can cause entry lesions.

It is important to check the skin every time the leg is washed because entry lesions allow bacteria to enter the skin and this will cause acute attacks. If entry lesions are found, they should be cleaned carefully.

3. Wash the leg: (i) Wet the leg with clean water at room temperature. Do not use hot water to wash the leg. (ii) Begin soaping at the highest point of swelling (usually around the knee), (iii) Wash down the leg towards the foot, (iv) Gently clean between all skin folds and between the toes, preferably using a small cloth or cotton swab, and paying particular attention to the entry lesions. Brushes should not be used as they can damage the skin, (v) Rinse with clean water, (vi) Repeat this careful washing until the rinse water is clean, (vii) Wash the other leg in the same way, even if it looks normal.

Washing and drying should be done daily ideally at night. Some patients may need to wash twice daily.

4.Dry the skin : (i) Pat the area lightly with a clean towel. Do not rub hard because this can cause damage to the skin, (ii) Carefully dry between the toes and between skin folds using a small cloth, gauze or cotton swab

Wet areas between the toes, skin folds and entry lesions promote bacterial and fungal growth leading to frequent acute attacks.

B Prevention and cure of entry lesions

1. Entry lesions are common in patients with lymphoedema and are most frequently found between the toes and deep skin folds and around the toenails. Entry lesions, such as wounds, can also be found on the surface of the skin. Both fungi and bacteria can cause entry lesions. Fungal infections frequently damage the skin and create entry lesions, especially between the toes, and may cause itching. The entry lesions allow bacteria to enter the body through the skin and this can cause acute attacks. Fungi and bacteria can cause bad odour.

2. Fungal infections are usually white or pink in colour and do not leak fluid. Bacterial infections may leak fluid that is thin and clear or thick and coloured.

3. Antifungal and antibacterial creams can be used for local application.

C. Elevation

Elevation is important for patients with pymphoedema of the leg. It helps prevent fluid from accumulating in the leg by improving the flow in the elevated position.

The knee should be slightly bent and a pillow placed under the knee for support.

While sitting, raise the foot as high as is comfortable, preferably as high as the hip. if sitting on the floor, place a small pillow under the knees. If lying down, the foot can be raised by placing a pillow under the mattress.

Patient with heart problems should not elevate their legs unless advised by a doctor.

1. Exercise is useful for patients with lymphoedema and in general, the more they exercise the better they are. Exercise helps by pumping the fluid and improving drainage. However, patients should not exercise during acute attacks.

2. Besides walking short distances, simple exercises can be done.

3. Standing (up on the toes exercise ) : (i) Stand with both feet slightly apart, holding on to a wall, a person or other support, (ii) Raise on to the tows of both feet at the same time and then sink back to flat feet. (iii) Repeat 5 - 15 times or as often as comfortable. If the patient is unable to rise on both feet at the same time, the exercise can be done one foot at a time.

2.2. Sitting or lying down (toe point exercise): (i) While sitting or lying down, point toes towards the floor, (ii) Then bend (extend) the toes upwards, (iii) Repear 5 - 15 times or as often as comfortable, (iv) Repeat with the other leg

2.3 Sitting or lying down (circle exercise): (i) While sitting or lying down move the foot in a circle to the right and to the left, (ii) Repeat with the other leg, (iii) If sitting on the floor, protect the heel with a flat pillow.

E Wearing proper footwear

Footwear protects feet from injury. Patients should avoid footwear that makes their feet hot and sweaty, or that are too tight.

MANAGEMENT OF AN ACUTE ATTACK

An acute attack is painful. The patient may complain of fever, nausea, headache and soreness of the lymph glands. Most patients can easily care for their acute attacks at home. Oral antibiotics can shorten the attack and are recommended, if the patient can be seen by a doctor. Paracetamol can be taken for fever every six hours until the fever lessens. A cloth soaked in water and placed around the leg can relieve pain. The leg can be soaked in bucket of cold water. The leg should be washed with soap and clean water but more gently and carefully. After drying, antiseptic can be applied to the skin and medicated cream to any entry lesion. The patient should rest and elevate the leg comfortably as much as possible. It is advisable not to exercise during acute attack as such exercise will be painful. The patient should drink plenty of water. Cold compress will help the patient.

Patients, with any of the signs listed here, should be seen by a doctor: (i) Very high fever, confusion, headache, drowsiness or vomiting, (ii) Fever, shaking, chills, or pain in the leg that does not respond to treatment within 24 hours, (iii) Splitting of the skin because of rapid increase in the size of the leg. (iv) Pus in the area affected by the acute attack.

Surgical management of hydroceles due to lymphatic filariasis

Besides annual single dose administration of DEC for 4-6 consecutive years to the eligible population, morbidity management is also an important component to alleviate or prevent disability due to lymphatic filariasis. Hydrocele is one of the commonest manifestations seen in the endemic districts. Surgical management of hydroceles not only gives great relief to the patients but also augments community compliance for success of ELF in the country.

The first level peripheral health centres (PHCs) will be able to diagnose cases needing surgical intervention, while most of the second level health centres (CHCs) have facilities for undertaking hydrocelectomy. WHO brought out a publication on ‘Surgical Approaches to make Urogenital Manifestations of Lymphatic Filariasis’ with algorithm for management of scrotal swellings, assessment of needs for conducting hydrocelectomy, etc.

The prevalence of hydrocele manifestations under each CHC is to be obtained and the cases are to be line listed and a time schedule is to be prepared for augmenting surgical facilities, training of surgeons, wherever needed and undertaking hydrocelectomy operations. Besides CHCs, the private sector including NGOs are also to be involved for promoting the surgical intervention for management of hydroceles. The calendar of activities with pragmatic targets and the minimum financial inputs are to be worked out so that the Govt. of India and the State Govt. may be able to consider for allocation of funds for this specific activity.