Lymphoedema and its management in cases of lymphatic filariasis: the current situation in three suburbs of Matara, Sri Lanka, before the introduction of a morbidity-control programme

The impact of the National Programme to Eliminate Lymphatic Filariasis on filariasis morbidity in Sri Lanka: Comparison of current status with retrospective data following the elimination of lymphatic filariasis as a public health problem

INTRODUCTION

Sri Lanka implemented the National Programme for Elimination of Lymphatic Filariasis (NPELF) in its endemic regions in 2002. Five annual rounds of mass drug administration using the two-drug combination diethylcarbamazine (DEC) and albendazole led to sustained reductions in infection rates below threshold levels. In 2016, WHO validated that Sri Lanka eliminated lymphatic filariasis as a public health problem.

OBJECTIVE

To explore the impact of the NPELF on lymphatic filariasis morbidity in Sri Lanka.

METHODS

Passive Case Detection (PCD) data maintained in filaria clinic registries from 2006-2022 for lymphoedema and hospital admission data for managing hydroceles/spermatoceles from 2007-2022 were analyzed. The morbidity status in 2022 and trends in overall and district-wise PCD rates were assessed. Poisson log-linear models were used to assess the trends in PCD for endemic regions, including district-wise trends and hospital admissions for the management of hydroceles/spermatoceles.

RESULTS

In 2022, there were 566 new lymphoedema case visits. The mean (SD) age was 53.9 (16.0) years. The staging was done for 94% of cases, of which 79% were in the early stages (57.3% and 21.4% in stages two and one, respectively). Western Province had the highest caseload (52%), followed by the Southern (32%) and Northwestern (16%) Provinces, respectively. The reported lymphoedema PCD rate in 2022 was 0.61 per 10,000 endemic population. The overall PCD rate showed a decline of 7.6% (95%CI: 4.9% - 10.3%) per year (P < 0.0001) from 2007 to 2022. A steady decline was observed in Colombo, Gampaha and Kurunegala districts, while Kalutara remained static and other districts showed a decline in recent years. Further, admissions for inpatient management of hydroceles/spermatoceles showed a declining trend after 2015.

CONCLUSIONS

The PCD rates of lymphoedema and hydroceles/spermatoceles showed a declining trend in Sri Lanka after the implementation of the NPELF.

Mental health conditions in people affected by filarial lymphoedema in Malawi: prevalence, associated risk factors and the impact of an enhanced self-care intervention

BACKGROUND

This study aimed to determine the key mental health indicators affecting people affected by lymphatic filariasis (LF) lymphoedema by assessing the prevalence of depressive symptoms and quality of life (QOL), identifying associated sociodemographic and clinical risk factors, and evaluating the impact of an enhanced self-care intervention for lymphoedema management.

METHODS

A prospective cohort study of adults with filarial lymphoedema from two regions of Malawi was conducted over six months in 2021. Depressive symptoms and QOL were assessed using Patient Health Questionnaire (PHQ-9) and LF Specific QOL Questionnaire, respectively, at baseline (pre-intervention), 3- and 6-months (postintervention). Beta regression analysis identified risk factors, and assessed the impact of the intervention.

RESULTS

Three hundred eleven affected individuals were surveyed with 23% (95% CI 18%-29%) reporting mild/moderate depressive symptoms and 31% (95% CI 26%-37%) reporting moderately low/low QOL. Higher depressive symptom scores were associated with high frequency of acute filarial attack episodes. Individuals with higher depressive symptoms (Adjusted Odds Ratios (AOR) 0.93, 95% CI 0.93-0.93) and lower QOL (AOR 0.98, 0.98-0.98) showed greatest improvement in mental health indicators over 3-months but was not sustained to the same level at 6-months.

CONCLUSIONS

Sustained morbidity management and psychological support is recommended for affected persons to ensure long-term positive mental health and clinical outcomes.

CONTEXTE

Cette étude vise à déterminer les principaux indicateurs de santé mentale affectant les personnes atteintes de lymphœdème dû à la filariose lymphatique (FL) en évaluant la prévalence des symptômes dépressifs et la qualité de vie (QV), en identifiant les facteurs de risque sociodémographiques et cliniques associés, et en évaluant l'impact d'une intervention améliorée d'autosoins pour la gestion du lymphœdème.

MÉTHODES

Une étude de cohorte prospective d'adultes atteints de lymphoedème filaire dans deux régions du Malawi a été menée pendant six mois en 2021. Les symptômes dépressifs et la qualité de vie ont été évalués à l'aide du questionnaire sur la santé des patients (PHQ-9) et du questionnaire sur la qualité de vie spécifique au lymphœdème, respectivement, au début de l'étude (avant l'intervention), et à 3 puis 6 mois après l'intervention. Une analyse de régression beta a permis d'identifier les facteurs de risque et d'évaluer l'impact de l'intervention.

RÉSULTATS

Trois cent onze personnes affectées ont été interrogées, dont 23% (95% CI 18%-29%) ont déclaré des symptômes dépressifs légers/modérés et 31% (95% CI 26%-37%) ont déclaré une qualité de vie modérément faible/faible. Des scores élevés de symptômes dépressifs ont été associés à une fréquence élevée d'épisodes de crises filariennes aiguës. Les personnes présentant des symptômes dépressifs plus élevés (rapport de cotes ajusté (RCA) 0.93, IC à 95 % 0.93-0.93) et une qualité de vie plus faible (RCA 0.98, 0.98-0.98) ont montré la plus grande amélioration des indicateurs de santé mentale au cours des trois mois, mais cette amélioration ne s'est pas maintenue au même niveau au cours des six mois suivants.

