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

Kataraki Basavaraj,1a Shetty K Bharatesh,2b Dhar Murali,3c Kamath Ramachandra,4a Malamardi Sowmya5a 1Current Affiliation: Regional Coordinator – Karnataka, DNRT, National AIDS Control Organisation, Ministry of Health and Family Welfare, Govt. of India. aAffiliation where the work was primarily carried out: Dept. of Public Health, Manipal University, Manipal, Karnataka, India. 2Current Affiliation: Additional Project Director, Karnataka Health Promotion Trust, Bengaluru, India. bAffiliation where the work was primarily carried out: Lecturer, Melaka Manipal Medical College, Manipal University, Manipal, Karnataka, India. 3Current Affiliation: Associate Professor, Department of Population Policies & Programmes, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai 400088, India cAffiliation where the work was primarily carried out: Associate Professor, Department of Statistics, Manipal University, Manipal, Karnataka, India. 4Current Affiliation: Associate Professor, Dept. of Community Medicine, Melaka Manipal Medical College, Manipal University, Manipal, Karnataka, India. aAffiliation where the work was primarily carried out: Head of Dept, Dept. of Public Health, Manipal University, Manipal, Karnataka, India. 5Current Affiliation: Senior Project Consultant, Ernst & Young, Gurgaon, India. aAffiliation where the work was primarily carried out: Dept. of Public Health, Manipal University, Manipal, Karnataka, India. 1Current Affiliation: Regional Coordinator – Karnataka, DNRT, National AIDS Control Organisation,


INTRODUCTION
Lymphatic filariasis (LF), a mosquito-borne disease, is caused by the parasitic filarial nematodes (roundworms) Wuchereria bancrofti (W.bancrofti), Brugia malayi (B.malayi), or Brugia timori (B.timori).Because the burden of the disease is determined by the intensity and the duration of the infection, the greatest impact of LF is on older age groups. 1 LF is one the Neglected Tropical Diseases (NTDs).In 1997 World Health Organisation (WHO) declared LF as eradicable or potentially eradicable and in 2000 the Global Programme to Eliminate LF was launched. 2ass Drug Administration as one of the key strategy to eliminate LF and disability management is the other key component.The programme has a coverage of more than 500 million implemented in 27 countries. 3cording to World Health Organization (2011) an estimated 120 million people in 73 countries are currently infected with filariasis.It is one of the second leading cause of disability worldwide. 4About 15 million people are having lymphoedema (Elephantiasis) and 25 million with urogenital swelling especially the scrotal hydrocele.Around 65% of those at risk reside in WHO's South East Asia Region.India, Indonesia, Nigeria, and Bangladesh contribute about 70% of infection worldwide. 5F is a disfiguring and disabling disease which is usually acquired in childhood and manifestations are usually seen in adulthood.Lymphoedema is common with frequent attacks of infection causing swollen limbs, severe pain and fever.The disease is mainly transmitted by mosquito species Culex quinquefasciatus, Aedes aegypti and Mansonia annulifera/ M. uniformis. 4,5,6Culex species is main vector for W. Bancrofti and Mansonia is the vector for B. Malayi.Most of the time the disease is asymptomatic and the individual may carry millions of larval parasites called microfilariae in the blood and adult worms mainly in the lymphatic system. 7These adult worms get blocked in lymphatic system causing lymphoedema like lymphoedema of legs, scortum, breasts and arms. 8In India about 600 million people are considered at risk of developing the disease like LF. Indigenous LF is reported from 20 states including the union territories.An average of 250 districts have been identified to be endemic for filariasis.In India the filariasis is mainly caused by two species Wuchereria bancrofti and Brugia malayi.It is estimated that 99.4% of the cases are caused by Wuchereria bancrofti and 0.6% by Brugia malayi. 9In Karnataka there are 8 endemic districts for filariasis and Udupi is one among them.The main aim was to study the morbidity management among LF patients and the objective was to know the knowledge and practices for morbidity management of lymphoedema.

MATERIALS AND METHODS
A community based cross-sectional study was conducted in Udupi district which is administratively divided into three taluks, namely Udupi, Kundapura, and Karkala, between the months February and July 2013.All the subjects confirmed positive for LF were included in the study and who are bedridden and unable to speak were excluded from the study.Among the total 800 LF patients (District Vector Borne Disease Control (DVBDC), Udupi, 2012) in Udupi district, a sample of 224 patients was included in the study and out of which 178 agreed to participate in the study.A stratified random sampling with proportional allocation technique was used as sampling technique.Number of patients needed for the study, were selected according to urban and rural setting.Then proportionally allocated to all the three talukas (Udupi, Karkala and Kundapur) by randomizing the list of participants from the line list of LF patients given in the Udupi District (DVBDC, Udupi, 2012) in which name and addresses of the patients are mentioned.The randomly selected patients were included in the study.The sample size of 224 for the study was calculated based on the prevalence study which was found in the literature review and calculated using Prevalence (P) = 30%, Confidence Interval of 95%, Relative precision (ε) = 20% of p. SPSS version 15 (SPSS Inc., Chicago, IL) was used to analyse the data.Statistical analysis was done with categorical variables expressed as frequencies and percentages.Continuous variables were measured using mean and standard deviation.

