1. GLOBAL PROGRAMME TO ELIMINATE LYMPHATIC FILARIASIS DR. FULBERT ALEC R. GILLEGO, RMT, MD. CITY HEALTH OFFICER-II/CGDH-I BASIC PRINCIPLES AND FRAMEWORK for PREVENTING DISABILITY ASSOCIATED WITH LYMPHATIC FILARIASIS

2. DISABILITY ASSOCIATED WITH LYMPHATIC FILARIASIS 1. ACUTE CLINICAL MANIFESTATIONS: a) Acute adenolymphangitis b) Acute filarial lymphangitis c) Acute epididymo- orchitis

3. DISABILITY ASSOCIATED WITH LYMPHATIC FILARIASIS 2. CHRONIC CLINICAL MANIFESTATIONS: a) Lymphoedema b) Elephantiasis of extremities and genitalia

4. FACTORS LEADING TO DISABILITY IN LYMPHATIC FILARIASIS 1) Parasite induced pathology - the filarial worms cause obstruction of the lymphatic drainage 2) Secondary bacterial infection - bacteria will cause the swelling and infection of the surrounding tissues.

5. FILARIAL LYMPHOEDEMA PATHOGENESIS Adult Filarial Worms Dilatation of Lymphatics Secondary bacterial infection Lymphoedema Recurrent bacterial infections Elephantiasis

6. ACUTE CLINICAL MANIFESTATION Acute Adenolymphangitis Commonest acute manifestation Caused by secondary bacterial infections. Clinical features: recurrent attacks, fever, local pain, redness, warmth, and tenderness Presentation: 1) lymphangitis 2) lymphadenitis 3) cellulitis 4) abscess formation

7. CHRONIC MANIFESTATIONS LYMPHATIC FILARIASIS 1.Lymphoedema or Elephantiasis: a) Involving one or more extremities b) Mostly lower limbs, sometimes upper limbs, and rarely all four limbs c) Less often involves genitalia and breasts 2. Hydrocoele - is the most common manifestation in males with Wuchereria bancrofti infection in some endemic regions

8. LYMPHOEDEMA

9. FORMS OF ELEPHANTIASIS LYMPHOEDEMA

10. LOCAL ENTRY LESIONS 1) Mechanical Injury 2) Pyoderma- pus formation 3) Fissure in the foot – cracking of the soles of the foot 4) Insect bites – cause inflammation & secondary bacterial infection

11. LOCAL ENTRY LESIONS 5) Candidiasis – fungal infection of the soft tissue 6) Paronychia – fungal infection of the toe nails 7) Eczema

12. ENTRY OF LESIONS IN ELEPHANTHIASIS FFF pppParonychia

13. OVERVIEW OF FEATURES USED TO STAGE LYMHOEDEMA

14. HYDROCOELE

15. GOAL OF PREVENTION OF LF RELATED DISABILITY Enable all patients affected with lymphatic filariasis to lead a better quality of life and their full participation (both social and economic) in society

16. GUIDING PRINCIPLES IN THE PREVENTION OF DISABILITY ASSOCIATED WITH LYMPHATIC FILARIASIS 1) Disability and participation restriction: Socio-medical perspective consideration 2) Simple methods of self care arrest progression 3) Requires patients and families to work together 4) Occurrence of disability and its progression can be prevented at household level 5) Home-based approach

17. BASIC FRAMEWORK FOR LYMPHATIC FILARIASIS RELATED DISABILITY PREVENTION 1) High MDA Coverage 2) Sustainable Home-Based approach 3) Access to Surgical Intervention (hydrocoele) 4) Referral System for Management of Complications 5) Capacity Building of Health Workers (lymphoedema management, complications)

18. BASIC FRAMEWORK FOR LYMPHATIC FILARIASIS RELATED DISABILITY PREVENTION 6) Promote social inclusion and participation of people with disability into economic and social life 7) Define tasks at various levels 8) Social mobilization

19. Components of Disability Prevention Programs in Filariasis-Endemic Areas Case Contact Support Supplies Soap Clean Water Footwear Antiseptics Patient Instruction Knowledge and competency in self-care Referral Care and Networks Emotional Social Assistance with Care in home Physical rehabilitation Complicated Cases Scrotal swellings Acute attacks (Antibiotics) Economic Social Participation Sustained Lymphoedema Management (Home-based Care)

20. PRACTICAL ISSUES  All first contacts should give the same message  Patients are good motivators to similar patients  Lymphoedema patients are considered disabled, hence, given disabled benefits  Regular house to house visits (morbidity survey, monitor arrest or progression of disability)  Advertise services available  Mobilzed other sectors or oppurtunities (community-based rehabilitation)

21. MORBIDITY CONTROL IN BICOL REGION (Based on the Philippine Plan of Action Drafted November 2003, Colombo, Sri Lanka)

22. Milestone NBE 3,477 Filariasis Cases Morbidity Survey 132 Chronic Filariasis Cases (17 w/LE) Health Workers Orientation on Morbidity Control Patients, Caregivers & HWs instructed on self-care (15/17) Referral of hydrocoele patients for surgery (113/115) 1987-1998 2000 2001 2002 2003 Selective Treatment Mass Drug Administration Mid-Term Evaluation

23. Lymphoedema Management, by Stage

24. Prevention and Treatment of ADL attacks Prevention of entry lesions Local hygiene Comfortable footwear Antifungal agents Topical Systemic Antibiotics Topical Per oral Parenteral MORBIDITY CONTROL

25. LOCAL HYGIENE: 1) Care of affected limb 2) Wash with soap & water 3) Keep the limb dry & clean 4) Care of nails 5) Prevent entry lesions 6) Topical antifungal or antibiotic MORBIDITY CONTROL IN LYMPHATIC FILARIASIS

26. Local Hygiene Wash with soap & water

27. MORBIDITY CONTROL (Washing)

28. (Drying) MORBIDITY CONTROL

29. Simple Exercise and Limb Elevation MORBIDITY CONTROL

30. Wearing appropriate footwear inappropriate appropriate MORBIDITY CONTROL

31. Physical Examination Pre-Op preparation SURGICAL INTERVENTION (Hydrocoele)

32. ETVT (Eversion of the Tunica Vaginalis Testis)/ Hydrocoelectomy

33. Immediate Post-Op 6 months Post-Op

34. Referral System Patient/Family Community Volunteers and Barangay Officials BHS RHU District/Provincial Regional Hospitals/ Medical Centers/Private Facilities Medical, Surgical and Psycosocial Barangay CBOs MSWD, NGOs, Municipal CBOs DSWD Psycosocial and Economic

35. FLOWCHART OF SERVICES for PWD Associated with LF Community (Brgy. Officials, BHWs) Contact w/ Patients DOH – PHT Assessment Treatment Instruction (Morbidity Control Referral (Follow-up Further Treatment Surgery Livelihood, etc….) Other Health Facility Further Treatment (Complications) Surgery Adjunct (Footwear) NGOs/Other GOs Funds for Surgery (PCSO) Livelihood (DTI) LGU (Municipal/Provincial) RHU Assessment Tx and follow-up Instruction (Morbidity Control) Referral (Follow-up Further Treatment Surgery Livelihood) SWDO Livelihood Mainstreaming

36. ACT NOW! THANK YOU