A double-blind, placebo-controlled study of the efficacy of oral penicillin, diethylcarbamazine or local treatment of the affected limb in preventing acute adenolymphangitis in lymphoedema caused by brugian filariasis

Three decades of research in lymphatic filariasis-lessons learned

Lymphatic filariasis (LF), one of the 21 Neglected Tropical Diseases (NTD) which is the second leading cause for disability globally. Wuchereria Bancrofti, Brugia malayi and Brugia timori are the parasites causing this infection. World Health Assembly in 1997 declared LF to be eliminated and the Global Program to eliminate LF (GPELF) was launched by WHO in 2000 with the two strategies viz, 1) stop transmission of infection through Mass Drug Administration (MDA) and 2) to alleviate the suffering of the people affected with the disease through Morbidity Management and Disability Prevention (MMDP. The 'Filariasis research unit' recommended by WHO TDR and ICMR was established in Alappuzha, Kerala in 1989 for research studies related to LF. Over the last three decades 23 studies have been completed, which included different trials to find out the dose, effectiveness and safety of the various drugs used in preventive chemotherapy as single drug or combinations, for treatment of microfilaraemia,, various studies related to morbidity management in filarial disease, socio-economic aspects of filarial disability, Pharmacokinetic study of antifilarial drugs, Study on lymphatic filariasis in children, Studies on dignostics of LF, efficacy of drugs in management of lymphedema etc. In this article an attempt is made to explain the lessons learned from these studies and its importance in development of policy decision making for GPELF.

A Landscape on Lymphatic Filariasis with its Effects and Recent Advanced Treatments

Lymphatic filariasis is an infection caused by parasites that poses a significant health, social, and economic burden, affecting a vast population that exceeds 120 million individuals globally. The Etiology of the infection is attributed to three nematode parasites, namely Wuchereria bancrofti, B. timori, and Brugia malayi, as well as which are phylogenetically related. These parasites are transmitted to humans via mosquitoes belonging to the Anopheles, Aedes genera, and Culex. As per the estimation provided by the WHO, the current number of individuals infected with filariasis stands at approximately 120 million across 81 countries. Furthermore, it is estimated that around 1.34 billion individuals reside in regions that are endemic to filariasis, thereby putting them at risk of contracting the disease. Different synthetic drugs such as Ivermectin, Doxycycline, Albendazole, and Suramin are used in the treatment. Some natural plants are Azadirachta indica, Tinospora cordifolia, Zingiber officinal, as well as, some marine sources are also included for better treatment. We also touch briefly on a few additional filarial diseases. Although there are only a few medications available to treat filariasis, their frequent usage may result in drug resistance. Furthermore, there is no effective vaccination for the treatment of filariasis. Due to these restrictions, it has been crucial to create new anti-filarial medications, which motivates researchers to find novel pharmaceuticals with anti-filarial action. In this article, we examine the latest achievements in the anti-filarial area, including the many forms of filariasis and their historical contexts, elimination programmes, various therapeutic classes (both synthetic and natural), investigated product-derived targets as well as clinical investigations.

Self-care treatment for lymphoedema of lymphatic filariasis using integrative medicine

BACKGROUND

Lymphatic filariasis (LF) is a neglected tropical disease presenting mainly as lymphoedema (elephantiasis). At present, LF is not effectively treated. Integrative medicine (IM) treatment for lymphoedema uses a combination of Indian traditional medicine, Ayurveda, alongside yoga exercises, compression therapy, antibiotics and antifungal treatments, providing a useful combination where resources are limited and different practices are in use.

OBJECTIVES

To assess the effectiveness of the IM in the existing clinical practice of lower-limb lymphoedema management and to determine whether the treatment outcomes align with the World Health Organization (WHO) global goal of LF management.

METHODS

Institutional data from electronic medical records of all 1698 patients with LF between 2010 and 2019 were retrospectively analysed using pre- and post-treatment comparisons and the National Institute for Health and Care Excellence guidelines for clinical audit. The primary treatment outcomes evaluated were limb volume, bacterial entry points (BEEPs), episodes of cellulitis, and health-related quality of life (HRQoL). Secondary outcomes included the influence of the patient's sex, duration of illness, education and employment status on volume reduction. Multiple regression analysis, t-test, χ2-test, analysis of variance, Mann-Whitney U-test and the Kruskal-Wallis test were used to assess the association between IM and patients' treatment outcomes.

RESULTS

Limb volume reduced by 24.5% [95% confidence interval (CI) 22.47-26.61; n = 1660] following an intensive supervised care period (mean 14.84 days, n = 1660). Limb volume further reduced by 1.42% (95% CI 0.76-2.07; n = 1259) at the first follow-up visit (mean 81.45 days), and by 2.3% between the first and second follow-up visits (mean 231.32 days) (95% CI 1.26-3.34; n = 796). BEEPs were reduced upon follow-up; excoriations (78.4%) and intertrigo (26.7%) were reduced at discharge and further improvements was achieved at the follow-up visits. In total, 4% of patients exhibited new BEEPs at the first follow-up [eczema (3.9%), folliculitis (6.5%), excoriations (11.9%) and intertrigo (15.4%); 4 of 7 BEEPs were recorded]. HRQoL, measured using the disease-specific Lymphatic Filariasis Specific Quality of Life Questionnaire, showed an average score of 73.9 on admission, which increased by 17.8 at the first follow-up and 18.6 at the second follow-up. No patients developed new cellulitis episodes at the first follow-up, and only five patients (5.3%) developed new episodes of cellulitis at the second follow-up.

CONCLUSIONS

IM for lower-limb lymphoedema successfully reduces limb volume and episodes of cellulitis, and also reduces BEEPs, leading to improved HRQoL. IM aligns with the LF treatment goals of the WHO and is a low-cost, predominantly self-care management protocol. IM has the potential to change care models and improve the lives of patients with lymphoedema.

Stage-Dependent Increase of Systemic Immune Activation and CCR5+CD4+ T Cells in Filarial Driven Lymphedema in Ghana and Tanzania

Chronic lymphedema caused by infection of Wuchereria bancrofti is a disfiguring disease that leads to physical disability, stigmatization, and reduced quality of life. The edematous changes occur mainly on the lower extremities and can progress over time due to secondary bacterial infections. In this study, we characterized participants with filarial lymphedema from Ghana and Tanzania as having low (stage 1-2), intermediate (stage 3-4), or advanced (stage 5-7) lymphedema to determine CD4⁺ T cell activation patterns and markers associated with immune cell exhaustion. A flow cytometry-based analysis of peripheral whole blood revealed different T cell phenotypes within participants with different stages of filarial lymphedema. In detail, increased frequencies of CD4⁺HLA-DR⁺CD38⁺ T cells were associated with higher stages of filarial lymphedema in patients from Ghana and Tanzania. In addition, significantly increased frequencies of CCR5⁺CD4⁺ T cells were seen in Ghanaian participants with advanced LE stages, which was not observed in the Tanzanian cohort. The frequencies of CD8⁺PD-1⁺ T cells were augmented in individuals with higher stage lymphedema in both countries. These findings show distinct activation and exhaustion patterns in lymphedema patients but reveal that immunological findings differ between West and East African countries.

