Lymphedema Management in a Filaria Endemic Area

Lymphedema is prevalent worldwide, more so in India. There is lack of understanding about the disease [1]. Complete decongestive therapy (CDT) using skin care, exercises, and compression therapy through specialized bandages and stockings is the standard of care [1] but not used much in endemic areas. Physicians often only prescribe diethylcarbamazine [2] while the MMDP program under India’s Program for Elimination of Lymphatic Filariasis (PELF) prescribes only leg washing [3]. Outcomes are modest. In June 2015, a farmers’ co-operative in Sitapur, Uttar Pradesh, a filaria endemic area, approached our specialized center for help for their filaria patients. Patients were too poor to travel to cities for treatment. The prevalence of lymphatic filariasis in this region was 4.95%[4]. We organized camps [5], where we measured limb volumes using the stacked cylinders method, and initiated CDT focusing on leg cleaning, antibiotics (benzathine penicillin 1.2 megaunits three weekly), multi-layer lymphedema bandaging (MLLB)[6], and calf exercises. We provided self-care training so that cleaning and bandaging could continue at home. Training was repeated by trained volunteers as per need. Twenty-three patients with lower limb lymphedema had long-term follow-up data (mean 543ádays, range 432–641ádays) and showed a mean limb volume reduction of 927áml (from 4622áml before treatment to 3695áml)(independent samples t= 7.51, p< 0.00001). These results were compared with those achieved at our Delhi clinic. Twelve patients with lower limb lymphedema followed up for a similar duration (mean 468ádays) had a mean limb volume fall of 774áml. Patients who had been operated were excluded from this comparative analysis. Sitapur patients fared marginally but not significantly better as compared to patients treated at our Delhi clinic (Tableá 1). Filarial lymphedema patient volume is large. To effectively manage such numbers, we believe that CDT needs to be taken to the community. Travel to a city clinic entails loss of earning for patient and attendant, and, in any case, most care processes can be taught to the patient for self-help. The actual cost of the materials for CDT is low. Patients and local healthcare workers can be trained to ensure sustained high pressure in the initial treatment phase, progressing to elastic stockings only for maintenance. We encourage our patients to make videos so that they can confidently reapply the complicated multi-layer compression bandages. The industry providing compression devices is now creating smart textiles that are easy to use, empowering patients to manage their disease safely from the comfort of their own homes. Telemedicine-based support would be ideal and is being tried [7]. Oral penicillin can also be used [2], instead of intramuscular if allergic reactions are a concern. We conclude that care for lymphedema by CDT at the community level is feasible and gives results comparable to those obtained when patients are treated at an urban center. For achieving the goal of morbidity management, a critical component of the global plan to eliminate filariasis, healthcare workers need to expand their community-level interventions to include CDT.