CONCLUSION

Gestion de la morbidité et soutien psychologique sont des éléments clés pour garantir une santé mentale et des résultats cliniques satisfaisants de personnes atteintes sur le long terme.

ANTECEDENTES

Este estudio tuvo como objetivo determinar los indicadores clave de salud mental que afectan a las personas afectadas por linfedema por filariasis linfática (FL) mediante la evaluación de la prevalencia de síntomas depresivos y calidad de vida (CdV), la identificación de factores de riesgo sociodemográficos y clínicos asociados, y la evaluación del impacto de una intervención de autocuidado mejorada para el manejo del linfedema.

MÉTODOS

Se realizó un estudio prospectivo de cohortes de adultos con linfedema filarial de dos regiones de Malawi durante seis meses en 2021. Los síntomas depresivos y la calidad de vida se evaluaron mediante el Cuestionario de Salud del Paciente (PHQ-9) y el Cuestionario de Calidad de Vida específico para el LF Cuestionario, respectivamente, al inicio (preintervención) y a los 3 y 6 meses (posintervención). El análisis de regresión beta identificó los factores de riesgo y evaluó el impacto de la intervención.

RESULTADOS

Se encuestó a 311 afectados, de los cuales el 23% (IC 95%, 18%-29%) presentaba síntomas depresivos leves/moderados y el 31% (IC 95%, 26%-37%) una CdV moderadamente baja/baja CdV. Las puntuaciones más altas de síntomas depresivos se asociaron con una alta frecuencia de episodios de ataques agudos de filarias. Los individuos con mayores síntomas depresivos (Odds Ratios Ajustados [ORA] 0.93; IC 95%: 0.93-0.93) y menor CdV (ORA 0.98; 0.98-0.98) mostraron la mayor mejoría en los indicadores de salud mental a los 3 meses, pero no se mantuvo al mismo nivel a los 6 meses.

CONCLUSIONES

Se recomienda el manejo sostenido de la morbilidad y el apoyo psicológico a las personas afectadas para garantizar resultados clínicos y de salud mental positivos a largo plazo.

Health beliefs and health seeking behavior towards lymphatic filariasis morbidity management and disability prevention services in Luangwa District, Zambia: Community and provider perspectives

Background

Morbidity management and disability prevention (MMDP) services are essential for the management of chronic stages of lymphatic filariasis (LF) infection. However, there is limited information on health beliefs and health seeking behavior towards MMDP services for LF in endemic regions of Zambia. This study sought to document health beliefs and health seeking behavior towards MMDP services for LF in Luangwa District, Zambia.

Methods

This was an exploratory qualitative study conducted with community members including LF patients, community health workers and healthcare providers. Data was collected through a series of four focus group discussions stratified by sex and 26 in-depth interviews. Data was analyzed by thematic analysis using NVivo software.

Results

The perceived causes of the chronic manifestations of LF included; contact with animal faeces, use of traditional herbal aphrodisiacs (mutoto), witchcraft and sexual contact with women who were menstruating or had miscarried. LF patients opted to visit traditional healers before going to health facilities. Hydrocele patients were afraid of hydrocelectomies as they were thought to cause infertility or death. Very few community members were able to identify any home and facility-based care strategies for lymphoedema. Health system and cultural barriers to seeking healthcare included; long distances to the health facilities, lack of awareness of existing MMDP services, perceived costs of accessing MMDP services, gender and social norms, and fear of stigmatization.

Conclusion

Health seeking behavior for LF in the district is mainly driven by negative beliefs about the causes of the disease and lack of awareness of available MMDP services and homecare strategies. Lymphatic filariasis programs should promote strategies that seek to empower patients and community members with the required information to access and use the MMDP services at the health facilities, as well as adhere to self-care practices in their households.

Lymphatic filariasis (LF) infection if untreated results in fluid accumulation in the limbs or breasts (lymphedema) or genitalia (hydrocele) that is painful and causes great discomfort. Morbidity management and disability prevention (MMDP) strategies such as surgery for hydrocele, treatment of acute attacks and management of lymphedema are necessary for the management of the advanced stages of LF. However, very few countries including Zambia, have adequate information on the health beliefs and health seeking behavior of communities living in endemic areas towards MMDP services for LF. This study sought to explore community and health provider perspectives towards MMDP services for LF in a highly endemic region, Luangwa District, Zambia, between February and April 2019. Some of the perceived causes of lymphedema and hydrocele were; contact with animal faeces, use of traditional herbal aphrodisiacs (mutoto), witchcraft and sexual contact with women who were menstruating or had miscarried. There was limited knowledge of home-based and facility-based care strategies for lymphoedema. Nevertheless, patients would often go to health facilities after visiting traditional healers and observing no improvement. Barriers to accessing healthcare included; long distances to the health facilities, lack of awareness of existing MMDP services, perceived costs of accessing healthcare services, gender and social norms and fear of stigmatization.

Assessment of the impact of morbidity management and disability prevention for lymphatic filariasis on the disease burden in villupuram district of Tamil Nadu, India

Background:

The global program to eliminate lymphatic filariasis (GPELF) was started in 2003 with two strategies: the mass drug administration (MDA) to interrupt disease transmission and the morbidity management and disability prevention (MMDP) to provide the basic hygienic care to filariasis lymphedema patients. Among the two strategies, the MDA is well advanced and got the desired results, but the MMDP is lagging due to poor execution.

Objectives:

To assess the awareness of MMDP and ongoing morbidity management practices by lymphedema patients and to estimate the impacts of the MMDP on the prevalence and severity of lymphedema.