Health-related quality of life and associated factors among adult podoconiosis patients in Debre Elias district Northwest, Ethiopia

Background

Podoconiosis is endemic non-filarial elephantiasis and non-infective neglected tropical disease. It has a wide impact on the physical, social and psychological aspects of the well-being of a person. However, limited information is available about the disease burden on health-related quality of life and associated factors in Ethiopia.

Objective

This study aimed is to determine health-related quality of life and associated factors among adult podoconiosis patients in Debre Elias district, Northwest, Ethiopia.

Methods

A community-based cross-sectional study was conducted from February 1 to March 30, 2020 in the Debre Elias district. A multi-stage stratified; systematic random sampling technique was employed to select 403 podoconiosis patients. The data were collected through an interviewer-administered questionnaire. Data were entered into Epi data version 4.6 and exported to STATA version 14 for analysis. After the assumption check for the linear regression model, simple and multiple regression was done to see the association between the predictor and outcome variables. Predictor variables that had p-value <0.2 at simple linear regression were taken into multiple linear regression. β coefficient with 95% CI and p-value of <0.05 was considered as statistically significant variables in multiple linear regression analysis.

Result

The overall mean quality of life score among podoconiosis patients was 61.93±17.14. The mean quality of life score for the physical, psychological, social, and environmental domains were 75.57±21.86, 60.43±18.58, 30.34±10.46, and 81.38±22.77 respectively. Foot care had a statically significant association with all domains. Higher quality of life podoconiosis patients was associated with foot care. Lower quality of life was associated with the presence of anxiety, advanced stage of the disease, and frequent adenolymphangitis attack.

Conclusion

Social and psychological domains of quality of life were lowest as compared to physical and environmental domains of quality of life. Early medical treatment, psychosocial support, and home-based foot care should be encouraged to improve the quality of life in podoconiosis patients.

Podoconiosis: is a disease that affects the lymph vessels of the lower extremities and is caused by a person’s foot exposed to minerals found in red clay soil. Podoconiosis has been identified in 32 countries and globally 4 million people are affected with this disease. The disease is characterized by prominent swelling) of the lower extremities, it can be prevented through keeping good foot hygiene, wearing clean socks and shoes daily and covering floor in the home to avoid contact with irritant soil. Patients with podoconiosis significantly challenged by physical disability, poor mental health and social discrimination. This study identified quality of life and associated factors among adult podoconiosis patients in Debre Elias district Northwest, Ethiopia. Specifically, we addressed quality of life score for physical, psychological, social and environmental domain. We found from this study foot care had statically significant association with all domains. Lower quality of life was associated with presence of anxiety, advanced stage of the disease and frequent adenolymphangitis attack. Social and psychological domains of quality of life were lowest as compared to physical and environmental domains of quality of life. Therefore, this study encouraged early medical treatment, home-based foot care and psychosocial support to improve quality of life in podoconiosis patient.

Distinct Immune Profiles of Exhausted Effector and Memory CD8+ T Cells in Individuals With Filarial Lymphedema

CD8⁺ T cells are crucial for the clearance of viral infections, and current research begins to highlight their importance in parasitic diseases too. In-depth research about characteristics of CD8⁺ T-cell subsets and exhaustion remains uncertain, especially during filariasis, a chronic helminth infection. Lymphatic filariasis, elicited by Wuchereria bancrofti, remains a serious health problem in endemic areas in Ghana, especially in those suffering from morbidity due to lymphedema (LE). In this observational study, the characteristics and profiles of CD8⁺ T cells were compared between asymptomatic Wuchereria bancrofti-infected individuals, uninfected endemic normals, and those with LE (grades 2–6). Focusing on exhausted memory (CD8⁺ex_mem: CD8⁺ T-bet^dimEomes^hi) and effector (CD8⁺ex_eff: CD8⁺T-bet^hiEomes^dim) CD8⁺ T-cell subsets, advanced flow cytometry revealed that LE individuals presented reduced frequencies of IFN-γ⁺CD8⁺ex_mem T cells expressing Tim-3 or LAG-3 which negatively correlated to the presence of LE. Moreover, the LE cohort further showed significantly higher frequencies of IL-10⁺CD8⁺ex_eff T cells expressing either Tim-3, LAG-3, CD39, KLRG-1, or PD-1, all associated markers of exhaustion, and that these frequencies positively correlated with the presence of LE. In summary, this study shows that distinct exhausted CD8⁺ T-cell subsets are prominent in individuals suffering from LE, suggesting that enhanced inflammation and constant immune activation might drive exhaustion of CD8⁺ T cells. Since T-cell exhaustion is known to be associated with insufficient control of persisting antigen, the data presented here reveals that these CD8⁺ T-cell exhaustion patterns in filarial LE should be taken into consideration for prevention and control management of LE.

Foot care practice and associated factors among patients with lymphoedema in Boreda district, Gamo zone, southern Ethiopia, 2020. Implications for elimination of podoconiosis and lymphatic filariasis

BACKGROUND

Lymphatic filariasis is ranked as the second leading cause of disability world-wide. The current global programme to eliminate lymphatic filariasis is based on the interruption of transmission and the alleviation of disability and suffering.

OBJECTIVE

to assess foot care practice and associated factors among lymphoedema patients in Boreda district, Gamo zone Southern Ethiopia.

METHODS

a community based cross sectional study was employed from December 2020 to June 2021 in Boreda district. Simple random sampling technique was used for selecting participants. Pretested structured interviewer administered questionnaire was prepared in English and translated to local language.

FINDINGS

a total of 280 lymphedema patients were involved in this study. More than half 153 (54.6%) had poor practice towards foot care practice with 95% CI (48.7, 60.4%). Patients who fetched 50 l of water or below and wore shoes at the age above 20 years were negatively associated with foot care practice, (AOR = 0.383, 95%CI: 0.155, 0.945) and (AOR = 0.261, 95%CI: 0.107, 0.63), respectively. Patients who owned only one pair and two pairs were negatively associated with foot care practice (AOR = 0.04, 95%CI: 0.009, 0.182) and (AOR = 0.27, 95%CI: 0.087, 0.85), respectively. On the other hand, attending LMMDP service and frequency of adenolymphangitis once and twice or more per month were positively associated with foot care practice (AOR = 3.339, 95%CI: 1.53, 7.285) and (AOR = 8.15, 95% CI: 3.157, 21.058) and (AOR = 9.35, 95% CI: 3.118, 28.059), respectively.

CONCLUSION

this study indicated foot care practice among lymphedema patients in Boreda district was poor. Number of litre of water collected per day, age at which footwear first worn, number of shoes owned, attending LMMDP and frequency of adenolymphangitis were significantly associated with foot care practice. Standard foot care practice should be emphasized to control progression of lymphedema. Foot care practices like skin care, exercise and elevation, washing legs, bandaging and massaging are important factors that influence in reduction of lymphedema volume and acute attacks among people who are suffering from the diseases.

