First Visit to Myanmar September 2013

1. First Visit to Myanmar September 2013 Jan Douglass

2. Meetings with Dr Min and Dr Ni Ni • Dr Ni Ni arranged for a meeting with the Director general of the Ministry of health, Department of International Research • Dr Min was very supportive of the project and gave me some great advice about applying for ethical approval.

3. Pakukko MDA Distribution Centre • I was privileged to travel with a WHO team who were observing the Mass Drug Administration MDA for LF • Dr Khin (WHO) blue patterned suit. • Dr Myo (WHO) nearest to right gate post. • Dr Zaw far right The women in the yellow uniforms are volunteers of the Myanmar Maternal and Child Health Welfare Association MMCWA. In some Townships Red Cross will also assist.

4. Before going to observe the drug distribution we see some patients who are brought to the center for me to asses.I had some tubes of Paw Paw ointment with me and gave them to the ones that had skin changes. Px 3: ♂18 yrs Advanced LO L only however skin changes on both legs, arms and ears. ADLA weekly. Some entry lesion both legs. Some intertrigo L. Px 2: ♀ 16 yrs Bilateral stage 3 L>R. +ve stemmer sign R but not L. Early dermatosclerosis L distal shin/lateral leg Stemmer signs are a fold of skin at the base of the toes – an indication of tissue changes associated with lymphoedema. ADLA is an ‘acute attack’ – fever, redness, selling, pain. Very debilitating and may last several days. Intertrigo are lesions between the toes.

5. DrZaw and DrKhin were very interested in the physical assessments, especially evaluation of stemmer sign and palpation of popliteal lymph nodes.They did a lot of the explaining of the advice given – all Px were given the standard WHO, hygiene, exercise elevation and skin care recommendations. Px 5: ♂ Unilateral LO stage 3, shallow fold at ankle. No apparent entry lesions but some heel dryness which could develop fissures. Px 4: ♂ Very minimal changes R calf area only. Avid football player.

6. Initially there were 4 patients ready for assessment but others turned up. Eventually assessed 8. It was barely still light when we started and there was a desk lamp placed near the assessment area but it was all very tricky with the patients in chairs (I can’t squat for long! When they saw my discomfort they produced a small stool).The last two to turn up were men without problems or symptoms but had been told the were +ve for micro filarae (MF – baby worms). The same basic care guidelines were given to them for prevention. I wondered if they had come because they had hydrocele but Dr Zaw asked them about this and neither said they had any swelling. Px 6: ♀ Unilateral stage 3 but few skin changes. A dinner of fried food was served on the table before we went out to observe the MDA.

7. Wow, I didn’t realize I was such a terrible photographer! The Medical Officer and other officials from the hospital accompany us This is the entrance to the first house, it is quite dark in the interior

8. The nurse records the drugs taken by each member of the household There seem to be a lot of extra observers

9. Second house. The boy with his back to us takes the drugs while every looks on. All generations are present in the household

10. Amarapura Township Two men are at the hospital for assessment but neither have symptoms nor physical changes by stemmer, palpation or indurometry. This girl came to the MDA distribution center. She has a history of swelling since age 11 (now 27) but is not mf positive. Other characteristics lead me to think she is primary LO. Self care advised

11. Observing the MDA The NGO volunteer and Senior Nurse. NGO Volunteer with the tablets

12. These kids were delightful, they couldn’t get enough of seeing themselves on the camera screen after the photo was taken. They were all gathered around me pointing at their own images and laughing. I had to be dragged away when it was time to move on. I had taken some little koalas as gifts and you can see one clipped onto the finger of the girl in orange.

13. Tader Oo Township Hospital Hospital entrance complete with dogs. There are no smoking signs every where and lots of no smoking messages on TV but this doesn’t seem to affect the man here who is just about to light up inside the hospital. The hospital is recognized as being ‘baby friendly’

14. Cartoons are frequently used to convey health messages. Possibly the MoH can help us to develop similar cartoons for our information sheets? The two posters on the left are for Avian flu, the far left advising to wash and thoroughly cook chicken meat, the one in the middle advising to wash the eggs.

15. Px 2: ♀No symptoms but worried because she is mf+ve. No variables on circumference or stemmer but L thigh indurometry was lower when sitting so we move to a area she can lie down (and where we can see – the other room was very dark after the power went out). Supine the R thigh recorded a lower reading.

16. Leaving for the MDA

17. NGO’s by motorbike (we, the nurses and MO will be going in the van)

18. In the distribution centre NGO badges; MWAF & MMCWA Senior Nurses Badge The logo is also on all the hospital gates

19. Therguang Village. DrZaw and I don’t observe the MDA here, instead we set up an assessment clinic in the front yard of the village leader. In this area there are mf+ve cases in every second house. All Px for assessment are +ve. • ♂ 17 no symptoms. • He tells us he knew a woman who had a ‘big leg’ but she died about 6 months ago. • ♀ 18 No symptoms. • Dr Zaw teaches the foot paddling movements

20. Right; The village leader, this is his front yard.Group shot from left; DrKhin, NGO volunteer, senior nurse, me, NGO volunteer, junior nurse, MO, DrMyo. • ♂ 30 He had one episode 10 years ago with fever, chills, rigor and ‘hot’ intestines as well as groin pain. • Skin on L foot harder than R? No stemmer

21. Series of photos showing the assessment components. This is the first time I have been doing it from a chair, usually I had a low stool which was much easier. Age, mf status and history of acute events or symptoms Circumference Circumference measures taken at the ankle, through the widest part of the calf and just below the crease of the knee • ♀32 No palpable lymph nodes, no stemmer sign, no entry lesions

22. Palpate popliteal lymph nodes Stemmer test and check between the toes and sides of feet for entry lesions The test gently pinches skin from the dorsum of the foot close to the base of the toes. If only skin comes up then the test is –ve. If the underlying tissue also comes up the test is +ve Slow flowing lymph can create enlarged lymph nodes. In established lymphoedema they also become fibrotic.

23. Indurometer DrZaw teaches the self care The women are reluctant to uncover their legs – there are always a number of men observing. This should also be done lying supine after measuring the midpoint of the thigh. DrZaw gets better at this as we go along and starts asking them to repeat back the instructions to make sure they have understood everything

24. The results of the assessment are conveyed to the patient and all the cases with no symptoms or measureable changes are reassured they have no problems. The self care routine is then taught by DrZawexplaining that this is a good way to make sure they don’t develop any problems in the future. DrZaw also takes the opportunity to reinforce that since they tested +ve for mf they must make sure they take the drugs every year.

25. Compliance Assessment by DrMyo Entrance to the street that will be assessed Its late afternoon and there is traffic in the street

26. We visit every house The leader of that block accompanies Dr Myo as he asks the residents if they took the drugs

27. There are a few new concrete houses And many traditional houses with woven walls

28. It is very traditional for women to wear their combs in their hair Most houses are two storey and have electricity

29. We move to another village Volleyball using heads and feet, no hands allowed

30. Some dwellings are very poor This is a very rural village. The road in was through rice paddies and in a very bad state of repair

31. Dr Myo interviews a farmer?

32. Seems like everyone pitches in to repair the road In the rural areas there are a lot of ox drawn wagons