Materials and Methods:

This study was conducted among 100 lymphedema patients in 7 filariasis endemic villages of Villupuram district, Tamil Nadu, India through interviews using a structured, pretested questionnaire. The grading and adenolymphangitis (ADL) attack determination were done by a clinician. The impact was assessed in terms of changes in the lymphedema grades, frequency of ADL attacks, and changes in the burden.

Results:

Of the 100 patients, 70% were aware of the program and among them, only 48% were practising MMDP regularly (i.e. two times per day). The majority of them (80%) were taking treatment during ADL attacks. The overall lymphedema grades reversal and progression were observed in 13% and 52% of cases, respectively.

Conclusion:

This study has revealed that the second arm of the GPELF, “MMDP” has not yielded the desired results as evidenced by the incidence of frequent ADL attacks and advancement of lymphedema grades.

Clinical Benefits of Supervised Home Care of the Morbidity Management and Disability Prevention Under National Filariasis Elimination Programme

Introduction: Mass drug administration and morbidity management and disability prevention (MMDP) though considered as two pillars of global program for elimination of filariasis, implementation of MMDP was disregarded in several endemic countries. Limb hygiene is the main component of MMDP and to address its overall clinical benefits, a community-based study was undertaken in three sets of populations. Materials and Methods: After obtaining written informed consent, clinical, quality of life (QoL) assessments were carried out and lymphedema volume was measured for three groups of lymphedema patients at intake, at 6, and 12 months follow-up. Filarial lymphedema patients from three sets of villages categorized as "Previous VCRC MMDP," "State MMDP," and "Current VCRC MMDP" were considered for the study. Clinical examination and QoL assessment were carried out independently by a medical officer and a sociologist, respectively. Whoever available at the time of three field visits were registered and included in the study. In total, 67, 63, 66 and 75, 74 and 63 lymphedema (LE) patients completed clinical evaluation and QoL assessment from these groups, respectively. Results: Assessment of repeated measures of clinical parameters at baseline and two time points of follow-up by Friedman's test showed significant clinical improvements in skin color, texture, moisture, and ulcer (p > 0.05), in nails score and intertrigo score (p > 0.01). Assessed by Wilcoxon signed-rank test showed a significant reduction in the frequency Acute Dermato-Lymphangio-Adenitis episodes at 12 months follow-up in all the three MMDP groups (p < 0.001). However, the reduction of LE volume was significant (p = 0.009) only in the current Vector Control Research Centre (VCRC) MMDP group. There was no significant improvement in the QoL in all three groups. Conclusions: To achieve the desired clinical benefits by MMDP home care practices for the filarial lymphedema patients, regular monitoring by the auxiliary health workers is essential. National programs must consider monthly supervision through an integrated approach.

The Effect of Lymphoedema Exercises and Foot Elevation on the Quality of Life of Patients with Elephantiasis

Filariasis is a chronic infectious disease caused by filarial worms. Swelling in the legs in patients with filariasis can result in a significantly lower quality of life. The recommended treatments for patients who experience swelling or lymphoedema are lymphoedema exercises and foot elevation. This research is a quantitative study with a quasi-experimental design including pre- and posttreatment tests with a control group. This study used a cluster sampling method, which is a nonprobability sampling technique. The samples in this study were 48 respondents divided into two groups: 24 respondents from the Nebe Village comprising the intervention group and 24 respondents from the Bangkoor Village comprising the control group. The intervention group conducted lymphoedema exercises and foot elevation three times a week for 15–20 min for 1 month and measured their quality of life using the LFSQQ questionnaire. Measurements of pitting edema and ankle diameter were also carried out. Paired t-test revealed an improvement in the quality of life between pretest and posttest in the intervention and control groups (p=0.001). The quality of life in the pre-post intervention group improved from 67.42 to 81.58. In addition, the quality of life in the pre-post control group only improved from 62.50 to 72.58. The level of pitting edema decreased from severe (+++) to moderate (++) and from mild (+) to normal (0), and there was no difference in ankle diameter in each group (p=1.000). The quality of life improved before and after the administration of lymphoedema exercises and foot elevation for each group. Pitting edema decreased before and after lymphoedema exercises and foot elevation for each group. There was no decrease in ankle diameter after lymphoedema exercises and foot elevation in the intervention and control groups.

How lymphatic filariasis was eliminated from an urban poor setting in Santo Domingo, Dominican Republic

BACKGROUND

While progress has been made in the elimination of lymphatic filariasis, challenges that call for innovative approaches remain. Program challenges are increasingly observed in 'hard-to-reach' populations: urban dwellers, migrant populations, those living in insecurity, children who are out of school and areas where infrastructure is weak and education levels are low. 'Business-as-usual' approaches are unlikely to work. Tailored solutions are needed if elimination goals are to be reached. This article focuses on mass drug administrations (MDAs) in urban settings.

METHODS

We selected the urban poor area of Santo Domingo, Dominican Republic. With three rounds of MDA and with good coverage, elimination was achieved. We wanted to understand contributing factors to achieving good coverage. A qualitative study analyzed context, barriers and facilitators using a predefined framework based on review of the literature.

RESULTS

Results show that barriers commonly reported in urban settings were present (population density, lack of organization in household layout, population mobility, violence, shortage of human resources and challenges in monitoring treatment coverage). Tactics used included strong visibility in the community leading to high levels of awareness, the use of laminated photo sheets during house-to-house visits and a 1:4 supervision strategy. The importance of working through community leadership structures and building relationships with the community was evident.

DISCUSSION

The approach developed here has applications for large-scale treatment programs for lymphatic filariasis and other diseases in urban settings.