Economic Costs and Benefits of Community-Based Lymphedema-Management Programs for Lymphatic Filariasis in India

Lymphatic filariasis (LF) is endemic in 72 countries; 15 million persons live with chronic filarial lymphedema. It can be a disabling condition, frequently painful, leading to reduced mobility, social exclusion, and depression. The Global Program to Eliminate Lymphatic Filariasis aims to stop new infections and care for affected persons, but morbidity management has been initiated in only 38 countries. We examine economic costs and benefits of alleviating chronic lymphedema and its effects through simple limb care. We use economic and epidemiological data from 12 Indian states in which 99% of Indians with filariasis reside. Using census data, we calculate the age distribution of filarial lymphedema and predict the burden of morbidity of infected persons. We estimate lifetime medical costs and lost earnings due to lymphedema and acute dermatolymphangioadenitis (ADLA) with and without community-based limb-care programs. Programs of community-based limb care in all Indian endemic areas would reduce costs of disability by 52%, saving a per person average of US$2,721, equivalent to 703 workdays. Per-person savings are 185 times the program's per-person cost. Chronic lymphedema and ADLA impose a substantial physical and economic burden in filariasis-endemic areas. Low-cost programs for lymphedema management based on limb washing and topical medication are effective in reducing the number of ADLA episodes and stopping progression of disabling lymphedema. With reduced disability, people can work longer hours per day, more days per year, and in more strenuous, higher paying jobs, resulting in important economic benefits to themselves, their families, and their communities.

Effect of an Enhanced Self-Care Protocol on Lymphedema Status among People Affected by Moderate to Severe Lower-Limb Lymphedema in Bangladesh, a Cluster Randomized Controlled Trial

Background: Lymphatic filariasis (LF) is a major cause of lymphedema, affecting over 16 million people globally. A daily, hygiene-centered self-care protocol is recommended and effective in reducing acute attacks caused by secondary infections. It may also reverse lymphedema status in early stages, but less so as lymphedema advances. Lymphatic stimulating activities such as self-massage and deep-breathing have proven beneficial for cancer-related lymphedema, but have not been tested in LF-settings. Therefore, an enhanced self-care protocol was trialed among people affected by moderate to severe LF-related lymphedema in northern Bangladesh. Methods: Cluster randomization was used to allocate participants to either standard- or enhanced-self-care groups. Lymphedema status was determined by lymphedema stage, mid-calf circumference, and mid-calf tissue compressibility. Results: There were 71 patients in each group and at 24 weeks, both groups had experienced significant improvement in lymphedema status and reduction in acute attacks. There was a significant and clinically relevant between-group difference in mid-calf tissue compressibility with the biggest change observed on legs affected by severe lymphedema in the enhanced self-care group (∆ 21.5%, −0.68 (−0.91, −0.45), p < 0.001). Conclusion: This study offers the first evidence for including lymphatic stimulating activities in recommended self-care for people affected by moderate and severe LF-related lymphedema.

With Bare Feet in the Soil: Podoconiosis, a Neglected Cause of Tropical Lymphoedema

Podoconiosis is a form of lymphoedema that occurs in tropical highland areas in genetically susceptible individuals who are exposed to irritant volcanic soils. The disease is preventable through consistent use of footwear and attention to foot hygiene; however, in endemic areas there is a strong barefoot tradition, and many cannot afford shoes. Patients with podoconiosis face significant physical disability, psychological comorbidity, reduced quality of life and experience frequent episodes of systemic illness due to acute dermatolymphangioadenitis. This review provides an overview of this important and neglected tropical skin disease and summarizes the latest research findings.

Integrated morbidity mapping of lymphatic filariasis and podoconiosis cases in 20 co-endemic districts of Ethiopia

Background

Lymphatic filariasis (LF) and podoconiosis are neglected tropical diseases (NTDs) that pose a significant physical, social and economic burden to endemic communities. Patients affected by the clinical conditions of LF (lymphoedema and hydrocoele) and podoconiosis (lymphoedema) need access to morbidity management and disability prevention (MMDP) services. Clear estimates of the number and location of these patients are essential to the efficient and equitable implementation of MMDP services for both diseases.

Methodology/Principle findings

A community-based cross-sectional study was conducted in Ethiopia using the Health Extension Worker (HEW) network to identify all cases of lymphoedema and hydrocoele in 20 woredas (districts) co-endemic for LF and podoconiosis. A total of 612 trained HEWs and 40 supervisors from 20 districts identified 26,123 cases of clinical morbidity. Of these, 24,908 (95.3%) reported cases had leg lymphoedema only, 751 (2.9%) had hydrocoele, 387 (1.5%) had both leg lymphoedema and hydrocoele, and 77 (0.3%) cases had breast lymphoedema. Of those reporting leg lymphoedema, 89.3% reported bilateral lymphoedema. Older age groups were more likely to have a severe stage of disease, have bilateral lymphoedema and to have experienced an acute attack in the last six months.

Conclusions/Significance

This study represents the first community-wide, integrated clinical case mapping of both LF and podoconiosis in Ethiopia. It highlights the high number of cases, particularly of leg lymphoedema that could be attributed to either of these diseases. This key clinical information will assist and guide the allocation of resources to where they are needed most.

Patients affected by the clinical conditions of lymphatic filariasis (lymphoedema and hydrocoele) and podoconiosis (lymphoedema) require access to a minimum package of care to prevent progression of the disease, and to improve their quality of life. Clear estimates of the number and location of these patients is essential for the delivery of this care. To address this, a community-based cross-sectional study was conducted in Ethiopia using the Health Extension Worker (HEW) network to identify all cases of lymphoedema and hydrocoele in 20 co-endemic woredas (districts). A total of 26,123 cases of clinical morbidity were identified. Of these, 24,908 (95.3%) had leg lymphoedema, of which 89.3% were bilateral. The results of this study will help assist the Neglected Tropical Disease (NTD) programme at the Federal Ministry of Health (FMOH) in Ethiopia to effectively and equitably plan the delivery of a basic package of care to those suffering from the clinical manifestations of both diseases.

Lymphatic pathology in asymptomatic and symptomatic children with Wuchereria bancrofti infection in children from Odisha, India and its reversal with DEC and albendazole treatment

Background

Once interruption of transmission of lymphatic filariasis is achieved, morbidity prevention and management becomes more important. A study in Brugia malayi filariasis from India has shown sub-clinical lymphatic pathology with potential reversibility. We studied a Wuchereria bancrofti infected population, the major contributor to LF globally.

Methods

Children aged 5–18 years from Odisha, India were screened for W. bancrofti infection and disease. 102 infected children, 50 with filarial disease and 52 without symptoms were investigated by lymphoscintigraphy and then randomized to receive a supervised single oral dose of DEC and albendazole which was repeated either annually or semi-annually. The lymphatic pathology was evaluated six monthly for two years.

Findings

Baseline lymphoscintigraphy showed abnormality in lower limb lymphatics in 80% of symptomatic (40/50) and 63·5% (33/52) of asymptomatic children. Progressive improvement in baseline pathology was seen in 70·8, 87·3, 98·6, and 98·6% of cases at 6, 12, 18, and 24 months follow up, while in 4·2, 22·5, 47·9 and 64·8%, pathology reverted to normal. This was independent of age (p = 0·27), symptomatic status (p = 0·57) and semi-annual/bi-annual dosing (p = 0·46). Six of eleven cases showed clinical reduction in lymphedema of legs.

