Elephantiasis eradication drive in Maharashtra.

1. Training on Morbidity Management and
disability prevention (MMDP) for
lymphatic filariasis

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• Ikfgyh voLFkk (Stage 1 ):
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–lqtsP;k Hkkxkoj nkcwu ikfgys
vlrkuk iM.kkjk [kGxk
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• nqljh voLFkk (Stage 2) :
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& Ckkdh loZ ckch ifgY;k voLFks lkj[ksp
vlrkr-

6. • frljh voLFkk (Stage 3 ):
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vlrs-
gRrhik;kP;k voLFkk

7. • pkSFkh voLFkk (Stage 4) :
& Lkqt dk;e vlrs-
& Ropsoj xkBh vlrkr-
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& Ropsoj mFkG ?kM@;k fnlw 'kdrkr-
gRrhik;kP;k voLFkk

8. • ikpoh voLFkk (Stage 5) :
– Lkqt dk;e vlrs-
– RopsP;k ?kM@;k [kksyoj
vlrkr-
– Ropk tkM >kkysyh vlrs o R;koj
xkBh vkf.k mFkG ?kM@;k vlw
'kdrkr-
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9. • lgkoh voLFkk (Stage 6) :
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10. • lkroh voLFkk (Stage 7) :
& dk;e LojQih lqt vlrs
& jQX.k vkiys dke dj.;kl v{ke vlrks-
& nSufnu dke dj.;kdjhrk nql`;kaoj
voyacwu jgkos ykxrs-
gRrhik;kP;k voLFkk

11. The GPELF MMDP framework
courtesy of Indonesia and GSK
Situation
analysis
Plan Minimum package
of MMDP care
Situation
analysis
Dossier
development
VALIDATION
MMDP and
rehabilitation
integrated into health
services
Patient
estimation
Facility
inspection
2
years

12. Lymphoedema management ‒
Objectives
 The objectives of lymphoedema management are
not to completely cure lymphoedema but rather
to:
improve lymphatic flow and skin integrity
reduce the frequency and severity of acute
attacks
prevent lymphoedema progression
improve patient function
enhance patient quality of life

13. 5 measures for managing
lymphoedema
1.
Hygiene
2. Skin and wound
care
3.
Exercises
4. Elevation 5. Wearing suitable shoes
Illustrations courtesy of the USAID-funded MMDP
Project led by Helen Keller International

14. 1. hygiene

15. Recommended materials for
hygiene
 Clean water at room temperature
 Bucket
 Soap (unscented)
 Towels or gauze
 Cup
 Basin
 Chair or stool
 Comfortable shoes

16. Additional materials – Sometimes
needed
Antiseptics to help wash the leg
to remove bacteria from the skin
Antifungal creams to prevent
and treat fungal infections
Antibacterial creams
to treat entry lesions

17. Hygiene
 The affected area should be washed at least once
daily with soap and clean water at room temperature
and dried carefully with a clean towel or gauze.
 Diligent washing may reduce acute attacks and
prevent progression of lymphoedema

18. Hygiene
 Prepare the necessary materials: clean water, soap,
cup, basin, bucket, chair or stool, towel or gauze,
shoes (placed in close reach)

19. Hygiene
 Inspect the skin: the surface of the affected limb,
especially between the toes, between any skin folds,
and the bottom of the foot and in between fingers in
upper limb assessing for entry lesions (e.g. cuts,
scrapes, or inter-digital lesions) and needed nail care

20. Hygiene
 Wash the leg:
Wash hands before
beginning
Wet the leg with clean
water at room
temperature
Lather the soap either in
the hands or on a clean
cloth
Start washing at the knee
and progress towards the
foot

21. Hygiene
 Wash the leg (cont’d):
Gently clean between the toes and all skin folds,
using a clean cloth or gauze if needed
Gently clean any knobs or mossy lesions to prevent
skin breakage
Repeat the careful washing until the rinse water is no
longer dirty
Washing using an antiseptic fluid (e.g. potassium
permanganate) is also possible to clean and treat
entry lesions

22. Hygiene
 Dry the leg:
Use a clean towel to
pat the skin dry
Dry carefully between
the toes and any skin
folds using a cloth or
gauze if needed
Mossy lesions or
knobs or nodules may
require air-drying with
a fan

23. Hygiene
 Repeat with the other leg:
Follow the same
procedures with the other
leg
Wash both limbs even if
only one has lymphoedema
Wash the more affected
limb first

24. Hygiene
 Care for the skin:
Look carefully between the toes and
any skin folds for fungal infections
and entry lesions
Treat entry lesions with antibacterial
or antifungal cream/solution
Treat cuts, scrapes or wounds on the
skin with antibacterial cream/solution
Rub a small amount of antibacterial,
antifungal or combination cream
gently into the lesion until the cream
disappears

25. Hygiene
 Take care for the
nails after washing
 Put on comfortable
shoes

26. Hygiene of other affected areas
 The same principles should be applied to other
areas affected by lymphoedema (arm, breast,
scrotal skin, penis, etc.)