Morbidity management and disability prevention for lymphatic filariasis in Sri Lanka: Current status and future prospects

Background

Sri Lanka was acknowledged to have eliminated lymphatic filariasis (LF) as a public health problem in 2016, largely due to its success in Mass Drug Administration (MDA) to interrupt disease transmission. Analysis of the Strengths, Weaknesses, Opportunities and Threats (SWOT) of the national Morbidity Management and Disability Prevention (MMDP) program, the other pillar of the LF control program, was carried out with the objective of evaluating it and providing recommendations to optimize the use of available resources.

Methodology

A situation analysis of the MMDP activities provided by the state health sector was carried out using published records, in-depth interviews with key informants of the Anti Filariasis Campaign, site-visits to filariasis clinics with informal discussions with clinic workforce and personal communications to identify strengths and weaknesses; and opportunities to overcome weaknesses and perceived threats to the program were explored.

The principal strength of the MMDP program was the filariasis clinics operational in most endemic districts of Sri Lanka, providing free health care and health education to clinic attendees. The weaknesses identified were the low accessibility of clinics, incomplete coverage of the endemic region and lack of facilities for rehabilitation. The perceived threats were diversion of staff and resources for control of other vector-borne infections, under-utilization of clinics and non-compliance with recommended treatment. Enhanced high level commitment for MMDP, wider publicity and referral systems, integration of MMDP with other disease management services and collaboration with welfare organizations and research groups were identified as opportunities to overcome weaknesses and challenges.

Conclusions

The recommended basic package of MMDP was functional in most of the LF-endemic region. The highlighted weaknesses and challenges, unless addressed, may threaten program sustainability. The identified opportunities for improvement of the programme could ensure better attainment of the goal of the MMDP program, namely access to basic care for all affected by lymphatic filarial disease.

Lymphatic filariasis (LF) is a tropical disease causing swelling of limbs (lymphoedema, elephantiasis) and male genitalia (hydrocele). It is a disabling and deforming disease caused by parasitic worms transmitted by mosquitoes. The Sri Lankan Anti Filariasis Campaign was successful in reducing LF transmission to very low levels by annual mass drug administration, resulting in recent achievement of elimination status. The other pillar of LF elimination is the management of morbidity and disability prevention (MMDP) among those with lymphatic filarial disease. The strengths, weaknesses and threats of the MMDP program were evaluated and opportunities for improvement were explored in June 2017. The filariasis clinics established in the endemic area, providing care for patients with lymphoedema and elephantiasis, were identified as the main strength. Hospital surgical units were important in the treatment of hydrocele. The weaknesses were low accessibility of clinics, incomplete coverage of endemic districts, lack of facilities for rehabilitation and lack of morbidity targets. The threats were diversion of staff and resources, under-utilization of clinics, social stigma and loss of alliances. Enhanced commitment to improve coverage and access to clinics in the endemic areas, wider publicity, referral systems, integration of MMDP into other disease management services, collaborations with welfare organizations and research groups were the opportunities identified.

Worldwide assessment of healthcare personnel dealing with lymphoedema

BACKGROUND

Lymphoedema is a pandemic with about 250 million people suffering from this condition worldwide. Lymphatic diseases have considerable public health significance, but yet few professionals are specialised in their management causing a substantial burden on health resources.

AIMS AND OBJECTIVES

This study aims to give an overview of the approximate number of medical professionals, professional societies, institutions and companies dealing with lymphoedema in various countries. Concepts of improvement for current human resources are considered.

METHODS

An online database analysis (Google search engine and PubMed) was carried out for each country of the world. Additionally, relevant congress participant lists as well as member lists of significant medical societies and reports of the World Health Organisation were analysed.

RESULTS

Overall distribution of tertiary level professionals specialised in this field is heterogenous. A decrescent gradient of professionals can be seen between developed and developing countries and between urban and rural areas. Countries in general do not seem to have yet met the current demand for specialists at tertiary level in this field.

CONCLUSIONS

This study intends to draw attention to the current medical coverage gaps due to a low number of lymphoedema specialists at tertiary level. It wishes to start a discussion about structured reimbursement and certification of knowledge and skills that are essential incentives for experts to act as multiplicators and change the lack of care in the mid-term. Current fail prescriptions and evitable disability and sick certificates represent a high financial burden that could be reinvested in a correct management. Policy makers must focus in the two above mentioned essential measures. Medical training and the consequent development of the industry will then naturally take place, as it was the case for other professional groups in the past.

Skin and Wound Care in Lymphedema Patients: A Taxonomy, Primer, and Literature Review

BACKGROUND

Lymphedema is a condition of localized protein-rich swelling from damaged or malfunctioning lymphatics. Because the immune system is compromised, there is a high risk of infection. Infection in patients with lymphedema may present in a variety of ways.

OBJECTIVE

The goals of this review were to standardize the terminology of skin breakdown in the context of lymphedema, synthesize the available information to create best practice recommendations in support of the American Lymphedema Framework Project update to its Best Practices document, and create recommendations for further research.

DATA SOURCES

Publications on skin care and wounds were retrieved, summarized, and evaluated by a team of investigators and clinical experts.

STUDY SELECTION AND DATA EXTRACTION

Terms for lymphedema-associated skin breakdown were compiled and paired with photographs of commonly noted skin changes among patients with lymphedema. A list of standard dermatological terms was created. A more extensive literature search was then conducted by all authors.

DATA SYNTHESIS

Skin disorders associated with lymphedema have been classified into 5 categories. Descriptions, photographs, and recommendations for treatment are presented.

CONCLUSIONS

Skin care is an important defense against infection. Because of the lack of research, a consensus of thought and content leaders' opinion should guide the best practices for wound care in lymphedema.