Interpretation

A significant proportion of a young W. bancrofti infected population exhibited lymphatic pathology which was reversible with annual dosage of DEC and albendazole. This provides evidence for morbidity prevention & treatment of early lymphedema. It can also be used as a tool to improve community compliance during mass drug administration.

Trial registration

ClinicalTrials.gov No CTRI/2013/10/004121

Infection with lymphatic filarial parasites usually occurs early in childhood in endemic areas, but clinical signs appear much later. Reversal of lymphatic pathology has been shown with the much less common Brugia malayi infection using DEC and albendazole and there is scarce evidence whether the same occurs with bancroftian filariasis using the above drugs. We designed this study to look for prevalence of lymphatic pathology in children with and without clinical signs of infection and to observe the effect on the pre-treatment pathology using DEC and albendazole given once or twice a year. We have shown, using lymphoscintigraphy, that lymphatic vessel changes occur very early in infection, and treatment can reverse these changes, even when clinical symptoms are already apparent. This has important implications for lymphedema prevention, case management and for advocacy in the Lymphatic Filariasis Elimination Program. It also strengthens the previous evidence of benefit of treatment on early lymphedema management.

Interventions for the prevention of recurrent erysipelas and cellulitis

BACKGROUND

Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear.

OBJECTIVES

To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16.

SEARCH METHODS

We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews.

SELECTION CRITERIA

Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis.

DATA COLLECTION AND ANALYSIS

Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality.

MAIN RESULTS

We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study.Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow-up period of up to one and a half to two years. Four studies were single-centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria.Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate.Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate-certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate-certainty evidence).The protective effects of antibiotic did not last after prophylaxis had been stopped ('post-prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty.Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years.We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay.The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin).None of the included studies assessed the development of antimicrobial resistance or quality-of-life measures.With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding.

AUTHORS' CONCLUSIONS

In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate-certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low-certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low-certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high-quality studies are warranted, including long-term follow-up and other prophylactic measures.

Economic Costs and Benefits of a Community-Based Lymphedema Management Program for Lymphatic Filariasis in Odisha State, India

Lymphatic filariasis afflicts 68 million people in 73 countries, including 17 million persons living with chronic lymphedema. The Global Programme to Eliminate Lymphatic Filariasis aims to stop new infections and to provide care for persons already affected, but morbidity management programs have been initiated in only 24 endemic countries. We examine the economic costs and benefits of alleviating chronic lymphedema and its effects through a simple limb-care program. For Khurda District, Odisha State, India, we estimated lifetime medical costs and earnings losses due to chronic lymphedema and acute dermatolymphangioadenitis (ADLA) with and without a community-based limb-care program. The program would reduce economic costs of lymphedema and ADLA over 60 years by 55%. Savings of US$1,648 for each affected person in the workforce are equivalent to 1,258 days of labor. Per-person savings are more than 130 times the per-person cost of the program. Chronic lymphedema and ADLA impose a substantial physical and economic burden on the population in filariasis-endemic areas. Low-cost programs for lymphedema management based on limb washing and topical medication for infection are effective in reducing the number of ADLA episodes and stopping progression of disabling and disfiguring lymphedema. With reduced disability, people are able to work longer hours, more days per year, and in more strenuous, higher-paying jobs, resulting in an important economic benefit to themselves, their families, and their communities. Mitigating the severity of lymphedema and ADLA also reduces out-of-pocket medical expense.

Self-Care for Management of Secondary Lymphedema: A Systematic Review

BACKGROUND

Lymphedema is a debilitating and disfiguring sequela of an overwhelmed lymphatic system. The most common causes of secondary lymphedema are lymphatic filariasis (LF), a vector-borne, parasitic disease endemic in 73 tropical countries, and treatment for cancer in developed countries. Lymphedema is incurable and requires life-long care so identification of effective lymphedema management is imperative to improve quality of life, reduce the burden on family resources and benefit the local community. This review was conducted to evaluate the evidence for effective lymphedema self-care strategies that might be applicable to management of all types of secondary lymphedema.

METHODOLOGY/PRINCIPAL FINDINGS

Searches were conducted in Medline, CINAHL and Scopus databases in March 2015. Included studies reported before and after measures of lymphedema status or frequency of acute infections. The methodological quality was assessed using the appropriate Critical Appraisal Skills Program checklist. Descriptive synthesis and meta-analysis were used to evaluate effectiveness of the outcomes reported. Twenty-eight papers were included; two RCTs were found to have strong methodology, and overall 57% of studies were rated as methodologically weak. Evidence from filariasis-related lymphedema (FR-LE) studies indicated that hygiene-centred self-care reduced the frequency and duration of acute episodes by 54%, and in cancer-related lymphedema (CR-LE) home-based exercise including deep breathing delivered significant volume reductions over standard self-care alone. Intensity of training in self-care practices and frequency of monitoring improved outcomes. Cultural and economic factors and access to health care services influenced the type of intervention delivered and how outcomes were measured.

CONCLUSIONS/SIGNIFICANCE

There is evidence to support the adoption of remedial exercises in the management of FR-LE and for a greater emphasis on self-treatment practices for people with CR-LE. Empowerment of people with lymphedema to care for themselves with access to supportive professional assistance has the capacity to optimise self-management practices and improve outcomes from limited health resources.

The Effect of Hygiene-Based Lymphedema Management in Lymphatic Filariasis-Endemic Areas: A Systematic Review and Meta-analysis

Background

Lymphedema of the leg and its advanced form, known as elephantiasis, are significant causes of disability and morbidity in areas endemic for lymphatic filariasis (LF), with an estimated 14 million persons affected worldwide. The twin goals of the World Health Organization’s Global Program to Eliminate Lymphatic Filariasis include interrupting transmission of the parasitic worms that cause LF and providing care to persons who suffer from its clinical manifestations, including lymphedema—so-called morbidity management and disability prevention (MMDP). Scaling up of MMDP has been slow, in part because of a lack of consensus about the effectiveness of recommended hygiene-based interventions for clinical lymphedema.

Methods and Findings

We conducted a systemic review and meta-analyses to estimate the effectiveness of hygiene-based interventions on LF-related lymphedema. We systematically searched PubMed, Embase, ISI Web of Knowledge, MedCarib, Lilacs, REPIDISCA, DESASTRES, and African Index Medicus databases through March 23, 2015 with no restriction on year of publication. Studies were eligible for inclusion if they (1) were conducted in an area endemic for LF, (2) involved hygiene-based interventions to manage lymphedema, and (3) assessed lymphedema-related morbidity. For clinical outcomes for which three or more studies assessed comparable interventions for lymphedema, we conducted random-effects meta-analyses. Twenty-two studies met the inclusion criteria and two meta-analyses were possible. To evaluate study quality, we developed a set of criteria derived from the GRADE methodology. Publication bias was assessed using funnel plots. Participation in hygiene-based lymphedema management was associated with a lower incidence of acute dermatolymphagioadenitis (ADLA), (Odds Ratio 0.32, 95% CI 0.25–0.40), as well as with a decreased percentage of patients reporting at least one episode of ADLA during follow-up (OR 0.29, 95% CI 0.12–0.47). Limitations included high heterogeneity across studies and variation in components of lymphedema management.