Ethical approval
The ethical clearance was obtained from the Institutional Ethics Committee of Kasturba Hospital, Manipal Univesity; and measures were un- dertaken to maintain patient confidentiality throughout the study and during analysis of data.Written informed consent was obtained from each participant.

Tools
Included the socio-demographic details followed by lympoedema morbidity management questionnaire 10 which was designed based on the guidelines provided by NVBDCP for morbidity management among lymphatic filariasis patients.This tool included knowledge about nail hygiene, washing of the affected part, exercises as recommended.

RESULTS
A total of 178 participants were covered in the study.Majority of the participants were from Udupi taluk (67.4%) and among the three talukas, maximum participants were from rural (78%) (Table 1).In this study majority of the participants were females patients (66.3%), 88.8% were Hindu and close to 61% were above 56 years, 75% male and 52% female respondents were married.About 30% of male and 31% of female respondents were educated up to primary and 15% of male and 34% of female were illiterate.Regarding occupation 73% female were housewives and among men 28% were unskilled workers (Table 2).
Grading of lymphoedema showed that 52.2% had grade I staging, 31% had grade II staging and 13% had grade III (elephantiasis) staging.Single leg morbidity was high among the respondents, 33% men had lymphoedema of left leg, and 25% had on right leg.Among women 44.07%had lymphoedema of left leg and 37.29% of right leg.In men 33% had scrotal swelling (Hydrocele).Knowledge of how the disease is caused was responded by 34%.Women (32%) were more aware about the disease than men (22%).For morbidity management, 58% were aware about nail hygiene and 94.4% had the knowledge of Mass Drug Administration (MDA).Regarding recommended practices for morbidity management, 98% patients said they wash the affected body part daily with soap.Regarding frequency of cleaning affected part, 62% wash twice daily and 17% wash during morning and evening time.Among 178 patients inter-  viewed, 152 had lymphoedema of leg.Daily leg exercise is necessary for the morbidity management as recommended by the NVBDCP program.It was found that only 30% of them practiced one or the other exercise regularly (Figure 1).Elevation of the leg was practiced by 45% patients, 'Up on toe' exercise by 30%, 'Toe pointing exercise' by 31%, 'circle exercise' by 25 %.Wearing of customized footwear was practiced by only 2.6% (Table 3).Attendance to morbidity management camp was very less i.e 28%.For protection against mosquitoes, 48% used mosquito repellent coils and only 6% used bed nets (Figure 2).

DISCUSSION
Global Programme to Eliminate LF (GPELF) focuses on two major components 1. Interrupting transmission, 2. Managing morbidity and preventing disability. 2 Present study focused on the second major component of the GPELF.One of the study conducted in tertiary care centre Kerala, 11 72.6% (82) had in the age group of 60-85 years which was almost similar to our study were most of the patients were above age of 56 years 60.7 % (108).Other similar study conducted in Srilanka 12 had male patients 33.3% (22) and female patients 66.7% (44), both legs affected patients were 9% (6).45.5% (30) were in Grade 1 stage and 16.7% (11)  were in Grade 3 stage, which was similar to our study as female patients were 66.3% (118) and male patients 33.7% (60).Both legs patients were 21 (11.8%),52.2% (93) were in Grade 1 stage and 12.9% (23) were in Grade 3 stage.Knowledge of nail hygiene was lower in present study (57.3%) compared to the above study in which it was above 80%.A study conducted in northeastern Brazil 13 showed that the patients who were not using bed nets at night were at two times high risk of developing infection than those who were using the bed nets at night (OR=1.87;95CI:1.47-2.38).As present study did not focus on the risk factors, rather use of protective measures was studied.Only 6.2% of the patients used bed nets and 4.5% used both bed nets and coils, 41% did not use any form of protective measure against mosquitoes.

CONCLUSION
The program has to ensure that all the LF patients will undergo morbidity management training and know how to take care of lymphoedema.A total of 178 people were interviewed in the study among them most of the patients i.e. 60.7% were above 55 years and women were more (66.3%)than men (33.7%).The literacy rate among subjects was fairly good, 31% had up to primary level 27% of them up to secondary level.Regarding knowledge on how filariasis is caused, women (32%) had better knowledge than men (22%).Regarding MDA both men and women had good knowledge and 95% of men and 84% women had received drugs during recent MDA.The lymphoedema of leg was found both in men and women.More than 50% of them had grade I stage lymphoedema followed by grade II (31%).In morbidity management, washing was practiced by 98.3% among which majority (42.7%) said that they washed both morning and night before going to sleep.Recommended exercises for morbidity management were not practiced by most of the patients.

Limitations
Due to the cross sectional study design, a temporal association cannot be made.Moreover, lesser duration of the study and in depth perception of the patients regarding morbidity management was not possible.