Comparison of three quality of life instruments in lymphatic filariasis: DLQI, WHODAS 2.0, and LFSQQ

Background

The Global Program to Eliminate Lymphatic Filariasis aims to interrupt transmission of lymphatic filariasis and manage morbidity in people currently living with the disease. A component of morbidity management is improving health-related quality of life (HRQoL) in patients. Measurement of HRQoL in current management programs is varied because of the lack of a standard HRQoL tool for use in the lymphatic filariasis population.

Methodology/Principal Findings

In this study, the psychometric properties of three health status measures were compared when used in a group of lymphatic filariasis patients and healthy controls. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), the Dermatology Life Quality Index (DLQI), and the Lymphatic Filariasis Quality of Life Questionnaire (LFSQQ) were administered to 36 stage II and stage III lymphatic filariasis subjects and 36 age and sex matched controls in Kerala, India. All three tools yielded missing value rates lower than 10%, suggesting high feasibility. Highest internal consistency was seen in the LFSQQ (α = 0.97). Discriminant validity analysis demonstrated that HRQoL was significantly lower in the LF group than in controls for the WHODAS 2.0, DLQI, and LFSQQ, but total HRQoL scores did not differ between stage II and stage III lymphedema subjects. The LFSQQ total score correlated most strongly with the WHODAS 2.0 (r = 0.91, p<0.001) and DLQI (r = 0.81, p<0.001).

Conclusions/Significance

The WHODAS 2.0, DLQI, and LFSQQ demonstrate acceptable feasibility, internal consistency, discriminate validity, and construct validity. Based on our psychometric analyses, the LFSQQ performs the best and is recommended for use in the lymphatic filariasis population.

Lymphatic filariasis affects approximately 120 million people and is the second leading cause of life-long disability worldwide. Because lymphatic filariasis is one of the World Health Organization's six eradicable diseases, much effort has been placed into reducing transmission of the disease and managing morbidity. Novel interventions frequently use health-related quality of life as an outcome measure to monitor efficacy of the intervention. In an effort to delineate the strengths and weaknesses of health status measures and recommend use of a single tool in the lymphatic filariasis population, we compared the use of three health status tools (The World Health Organization Disability Assessment Schedule 2.0, the Dermatology Life Quality Index, and the Lymphatic Filariasis Quality of Life Questionnaire) in lymphatic filariasis subjects and healthy controls in Kerala, India. The Lymphatic Filariasis Quality of Life Questionnaire performed the best by discriminating well between subjects and controls, possessing significant content overlap with the other two tools, yielding a low missing value rate, and being internally consistent. This is the first study to compare health status measures in lymphatic filariasis subjects and provides insight into the use of the tools in quality of life analysis.

Self care integrative treatment demonstrated in rural community setting improves health related quality of life of lymphatic filariasis patients in endemic villages

This study assessed impact of community based self care integrative treatment provided through mass camps in villages of three districts of Kerala, India endemic for lymphatic filariasis (LF). Two most endemic Primary Health centres (PHCs) were selected from each of the three districts, where maximum concentration of LF patients is recorded. Fourteen one day LF camps, each attended by 30-40 patients were conducted. Trained Accredited Social Health Activists encouraged LF patients to attend camps. Skin wash and drying, care of bacterial entry points using dermatology drugs, and simple yoga and breathing exercises were demonstrated in these camps. Patients were advised to continue these self care activities daily at home for six months. The quality of life (QoL) of LF patients was determined for Indian life style domains using validated and pretested specific questionnaire (LF-specific QoL questionnaire-LFSQQ). It addressed conditions and state of individuals with reference to LF. The questionnaire had 7 domains and each domain consisted of a series of questions with likert scale (no problem, mild, moderate, severe, most severe). 446 patients attended one day camps to get training on integrative self care treatment. 425 patients (95.3%) were followed up after six months and QoL was reassessed. Each patient's QoL in mobility, self care, usual activity, pain and discomfort and social relationship significantly improved (P value <0.01). Psychological health showed no significant change. The disease burden, for the purpose of the study was measured by asking questions about history of painful redness, swelling and cellulitis of legs (filarial fever), foul smell (odor), itching (eczema/discharge from limb), wound (non healing ulcer) and weight/size of the limb. The difference in disease burden as recorded during the sixth month follow up was measured using dependent t test, reduced significantly (P value <0.01) in 409 (96.2%) patients. 103 (24.2%) patients experienced fever during follow up. Severity of inflammatory episodes reduced from severe problem to no problem, after six months of home based self care. There was significant relation between treatment regularity and QoL status (P value=0.003). The community based one day camps that trained LF patients on skin care and daily yoga and breathing practices improved QoL.

Disability measurement for lymphatic filariasis: a review of generic tools used within morbidity management programs

Lymphatic filariasis (LF)-related disability affects 40 million people globally, making LF the leading cause of physical disability in the world. Despite this, there is limited research into how the impacts of LF-related disability are best measured. This article identifies the tools currently being used to measure LF-related disability and reviews their applicability against the known impacts of LF. The findings from the review show that the generic disability tools currently used by LF programs fail to measure the majority of known impacts of LF-related disability. The findings from the review support the development of an LF-specific disability measurement tool and raise doubt about the suitability of generic disability tools to assess disability related to neglected tropical diseases (NTDs) globally.

Issues in delivering morbidity management for lymphatic filariasis elimination: a study in Pondicherry, South India

Lymphatic filariasis is a vector borne parasitic disease causing long term disability. The Global Programme to Eliminate Lymphatic Filariasis aims to achieve its objective through two strategies; Mass Drug Administration (MDA) to interrupt transmission and Morbidity Management (MM) to manage disability for those already affected. MDA is going on in full swing in endemic areas; but MM is lagging behind. An exploratory study was conducted in Pondicherry through focus group discussions to find out whether there are delivery issues if any, in the MM programme and get suggestions from end users. The study results show that MM has not received the same attention as MDA and there are shortcomings in the delivery mechanism of the programme. The importance of these findings are discussed and suggestions given for improving the programme.