Conclusions

Available evidence strongly supports the effectiveness of hygiene-based lymphedema management in LF-endemic areas. Despite the aforementioned limitations, these findings highlight the potential to significantly reduce LF-associated morbidity and disability as well as the need to develop standardized approaches to MMDP in LF-endemic areas.

The tropical disease lymphatic filariasis (LF) causes chronic swelling of the leg—lymphedema—in 14 million people worldwide. To stop the spread of LF, a program led by the World Health Organization (WHO) offers annual preventive drug treatment to affected communities. For people who already have lymphedema, WHO recommends simple hygiene-based measures that include skin care and limb movement. Yet only a small proportion of those with LF-related lymphedema have been trained in these measures. To determine the effectiveness of hygiene-based lymphedema management, we reviewed the scientific literature. Twenty-two studies were found that 1) used hygiene-based interventions to manage lymphedema; 2) measured the effect of these interventions; and 3) were done in an area where LF occurs. Overall, use of hygiene-based measures was associated with 60% lower odds of inflammatory episodes, known as “acute attacks,” in the affected limb. Acute attacks cause severe pain, fever, and disability, and they make lymphedema worse. Hygiene and sanitation are necessary for control of many tropical diseases. Hygiene is also effective for managing LF-related lymphedema and reducing suffering caused by acute attacks. Training people with lymphedema in hygiene-based interventions should be a priority for LF programs everywhere.

Impact of a community-based lymphedema management program on episodes of Adenolymphangitis (ADLA) and lymphedema progression--Odisha State, India

BACKGROUND

Lymphedema management programs have been shown to decrease episodes of adenolymphangitis (ADLA), but the impact on lymphedema progression and of program compliance have not been thoroughly explored. Our objectives were to determine the rate of ADLA episodes and lymphedema progression over time for patients enrolled in a community-based lymphedema management program. We explored the association between program compliance and ADLA episodes as well as lymphedema progression.

METHODOLOGY/PRINCIPAL FINDINGS

A lymphedema management program was implemented in Odisha State, India from 2007-2010 by the non-governmental organization, Church's Auxiliary for Social Action, in consultation with the Centers for Disease Control and Prevention. A cohort of patients was followed over 24 months. The crude 30-day rate of ADLA episodes decreased from 0.35 episodes per person-month at baseline to 0.23 at 24 months. Over the study period, the percentage of patients who progressed to more severe lymphedema decreased (P-value  = 0.0004), while those whose lymphedema regressed increased over time (P-value<0.0001). Overall compliance to lymphedema management, lagged one time point, appeared to have little to no association with the frequency of ADLA episodes among those without entry lesions (RR = 0.87 (0.69, 1.10)) and was associated with an increased rate (RR = 1.44 (1.11, 1.86)) among those with entry lesions. Lagging compliance two time points, it was associated with a decrease in the rate of ADLA episodes among those with entry lesions (RR = 0.77 (95% CI: 0.59, 0.99)) and was somewhat associated among those without entry lesions (RR = 0.83 (95% CI: 0.64, 1.06)). Compliance to soap was associated with a decreased rate of ADLA episodes among those without inter-digital entry lesions.

CONCLUSIONS/SIGNIFICANCE

These results indicate that a community-based lymphedema management program is beneficial for lymphedema patients for both ADLA episodes and lymphedema. It is one of the first studies to demonstrate an association between program compliance and rate of ADLA episodes.

A longitudinal analysis of the effect of mass drug administration on acute inflammatory episodes and disease progression in lymphedema patients in Leogane, Haiti

We conducted a longitudinal analysis of 117 lymphedema patients in a filariasis-endemic area of Haiti during 1995-2008. No difference in lymphedema progression between those who received or did not receive mass drug administration (MDA) was found on measures of foot (P = 0.24), ankle (P = 0.87), or leg (P = 0.46) circumference; leg volume displacement (P = 0.09), lymphedema stage (P = 0.93), or frequency of adenolymphangitis (ADL) episodes (P = 0.57). Rates of ADL per year were greater after initiation of MDA among both groups (P < 0.01). Nevertheless, patients who received MDA reported improvement in four areas of lymphedema-related quality of life (P ≤ 0.01). Decreases in foot and ankle circumference and ADL episodes were observed during the 1995-1998 lymphedema management study (P ≤ 0.01). This study represents the first longitudinal, quantitative, leg-specific analysis examining the clinical effect of diethylcarbamazine on lymphedema progression and ADL episodes.

Doxycycline improves filarial lymphedema independent of active filarial infection: a randomized controlled trial

BACKGROUND

The aim of this study was to determine whether improvement of filarial lymphedema (LE) by doxycycline is restricted to patients with ongoing infection (positive for circulating filarial antigen [CFA]), or whether the majority of CFA-negative patients with LE would also show a reduction in LE severity.

METHODS

One hundred sixty-two Ghanaian participants with LE stage 1-5 (Dreyer) were randomized blockwise into 2 groups (CFA positive or negative) and allocated to 3 treatment arms of 6 weeks: (1) amoxicillin (1000 mg/d), (2) doxycycline (200 mg/d), or (3) placebo matching doxycycline. All groups received standard hygiene morbidity management. The primary outcome was reduction of LE stages. Secondary outcomes included frequency of acute attacks and ultrasonographic assessment of skin thickness at the ankles. Parameters were assessed before treatment and after 3, 12, and 24 months.

RESULTS

Doxycycline-treated patients with LE stage 2-3 showed significant reductions in LE severity after 12 and 24 months, regardless of CFA status. Improvement was observed in 43.9% of doxycycline-treated patients, compared with only 3.2% and 5.6% in the amoxicillin and placebo arms, respectively. Skin thickness was correlated with LE stage improvement. Both doxycycline and amoxicillin were able to reduce acute dermatolymphangioadenitis attacks.

CONCLUSIONS

Doxycycline treatment improves mild to moderate LE independent of ongoing infection. This finding expands the benefits of doxycycline to the entire population of patients suffering from LE. Patients with LE stage 1-3 should benefit from a 6-week course of doxycycline every other year or yearly, which should be considered as an improved tool to manage morbidity in filarial LE. Clinical Trials Registration. ISRCTN 90861344.

Physical, psychological, and social aspects of quality of life in filarial lymphedema patients in Colombo, Sri Lanka

Quality of life (QOL) was assessed in 141 filarial lymphedema patients and 128 healthy people in the Colombo district, Sri Lanka, by administering modified, translated, and validated (in Sri Lanka) versions of the Short Form 36 health survey questionnaire (SF-36) and the 30-item General Health questionnaire (GHQ-30). The GHQ-30 assesses the current mental health status. The SF-36 measures health on 8 multi-item dimensions covering functional state, well-being, and overall evaluation of health (physical functioning, role limitations resulting from physical health problems, role limitations resulting from emotional problems, energy/fatigue, emotional well-being, social functioning, pain and general health). By SF-36, patients experienced poorer physical functioning, more role limitations resulting from physical health conditions, less emotional well-being, poorer social functioning, and more pain than healthy individuals. By GHQ-30, mental well-being of healthy controls was significantly better than that of patients. The significant difference in the QOL as perceived by filarial lymphedema patients and healthy individuals reiterates the importance of morbidity control in patients affected by this disease.