27. Hygiene – Don’ts!
 DO NOT use
hot water
 DO NOT wash
with a brush or
abrasive
material as it
can damage the
skin
 DO NOT rub
harshly when
drying to avoid
damage to the
skin

28. Hygiene – Tips
 Air-drying with a fan (hand-held
or electric) may help to dry the
affected skin, especially mossy
lesions
 Family, friends or community
health workers can assist
patients who need
help

29. 2. Skin AND Wound care

30. Skin and wound care – Do’s
 Protect skin from injury
 Use washing as an opportunity to identify and address
entry lesions
 Treat entry lesions promptly using antibiotic or
antifungal creams
 Seek care at a primary health care unit if an entry
lesion has drainage, a foul odour, redness or swelling,
or if a fever develops

31. Skin and wound care – Do’s
Skin should be protected from injury
(by wearing clothing and shoes)

32. Skin and wound care – Don’ts!
 DO NOT pop, open
or cut blisters or
damage the skin
 DO NOT perform harmful
traditional practices (cut the skin,
rub herbs or other unclean
substance into the skin, etc.)

33. Skin and wound care – Don’ts!
 DO NOT use too much
medicated cream as this
causes waste and attracts
dirt; rub cream into the skin
 DO NOT
completely
remove the nail

34. Skin and wound care – Tips
 Recognizing fungal infections
Commonly occur in interdigital
spaces and in deep skin folds
Skin:
•can change colour (usually white
or pink)
•can become either broken,
cracked, dry and scaly or moist,
soft and tender
•can often itch
Treat with an antifungal agent (e.g.
Whitfield’s ointment, clotrimazole,
Flucanazole) until infection resolves

35. Skin and wound care – Tips
 Recognizing fungal infections
Photos: Courtesy of Caitlin

36. Skin and wound care – Tips
 Recognizing bacteria-infected
lesions or wounds
Can occur anywhere on the skin,
but interdigital spaces or areas with
knobs or mossy lesions may be at
higher risk
Can experience increased pain,
redness, pus, wetness and odour
May occur with or without fever
Treat with an antibacterial agent
(e.g. antibiotic ointment, neomycin,
bacitracin) until lesion heals

37. Skin and wound care – Tips
 Recognizing bacteria-infected lesions or wounds
Photos: Courtesy of Caitlin

38. 3. Exercises

39. Exercises – Do’s
 Patients should perform low-intensity movement
around the joints affected by lymphoedema
 Perform exercises several times a day (e.g. at home,
while working, taking public transportation)

40. Recommended leg exercises
 “Up on the toes”
Stand with feet slightly apart,
while holding the wall or a chair
Rise up onto the toes with both
feet, then sink back down to the
floor
Repeat this 5‒15 times or as
much as is comfortable

41. Recommended leg exercises
 “Toe point”
While sitting or lying
down, point the toes
towards the floor
Then flex the ankle
upward
Repeat this 5‒15 times
or as much a is
comfortable

42. Recommended leg exercises
 “Circle exercise”
While sitting or lying
down, point the big toe
then rotate the foot in a
circular motion to the right
(clockwise) and to the left
(counter clockwise)
Repeat this 5‒15 times or
as much as is comfortable
Repeat sequence with the
other leg

43. Stand up! Time to practise leg
exercises!
1.Up on the
toes
2.Toe point
3.Circle
exercise

44. Recommended arm exercises
 “Wrist flex”
Place the arm straight
Move the wrist joints
upwards and downwards
Repeat this 5‒15 times or as
much as is comfortable

45. Recommended arm exercises
 “Elbow flex”
Place arm straight
Flex the elbow joint and
extend the elbow joint
Repeat this 5‒15 times or as
much as is comfortable

46. Recommended arm exercises
 “Circle exercise”
Place arm straight
Rotate the wrist clockwise
and counterclockwise
Repeat this 5‒15 times or as
much as is comfortable