Neglected tropical diseases and mental health: a perspective on comorbidity

Mental health conditions will be the largest contributor to the global health burden by 2030. Our review suggests that neglected tropical diseases (NTDs) predispose individuals to poor mental health. Factors predisposing to poor mental health include stigma and discrimination, exclusion from participating fully in society, reduced access to health and social services, lack of educational opportunities, exclusion from income-generation and employment opportunities, and restrictions in exercising civil and political rights. These characteristics are all features of NTDs, but the mental health of these sufferers has been ignored. This review raises an issue of concern and highlights the opportunities for research by psychiatrists and psychologists on NTDs.

Life quality impairment caused by hookworm-related cutaneous larva migrans in resource-poor communities in Manaus, Brazil

Background

Hookworm-related cutaneous larva migrans (CLM) is a common but neglected tropical skin disease caused by the migration of animal hookworm larvae in the epidermis. The disease causes intense pruritus and is associated with important morbidity. The extent to which CLM impairs skin disease-associated life quality has never been studied.

Methods

A modified version of the Dermatology Life Quality Index (mDLQI) was used to determine skin disease-associated life quality in 91 adult and child patients with CLM, living in resource-poor communities in Manaus, Brazil. Symptoms and signs were documented and skin disease-associated life quality was semi-quantitatively assessed using mDLQI scores. The assessment was repeated two and four weeks after treatment with ivermectin.

Results

Ninety-one point five percent of the study participants showed a considerable reduction of skin disease-associated life quality at the time of diagnosis. The degree of impairment correlated with the intensity of infection (rho = 0.76, p<0.001), the number of body areas affected (rho = 0.30; p = 0.004), and the presence of lesions on visible areas of the skin (p = 0.002). Intense pruritus, sleep disturbance (due to itching) and the feeling of shame were the most frequent skin disease-associated life quality restrictions (reported by 93.4%, 73.6%, and 64.8% of the patients, respectively). No differences were observed in skin disease-associated life quality restriction between boys and girls or men and women. Two weeks after treatment with ivermectin, skin disease-associated life quality improved significantly. After four weeks, 73.3% of the patients considered their disease-associated life quality to have returned to normal.

Conclusions

CLM significantly impaired the skin disease-associated life quality in child and adult patients living in urban slums in North Brazil. After treatment with ivermectin, life quality normalised rapidly.

Hookworm-related cutaneous larva migrans (CLM) is a parasitic skin disease common in developing countries with hot climates. In resource-poor settings, CLM is associated with considerable morbidity. The disease is caused by animal hookworm larvae that penetrate the skin and migrate aimlessly in the epidermis as they cannot penetrate the basal membrane. Particularly in the rainy season, the intensity of infection is high with up to 40 larval tracks in an affected individual. Tracks are very itchy and are surrounded by a significant inflammation of the skin. Bacterial superinfection is common and intensifies the inflammation. The psychosocial consequences caused by CLM have never been investigated. We showed that CLM causes skin disease-associated life quality impairment in 91 patients with CLM. Skin disease-associated life quality was significantly impaired. The degree of impairment correlated to the intensity of infection and the number of body areas affected. After treatment with ivermectin, life quality was rapidly restored.

The experience of living with chronic manifestations of Lymphatic Filariasis among patients 15 years and older in developing countries: a systematic review

BACKGROUND

Lymphatic filariasis is considered a disease of the poor with painful and profoundly disfiguring consequences. It is transmitted by the mosquito. Lymphatic filariasis is found among persons residing in rural areas and at the periphery of communities predominantly in developing countries in the tropics.

OBJECTIVES

To present the best evidence regarding the experiences of persons living with chronic manifestations of lymphatic filariasis, their experiences of treatment strategies and how the condition influences their social relationships within the context of developing countries.

INCLUSION CRITERIA

Study subjects were persons 15 years and older with chronic lymphatic filariasis living in developing countries.Phenomena of interest Publications that were selected considered the experiences of persons living with chronic lymphatic filariasis, their experiences of treatment measures and their social relationships.Types of studies Qualitative research papers (including but not limited to: phenomenology, grounded theory, action research, narrative studies, descriptive studies, ethnographies, cultural studies, behavioral studies, case studies and feminist research) exploring the experiences of persons living with chronic manifestations of lymphatic filariasis within the context of developing countries SEARCH STRATEGY: A three-step search strategy was utilised to search for published and unpublished studies over the period of 1980-2007. MEDLINE and CINAHL were initially searched for keywords and index terms that were then used to search across all the other data bases and finally the reference list of identified studies.

METHODOLOGICAL QUALITY

Eligible publications were assessed by two independent reviewers for methodological validity using the standardised critical appraisal tools of the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) DATA EXTRACTION: Data extraction was conducted using the standardised data extraction tools of the JBI-QARI. Extracted information consisted of details on relevant aspects of the identified studies.

DATA SYNTHESIS

Study findings were categorised according to the JBI-QARI degrees of credibility scale, and placed in categories of similar meaning. Categories were finally meta-synthesised.

RESULTS

Six (6) included studies yielded 41 findings that were placed in 8 categories and finally meta-synthesised into 3 synthesised findings: CONCLUSION: Policy guidelines on chronic lymphatic filariasis management need to provide a holistic approach with the involvement of communities.

IMPLICATIONS FOR RESEARCH

Much more research into elephantiasis management should be encouraged; so should qualitative research with rigorous methodological approaches into all aspects of lymphatic filariasis.