Lymphatic filariasis in children: clinical features, infection burdens and future prospects for elimination

Lymphatic filariasis (LF), a common parasitic infection in tropical countries, causes lymphoedema of limbs, hydrocele and acute attacks of dermato-lymphangio-adenitis. Recent advances in diagnosis have helped to recognize that LF infection is often acquired in childhood. Newly available diagnostic techniques like sensitive antigen and antibody assays, Doppler ultrasonography and lymphoscintigraphy have helped to understand the subclinical pathology caused by this infection, which was hitherto generally believed to be irreversible. Recent studies indicate that drugs used in the mass drug administration (MDA) programme under GPELF are capable of reversing the sub-clinical lymphatic damage in children and provide benefits other than interruption of transmission. Albendazole and ivermectin used in MDA are effective against soil-transmitted helminthic infections common in children in LF endemic areas. Thus MDA had other 'beyond LF' benefits in treated children including increased appetite, weight gain, greater learning ability and concentration, better school attendance and prevention of anaemia. MDA should no longer be viewed as a measure for interrupting transmission alone. Recent findings of reversibility of early lymphatic pathology in treated children indicate that both MDA and 'foot-hygiene' measures are effective strategies in preventing and managing morbidity. Programme managers should effectively utilize this information to strengthen their advocacy efforts to achieve high and sustainable coverage in MDA.

Reduction in acute filariasis morbidity during a mass drug administration trial to eliminate lymphatic filariasis in Papua New Guinea

BACKGROUND

Acute painful swelling of the extremities and scrotum are debilitating clinical manifestations of Wuchereria bancrofti infection. The ongoing global program to eliminate filariasis using mass drug administration is expected to decrease this and other forms of filarial morbidity in the future by preventing establishment of new infections as a consequence of eliminating transmission by the mosquito vector. We examined whether mass treatment with anti-filarial drugs has a more immediate health benefit by monitoring acute filariasis morbidity in Papua New Guinean communities that participated in a 5-year mass drug administration trial.

METHODOLOGY/PRINCIPAL FINDINGS

Weekly active surveillance for acute filariasis morbidity defined by painful swelling of the extremities, scrotum and breast was performed 1 year before and each year after 4 annual mass administrations of anti-filarial drugs (16,480 person-years of observation). Acute morbidity events lasted <3 weeks in 92% of affected individuals and primarily involved the leg (74-79% of all annual events). The incidence for all communities considered together decreased from 0.39 per person-year in the pre-treatment year to 0.31, 0.15, 0.19 and 0.20 after each of 4 annual treatments (p<0.0001). Residents of communities with high pre-treatment transmission intensities (224-742 infective bites/person/year) experienced a greater reduction in acute morbidity (0.62 episodes per person-year pre-treatment vs. 0.30 in the 4(th) post-treatment year) than residents of communities with moderate pre-treatment transmission intensities (24-167 infective bites/person/year; 0.28 episodes per person-year pre-treatment vs. 0.16 in the 4(th) post-treatment year).

CONCLUSIONS

Mass administration of anti-filarial drugs results in immediate health benefit by decreasing the incidence of acute attacks of leg and arm swelling in people with pre-existing infection. Reduction in acute filariasis morbidity parallels decreased transmission intensity, suggesting that continuing exposure to infective mosquitoes is involved in the pathogenesis of acute filariasis morbidity.

Feasibility and effectiveness of basic lymphedema management in Leogane, Haiti, an area endemic for bancroftian filariasis

Background

Approximately 14 million persons living in areas endemic for lymphatic filariasis have lymphedema of the leg. Clinical studies indicate that repeated episodes of bacterial acute dermatolymphangioadenitis (ADLA) lead to progression of lymphedema and that basic lymphedema management, which emphasizes hygiene, skin care, exercise, and leg elevation, can reduce ADLA frequency. However, few studies have prospectively evaluated the effectiveness of basic lymphedema management or assessed the role of compressive bandaging for lymphedema in resource-poor settings.

Methodology/Principal Findings

Between 1995 and 1998, we prospectively monitored ADLA incidence and leg volume in 175 persons with lymphedema of the leg who enrolled in a lymphedema clinic in Leogane, Haiti, an area endemic for Wuchereria bancrofti. During the first phase of the study, when a major focus of the program was to reduce leg volume using compression bandages, ADLA incidence was 1.56 episodes per person-year. After March 1997, when hygiene and skin care were systematically emphasized and bandaging discouraged, ADLA incidence decreased to 0.48 episodes per person-year (P<0.0001). ADLA incidence was significantly associated with leg volume, stage of lymphedema, illiteracy, and use of compression bandages. Leg volume decreased in 78% of patients; over the entire study period, this reduction was statistically significant only for legs with stage 2 lymphedema (P = 0.01).

Conclusions/Significance

Basic lymphedema management, which emphasized hygiene and self-care, was associated with a 69% reduction in ADLA incidence. Use of compression bandages in this setting was associated with an increased risk of ADLA. Basic lymphedema management is feasible and effective in resource-limited areas that are endemic for lymphatic filariasis.

Lymphatic filariasis is a parasitic disease that is spread by mosquitoes. In tropical countries where lymphatic filariasis occurs, approximately 14 million people suffer from chronic swelling of the leg, known as lymphedema. Repeated episodes of bacterial skin infection (acute attacks) cause lymphedema to progress to its disfiguring form, elephantiasis. To help achieve the goal of eliminating lymphatic filariasis globally, the World Health Organization recommends basic lymphedema management, which emphasizes hygiene, skin care, exercise, and leg elevation. Its effectiveness in reducing acute attack frequency, as well as the role of compressive bandaging, have not been adequately evaluated in filariasis-endemic areas. Between 1995 and 1998, we studied 175 people with lymphedema of the leg in Leogane, Haiti. During Phase I of the study, when compression bandaging was used to reduce leg volume, the average acute attack rate was 1.56 episodes per year; it was greater in people who were illiterate and those who used compression bandages. After March 1997, when hygiene and skin care were emphasized and bandaging discouraged, acute attack frequency significantly decreased to 0.48 episodes per year. This study highlights the effectiveness of hygiene and skin care, as well as limitations of compressive bandaging, in managing lymphedema in filariasis-endemic areas.

Filariasis: diagnosis and treatment

Filariasis is an infectious disease of the lymphatics and subcutaneous tissues caused by nematodes or filariae. Carried by mosquito vectors, this disease causes millions of people to suffer from lymphedema and elephantiasis, characteristics of filariasis infection. This disease can be diagnosed through the identification of microfilariae in blood or skin samples, antigen detection, radiographic imaging, or polymerase chain reaction. Mass drug administration by the World Health Organization has helped to diminish the incidence of filariasis. However, continued research on new drugs and vaccinations will be needed to control and reduce the microfilarial levels in the human population.

WITHDRAWN: Antibiotics / anti-inflammatories for reducing acute inflammatory episodes in lymphoedema of the limbs

BACKGROUND

Lymphoedema is a chronic, progressive condition and one area of debate is the optimum management for infective/inflammatory episodes (AIE's).