47. Exercises – Don’ts!
 DO NOT exercise during an acute attack

48. Sit up! Time to practise arm
exercises!
1.Wrist flex 2. Elbow flex
3.Circle
exercise

49. 4. Elevation

50. Elevation – Do’s
 The affected limb should be raised at night and
when possible during the day.

51. Elevation – Do’s
 During the day
Can be performed during
regular activities (e.g.
work, leisure, breast-
feeding)

52. Elevation – Do’s
 During the day
While sitting, raise leg
ideally to the height of
the hip or as high as is
comfortable

53. Elevation – Do’s
 During the day
Place the leg onto a
stool, using a pillow to
support the leg from the
knee to the foot

54. Elevation – Do’s
 During the night
Elevate the legs slightly higher than the level of
the heart. This can be accomplished by placing a
support (e.g. pillow or bricks) under the mattress
or foot of the bed to raise the foot of the bed
evenly.
Raise the entire leg, not just the foot.

55. Elevation – Don’ts!
 Patients with heart problems should not elevate
their legs, unless advised by a doctor.

56. Elevation – Don’ts!
 DO NOT elevate legs on any surface with sharp
edges or which can pinch or pressure the leg

57. Elevation – Don’ts!
 DO NOT elevate the leg to a painful position.
Change to a comfortable position.

58. Elevation – Don’ts!
 Patients should not place a pillow directly under
only the feet while sleeping as the feet may fall off
the pillow.

59. 5. Wear comfortable shoes

60. Comfortable shoes – Do’s
 Wear comfortable shoes that
protect the foot from injury and
dirt
 Wear shoes adapted to the
volume and shape of the foot
 Choose shoes that allow air to
circulate around the foot

61. Comfortable shoes – Don’ts!
 DO NOT wear shoes that are:
 too tight
 rub or pinch the foot
 cause blisters

62. Comfortable shoes – Tips
 Local shoemakers or cobblers may be engaged to
make adapted shoes for patients
Photos: Courtesy of Charles

63. Adjunct measures for managing
lymphoedema
 Adjunct measures to manage lymphoedema are
not included in the WHO minimum package of care
 These measures should only be applied by skilled
staff and may not be appropriate for all settings:
compressive bandaging or garments
lymphatic massage
decongestive therapy

64. Referral criteria
 Patients with lymphoedema should be referred to a
primary health care unit when:
there is a concern for non-filarial lymphoedema*
the acute attack is accompanied by confusion, vomiting or high
fever
the patient has an acute attack and is pregnant
the patient has an acute attack that does not improve after 48
hours of administering antibiotics
the patient has an entry lesion with drainage and a foul odour
as well as redness or swelling, or if a fever develops
the patient has advanced lymphoedema with repeated acute
attacks despite institution of hygiene measures
the patient is in need of psychological services
*The clinical evaluation of non-filarial lymphoedema should follow national health
policy guidelines.

65. Impact of
lymphoedema
management
• Clinical and psychosocial:
–Reduced incidence of acute attacks
–Decreased prevalence and severity of entry lesions
–Prevented progression and possible regression of
lymphoedema
–Reduction in perceived disability
• Economic
–In one setting, per-person savings are 130 times that of
the per-person costs of the lymphoedema management
programme
• Other

66. Summary
• Managing lymphoedema is one of the four
components of the WHO minimum package of
care
• Basic measures to manage lymphoedema
include:
–hygiene
–skin and wound care
–elevation
–exercises
–wearing comfortable shoes
• Consistent application of lymphoedema
management strategies can reduce the
incidence of acute attacks and may prevent the
progression of lymphoedema

67. Programmatic Goal:- 100%
geographical coverage with the
essential package of care
Health facilities in every district (
Medical Colleges, District Hosp,
Municipal Corporation Hosp, Block
Hosp & PHCs) with known patients
must be able to provide:
• Treatment of acute attacks
• Management of lymphoedema
• Management of hydrocele
• Antifilarial medicines
Courtesy: Indonesia and GSK
MMDP
Slide 67
Way to
achieve it
Establish
MMDP Clinics
Kerala Model

68. Tracking to be done from NCVBDC
Stat
e
Number of
MMDP
clinics at
all levels
Total No. of
patients
enrolled in
MMDP Clinics
Number of
MMDP kits
distributed in
this month
Number of
hydrocele
surgeries done in
this month

69. Thank you!
Courtesy of Zanzibar
and GSK