IMPLICATIONS FOR PRACTICE

Interventions should address in concert with other needs the psycho-emotional health of patients. Counseling should be incorporated into surgical management of hydroceles to allay fears of death.

Quality of life in filarial lymphoedema patients in Colombo, Sri Lanka

The quality of life (QOL) was assessed in 141 filarial lymphoedema patients and 128 healthy people in the Colombo district of Sri Lanka. Information was gathered by administering the validated translated version of the WHO 100-item QOL questionnaire (WHOQOL-100), which ascertains an individual's perception of QOL in the physical, psychological, level of independence, environmental and spiritual domains, as well as the general QOL. Healthy controls had a better QOL in all domains as well as in the overall general QOL, when compared to patients with lymphoedema. Several facets such as pain and discomfort, sleep and rest, activities of daily living, dependence on medication and treatment, working capacity and social support were significantly affected by the acute adenolymphangitis attack/s patients had suffered. The environmental and spiritual domains were significantly affected by the maximum grade of lymphoedema. The significant difference in the QOL as perceived by patients suffering from filarial lymphoedema and apparently healthy individuals reiterates the importance of morbidity control in patients already affected by filarial lymphoedema.

The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results

BACKGROUND

The Dermatology Life Quality Index (DLQI) is one of the most widely used dermatology-specific quality of life instruments. Over the last 5 years there has been great interest in its use.

OBJECTIVES

To collect and present all information regarding the technical properties and the clinical use of the DLQI from the date it was published to the end of 2007 for use as a single source of reference.

METHODS

A detailed literature search was conducted using electronic reference databases and the DLQI library in the Department of Dermatology, Cardiff University. All publications mentioning any aspect of the DLQI, from the time of its development to the end of 2007, were identified and the data concerning the DLQI in terms of its psychometric analysis, and use in clinical trials, epidemiological studies and health services research, were extracted and tabulated with all the relevant references.

RESULTS

In total, 272 full articles which have included the DLQI were reviewed. Studies described in these articles were divided into five main categories: psychometric studies, descriptive/epidemiological studies, drug (topical and systemic) trials, clinical practice research, and therapeutic interventions. The DLQI has been used in 33 different skin conditions in 32 countries and is available in 55 languages. Psychometric aspects of the DLQI such as validity, reliability, responsiveness to change, factor structure, and minimal important difference were described in 115 studies. The DLQI has been used in 33 studies assessing the effectiveness of 14 different types of therapeutic interventions and in 37 studies evaluating nine types of clinical practice research. Sixty studies have used it alone or in parallel with other instruments as an outcome measure in clinical trials of 18 systemic drugs while 22 studies have used it in 14 different topical drug trials. The DLQI has also been used in 27 multinational studies.

CONCLUSIONS

During the last 14 years there has been a gradual increase in the international use of the DLQI. The brevity and simplicity of use of the DLQI has resulted in its popularity both in clinical practice and in research. However, there are various issues in particular regarding its unidimensionality, differential item functioning, and minimal clinically important difference, which require further research. This article should facilitate the work of potential users of the DLQI by providing a readily available source of references for different aspects of the DLQI.

Neglected patients with a neglected disease? A qualitative study of lymphatic filariasis

BACKGROUND

Lymphatic filariasis (LF) is a so-called neglected tropical disease, currently overshadowed by higher-profile efforts to address malaria, tuberculosis, and HIV/AIDS. Despite recent successes in arresting transmission, some 40 million people who already have the disease have been largely neglected. This study aims to increase understanding of how this vulnerable, neglected group can be helped.

METHODS

We used purposive sampling to select 60 men and women with filarial lymphoedema (45 with filarial elephantiasis and 15 men with filarial hydrocoele) from the south of Sri Lanka in 2004-2005. Participants were selected to give a balance of men and women and poor and nonpoor, and a range of stages of the disease. Participants' experiences and the consequences of their disease for the household were explored with in-depth qualitative, semistructured interviews.

FINDINGS

LF was extremely debilitating to participants over long periods of time. The stigma attached to the condition caused social isolation and emotional distress, and delayed diagnosis and treatment, resulting in undue advancement of the disease. Free treatment services at government clinics were avoided because the participants' condition would be identifiable in public. Loss of income due to the condition was reported by all households in the sample, not just the poorest. Households that were already on low incomes were pushed into near destitution, from which it was almost impossible to escape. Affected members of low-income households also had less opportunity to obtain appropriate treatment from distant clinics, and had living and working conditions that made hygiene and compliance difficult.

SIGNIFICANCE

This highly vulnerable category of patients has low visibility, thus becoming marginalized and forgotten. With an estimated 300,000 total cases of elephantiasis and/or oedema in Sri Lanka, and around 300,000 men with filarial hydrocoele, the affected households will need help and support for many years to come. These individuals should be specially targeted for identification, outreach, and care. The global strategy for elimination is aimed at the cessation of transmission, but there will remain some 40 million individuals with clinical manifestations whose needs and problems are illustrated in this study.

Physical disability and psychosocial impact due to chronic filarial lymphoedema in Sri Lanka

Background

Information on the physical and psychosocial disability of lymphatic filariasis in Sri Lanka is scarce. Therefore this study was carried out to describe the physical disability and psychosocial impact associated with chronic lymphoedema in patients attending filariasis clinics in the Colombo district, Sri Lanka.

Methods

Four hundred and thirteen patients with lymphoedema of limbs attending filariasis clinics in Werahera and Dehiwala in the Colombo district were enrolled in the study after obtaining informed written consent. Data were collected using a pre-tested, interviewer-administered questionnaire and analyzed using SPSS.