OBJECTIVES

To determine whether antibiotic/anti-inflammatory drugs given prophylactically reduce the number and severity of AIE's in patients with lymphoedema.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group register in September 2003, the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), CINAHL, MEDLINE, PASCAL, SIGLE, UnCover, reference lists produced by The British Lymphology Society, the National Research Register (NRR) and the International Society of Lymphology congress proceedings.

SELECTION CRITERIA

Randomised controlled trials testing an antibiotic or anti-inflammatory drug against placebo (with or without physical therapies) were included.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion was confirmed by two blinded reviewers. The papers were screened independently using a checklist of criteria relating to quality. Both reviewers extracted data from the eligible studies using a data extraction form.

MAIN RESULTS

Four studies (364 randomised patients) were included. Two studied the effects of intensive physical treatment plus selenium or placebo in preventing AIE's, and two studied the effects of Ivermectin, Diethylcarbamazine (DEC) (anti-filarial agents) and penicillin as prophylactic treatment for adeno lymphangitis(ADL) versus placebo.Both selenium trials reported no inflammatory episodes during the trial period in the treated group but one case of infection in the two placebo groups respectively. Seven additional cases of infection in trial one and 14 cases in trial two required treatment in the three month follow up period.One anti-filarial trial reported 127 ADL episodes for all groups during the treatment year (compared with 684 episodes during the pre-treatment year). There were 228 ADL episodes during the trial follow-up year but no findings were significant. No link was found between the grade of oedema and the frequency of ADL episodes. There was a significant link between increased episodes and the rainy season. Penicillin reduced the mean number of inflammatory episodes from 4.6 to 0.5 after treatment, which increased to 1.9 at the end of follow-up.

AUTHORS' CONCLUSIONS

The effectiveness of selenium in preventing AIE in lymphoedema remains inconclusive in the absence of properly conducted randomised-controlled trials. Anti-filarials do not appear to reduce ADL episodes in filarial lymphoedema. Penicillin appears to contribute to a significant reduction in ADL when combined with foot-care. The importance of foot-care should be recommended, which may also apply to care of the arm following breast cancer treatment. Properly conducted trials are needed to demonstrate any efficacy of these interventions.

Treatment-seeking behavior and treatment practices of lymphatic filariasis patients with lymphoedema in the Colombo district, Sri Lanka

This cross-sectional, descriptive study describes the treatment-seeking behavior of 413 lymphoedema patients attending 2 filariasis clinics in the Colombo district, Sri Lanka. A pretested, interviewer-administered questionnaire obtained information regarding sources and types of treatment taken, time taken for diagnosis, and details regarding diethylcarbamazine citrate (DEC) treatment. There was a mean delay of 2.37 years (SD 1.37) in diagnosing filariasis after the first appearance of limb swelling. General practitioners were the most frequent first-contact health care providers and the most visited source overall, followed by government hospitals and Ayurvedic practitioners. Approximately 95% of patients were on DEC treatment ranging from 10 days to 43 years (mean 2.5 years SD +/- 1.1). Sixty-one percent of patients reported always having taken the recommended DEC course. Nonsteroidal anti-inflammatory drugs, diuretics, and antibiotics were liberally prescribed. Approximately 97% had sought treatment from a medical practitioner for an acute adenolymphangitis attack. Despite the area being endemic for filariasis, there was a delay in treatment and inappropriate use of DEC in patients with chronic filarial lymphoedema.

Clinical and pathological aspects of filarial lymphedema and its management

Lymphatic filariasis, transmitted by mosquitoes is the commonest cause of lymphedema in endemic countries. Among 120 million infected people in 83 countries, up to 16 million have lymphedema. Microfilariae ingested by mosquitoes grow into infective larvae. These larvae entering humans after infected mosquito bites grow in the lymphatics to adult worms that cause damage to lymphatics resulting in dilatation of lymph vessels. This earliest pathology is demonstrated in adults as well as in children, by ultrasonography, lymphoscintigraphy and histopathology studies. Once established, this damage was thought to be irreversible. This lymphatic damage predisposes to bacterial infection that causes recurrent acute attacks of dermato-lymphangio-adenitis in the affected limbs. Bacteria, mainly streptococci gain entry into the lymphatics through 'entry lesions' in skin, like interdigital fungal infections, injuries, eczema or similar causes that disrupt integrity of skin. Attacks of dermato-lymphangio-adenitis aggravates lymphatic damage causing lymphedema, which gets worse with repeated acute attacks. Elephantiasis is a late manifestation of lymphatic filariasis, which apart from limbs may involve genitalia or breasts. Lymphedema management includes use of antifilarial drugs in early stages, treatment and prevention of acute attacks through 'limb-hygiene', antibiotics and antifungals where indicated, and physical measures to reduce the swelling. In selected cases surgery is helpful.

Doxycycline reduces plasma VEGF-C/sVEGFR-3 and improves pathology in lymphatic filariasis

Lymphatic filariasis is a disease of considerable socioeconomic burden in the tropics. Presently used antifilarial drugs are able to strongly reduce transmission and will thus ultimately lower the burden of morbidity associated with the infection, however, a chemotherapeutic principle that directly induces a halt or improvement in the progression of the morbidity in already infected individuals would constitute a major lead. In search of such a more-effective drug to complement the existing ones, in an area endemic for bancroftian filariasis in Ghana, 33 microfilaremic and 18 lymphedema patients took part in a double-blind, placebo-controlled trial of a 6-wk regimen of 200 mg/day doxycycline. Four months after doxycycline treatment, all patients received 150-200 microg/kg ivermectin and 400 mg albendazole. Patients were monitored for Wolbachia and microfilaria loads, antigenemia, filarial dance sign (FDS), dilation of supratesticular lymphatic vessels, and plasma levels of lymphangiogenic factors (vascular endothelial growth factor-C [VEGF-C] and soluble vascular endothelial growth factor receptor-3 [(s)VEGFR-3]). Lymphedema patients were additionally monitored for stage (grade) of lymphedema and the circumferences of affected legs. Wolbachia load, microfilaremia, antigenemia, and frequency of FDS were significantly reduced in microfilaremic patients up to 24 mo in the doxycycline group compared to the placebo group. The mean dilation of supratesticular lymphatic vessels in doxycycline-treated patients was reduced significantly at 24 mo, whereas there was no improvement in the placebo group. Preceding clinical improvement, at 12 mo, the mean plasma levels of VEGF-C and sVEGFR-3 decreased significantly in the doxycycline-treated patients to a level close to that of endemic normal values, whereas there was no significant reduction in the placebo patients. The extent of disease in lymphedema patients significantly improved following doxycycline, with the mean stage of lymphedema in the doxycycline-treated patients being significantly lower compared to placebo patients 12 mo after treatment. The reduction in the stages manifested as better skin texture, a reduction of deep folds, and fewer deep skin folds. In conclusion, a 6-wk regimen of antifilarial treatment with doxycycline against W. bancrofti showed a strong macrofilaricidal activity and reduction in plasma levels of VEGF-C/sVEGFR-3, the latter being associated with amelioration of supratesticular dilated lymphatic vessels and with an improvement of pathology in lymphatic filariasis patients.

Interdigital lesions and frequency of acute dermatolymphangioadenitis in lymphoedema in a filariasis-endemic area

BACKGROUND

Lymphatic filariasis (LF) is a mosquito-borne nematode infection that causes permanent lymphatic dysfunction in virtually all infected individuals and clinical disease in a subset of these. One major sequel of infection is lymphoedema of the limbs. Lymphoedema of the leg affects an estimated 15 million persons in LF-endemic areas worldwide. Acute dermatolymphangioadenitis (ADLA) in people with filarial lymphoedema causes acute morbidity and increasingly severe lymphoedema. Episodes of ADLA are believed to be caused by bacteria, and it has been shown that entry lesions in the skin play a causative role. Clinical observations suggest that interdigital skin lesions of the feet, often assumed to be fungal, may be of particular importance.

OBJECTIVES

To investigate the epidemiology and aetiology of interdigital lesions (IDL) of the feet in filarial lymphoedema.

METHODS

The frequency and mycological aetiology of IDL in 73 patients with filarial lymphoedema were compared with 74 individuals without lymphoedema in a region of Guyana highly endemic for Wuchereria bancrofti.

RESULTS

More than 50% of patients with lymphoedema had one or more IDL (odds ratio 2.69; 95% confidence interval 1.31-5.66; P<0.005 compared with controls). The number of lesions was the strongest predictor of frequency of ADLA. Only 18% of the lesions had positive microscopy or culture for fungi (dermatophytes and Scytalidium).

CONCLUSIONS

These findings highlight the importance of interdigital entry lesions as risk factors for episodes of ADLA and have implications for the control of morbidity from filarial lymphoedema.

Treatment costs and work time loss due to episodic adenolymphangitis in lymphatic filariasis patients in rural communities of Orissa, India

OBJECTIVE

To determine the economic loss in terms of treatment costs and loss of productive time because of acute episodes of adenolymphangitis (ADL) caused by lymphatic filariasis (LF) in a rural population of coastal Orissa, India.

METHODS

Data on expenditure on treatment and loss of work along with other epidemiological information were collected through a 1-year surveillance of 113 acute episodes of ADL from 72 individuals of the study population (5.42%). The activity patterns of patients for 24 h of one episode were documented, and data on age- and sex-matched controls were also collected. Standardized Z-test, paired t-test, logistic and multiple regressions were used.

RESULTS

Those patients who did incur expenses spent Indian Rupees 92 on average (approximately US$ 1.85) on each episode. The ADL episodes curtailed the productive activity of patients. Patients (88%) were unable to attend to any economic activity compared with 47% of controls who had no history of disease. Similarly during 55% of episodes, females (vs. 8% of controls) could not attend to any domestic work. The mean number of hours spent on economic or domestic activities was significantly lower among patients. Disease status and sex had significant influence on total absenteeism from gainful employment; and similarly, age, family type and disease status influenced total domestic work hours among women.

CONCLUSIONS

The results demonstrate the extent of the economic burden caused by acute LF and provide justification for strengthening the ongoing LF elimination programme.

Antibiotics / anti-inflammatories for reducing acute inflammatory episodes in lymphoedema of the limbs

BACKGROUND

Lymphoedema is a chronic and progressive condition and current debate revolves around the best course of management for infective/inflammatory episodes.

OBJECTIVES

To determine whether antibiotic/anti-inflammatory drugs given prophylactically reduce the number and severity of infective/inflammatory episodes in patients with lymphoedema.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group register in September 2003, the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), CINAHL, MEDLINE, PASCAL, SIGLE, UnCover, reference lists produced by The British Lymphology Society, the National Research Register (NRR) and the International Society of Lymphology congress proceedings.

SELECTION CRITERIA

Types of studies considered for review were randomised controlled trials testing an antibiotic or anti-inflammatory drug against placebo (with or without physical therapies).

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion was confirmed by two blinded reviewers who screened the papers independently using a checklist of criteria relating to the randomisation and blinding of a trial. Both reviewers extracted data from the eligible studies using a data extraction form.

MAIN RESULTS

Overall, four studies (364 randomised patients) were included. Two of these studied the effects of intensive physical treatment plus selenium or placebo in preventing AIE, and two studied the effects of Ivermectin, Diethylcarbamazine (DEC) (anti-filarial agents) and penicillin as prophylactic treatment for adeno lymphangitis(ADL) versus placebo. Both selenium trials reported no inflammatory episodes during the trial period in the treated group but one case of infection in the two placebo groups respectively during the first three weeks of each trial. Seven additional cases of infection in trial one and 14 cases in trial two required treatment in the three month follow up period. One anti filarial trial reported a total of 127 ADL episodes for all groups during the treatment year (compared with 684 episodes reported for the same participants during the pre-treatment year). Another 228 ADL episodes were reported during the trial follow-up year but no significant differences were found between the three groups. No apparent link was found between the grade of oedema and the frequency of ADL episodes. However, there was a significant link between increased episodes and the rainy season. In the penicillin group the mean number of inflammatory episodes was reduced from 4.6 to 0.5 after treatment and increased to 1.9 at the end of the follow-up year.

REVIEWERS' CONCLUSIONS

The effectiveness of selenium in preventing AIE in lymphoedema remains inconclusive in the absence of properly conducted randomised controlled trials. Anti-filarials (DEC and Ivermectin) do not appear to reduce ADL episodes in filarial lymphoedema. Foot care may be important in reducing ADL episodes, and penicillin appears to contribute to a significant reduction in ADL, when combined with foot-care. It seems reasonable to emphasise the importance of foot-care to patients and practitioners in preventing infection and this may also apply to care of the arm in women who develop lymphoedema following breast cancer treatment. However, properly conducted trials are needed to demonstrate any efficacy of these interventions.

Lymphatic filariasis: new insights into an old disease

Lymphatic filariasis has afflicted people in the tropical areas of the world for thousands of years but even up to comparatively recent times it has been poorly understood and its importance under recognised. In the last 2 decades or so there has been a flurry of activity in filariasis research, which has provided new insights into the global problem of filariasis, the pathogenesis of filarial disease, diagnosis and control.

[Recommendations for the treatment of bancroftian filariasis in symptomless and diseased patients]

The goals of treatment for lymphatic filariasis are: to prevent, reverse, or halt progression of disease; and to interrupt transmission of the parasite. Selecting the appropriate therapy for the patient with lymphatic filariasis requires knowledge of the various clinical features of filarial disease and their pathogenesis. In the past, treatment of lymphatic filariasis has focused primarily on antiparasitic chemotherapy; however, for many of the acute and chronic manifestations of lymphatic filariasis, it is now clear that supportive or other forms of clinical care are even more important than antiparasitic medication in order to prevent worsening of the disease. Regardless of the clinical manifestations of filarial disease in a particular patient, the following three components of treatment should, in general, be considered: supportive or disease specific clinical care (including hygiene and diet), patient education and counseling and finally, antiparasitic chemotherapy with diethylcarbamazine (DEC) and/or the combination of DEC with ivermectin. The authors also describe the proportional efficacy of diethylcarbamazine and ivermectin, alone or in combination, for use in mass treatment aiming at transmission interruption and the use of hygiene as a public health approach for lymphedema prevention.