Results

Majority (95%) of patients had lower limbs affected and there was a significant association with difficulty in walking (p = 0.023). The swollen limb affected the work of 87 (52 %) of employed patients and 26 persons reported loss of job. Approximately 25 % and 6 % reported having problems interacting with the community and family, respectively and 8.7 % felt that they were rejected by society. The swollen limb was perceived as a major problem by 36.8 % of patients. Of the married persons, 5.7 % and 6.2 % reported sexual and marital problems respectively, due to their swollen limb/s. Of those who had marital problems, 77.3% reported sexual problems as well (p < 0.001).

Conclusion

Lymphoedema significantly affects physical, psychological and social functioning in affected individuals. Morbidity control, in addition to control of physical disability, should target the psychosocial consequences.

Modified Dermatology Life Quality Index as a measure of quality of life in patients with filarial lymphoedema

The quality of life (QoL) and correlates of the QoL of lymphoedema patients attending filariasis clinics and a hospital outpatient department were studied using a Life Quality Index (LQI) in a region endemic for Bancroftian filariasis in Sri Lanka. The index was derived by modifying a previously validated Dermatology Life Quality Index (DLQI) to focus on the oedematous limb rather than the skin. The index was scored from 0 (normal) to 30 (severely affects QoL). Lymphoedema was graded using criteria recommended by the WHO. Another semi-structured questionnaire was used to assess the patient's socioeconomic status, frequency of acute adenolymphangitis attacks (ADLA) and measures practiced for morbidity control. Ninety-one patients (62 females, 29 males; mean age 50.4 years) were studied. A single lower limb, both lower limbs or a single upper limb were affected in 78 (85.7%), 10 (11.0%) and 3 (3.3%) patients, respectively. The severity of lymphoedema ranged from stage 1 (mild) to stage 6 (severe). The mean LQI was 8.2 (SD 5.2, range 0-20). The modified DLQI scores showed a significant positive correlation with severity of lymphoedema and a negative correlation with age (R=0.59 and R=-0.1, respectively). The frequency of ADLAs correlated with an increased modified DLQI score. Local pain, embarrassment and limitations of physical activities were the most distressing aspects of lymphoedema. Disease severity and early onset lymphoedema were found to be significantly associated with poorer QoL in filarial lymphoedema.

Morbidity management in the Global Programme to Eliminate Lymphatic Filariasis: a review of the scientific literature

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) has two major goals: to interrupt transmission of the parasite and to provide care for those who suffer the devastating clinical manifestations of the disease (morbidity control). This latter goal addresses three filariasis-related conditions: acute inflammatory episodes; lymphoedema; and hydrocele. Research during the last decade has confirmed the importance of bacteria as a cause of acute inflammatory episodes in filariasis-endemic areas, known as acute dermatolymphangioadenitis (ADLA). Current lymphoedema management strategies are based on the central role of ADLA as a trigger for lymphoedema progression. Simple intervention packages are in use that have resulted in dramatic reductions in ADLA rates, a lower prevalence of chronic inflammatory cells in the dermis and subdermis, and improvement in quality of life. During the past decade, the socioeconomic impact of ADLA and lymphoedema in filariasis-endemic areas has received increasing attention. Numerous operational research questions remain to be answered regarding how best to optimize, scale up, monitor, and evaluate lymphoedema management programmes. Of the clinical manifestations targeted by the GPELF, hydrocele has been the focus of the least attention. Basic information is lacking on the effectiveness and complications of hydrocele surgery and risk of post-operative hydrocele recurrence in filariasis-endemic areas. Data on the impact of mass administration of antifilarial drugs on filarial morbidity are inconsistent. Several studies report reductions in acute inflammatory episodes, lymphoedema, and/or hydrocele following mass drug administration, but other studies report no such association. Assessing the public health impact of mass treatment with antifilarial drugs is important for programme advocacy and morbidity control strategies. Thus, although our knowledge of filariasis-related morbidity and its treatment has expanded in recent years, much work remains to be done to address the needs of more than 40 million persons who suffer worldwide from these conditions.

Interdigital skin lesions of the lower limbs among patients with lymphoedema in an area endemic for bancroftian filariasis

OBJECTIVES

An estimated 15 million persons suffer from lymphoedema of the leg in filariasis-endemic areas of the world. A major factor in the progression of lymphoedema severity is the incidence of acute dermatolymphangioadenitis (ADLA), which is triggered by bacteria that gain entry through damaged skin, especially in the toe web spaces ('interdigital skin lesions'). Little is known about the epidemiology of these skin lesions or about patients' awareness of them.

METHODS

We interviewed and examined 119 patients (89% women) with lymphoedema of the leg in Recife, Brazil, an area endemic for bancroftian filariasis.

RESULTS

We detected 412 interdigital skin lesions in 115 (96.6%) patients (mean, 3.5 lesions per patient, range 0-8). The number of interdigital skin lesions was significantly associated with lymphoedema stage (P<0.001) and frequency of ADLA (P<0.0001). Only 20 (16.8%) patients detected their own interdigital skin lesions or considered them abnormal. Patients reported a mean of 3.6 ADLA episodes during the previous 12 months (range, 0-20); reported ADLA incidence was associated with lymphoedema stage (P<0.0001) and the number of interdigital skin lesions detected by the examining physician (P<0.0001).

CONCLUSIONS

These data suggest that interdigital skin lesions are a significant risk factor for ADLA and that persons with lymphoedema in filariasis-endemic areas are unaware of their presence or importance. Prevention of ADLA through prompt recognition and treatment of interdigital skin lesions will require that patients be taught to identify lesions, especially between the toes and to recognize them as abnormal.