Epidemiology of episodic adenolymphangitis: a longitudinal prospective surveillance among a rural community endemic for bancroftian filariasis in coastal Orissa, India

Managing Lymphedema Induced by Lymphatic Filariasis: Implementing and Improving Care at the Individual and Programmatic Levels

Providing and improving the care of patients suffering from lymphedema remains an essential goal for the clinical management of populations affected by lymphatic filariasis. Although the Essential Package of Care (EPC) recommended by the WHO leads to important positive benefits for many of these lymphedema patients, it is important to continue to address the challenges that remain both in quantifying these effects and in ensuring optimal care. This report, based on the authors' scientific and field experience, focuses on the impact and significance of lymphedema, its clinical presentation, current treatment approaches, and the importance of lymphedema care to the Global Program to Eliminate Lymphatic Filariasis. It emphasizes specific practical issues related to managing lymphedema, such as the importance of beginning treatment in the condition's early stages and the development of effective approaches to assess patients' progress toward improving both their clinical status and their overall quality of life. Priorities for research are also examined, particularly the need for tools to identify patients and to assess disease burden in endemic communities, the creation of EPC accessibility to as many patients as possible (i.e., targeting 100% "geographic coverage" of care), and the empowerment of patients to ensure the sustainability, and ultimately the provision of care from sectors of the national public health systems of endemic countries.

A refined and updated health impact assessment of the Global Programme to Eliminate Lymphatic Filariasis (2000-2020)

Background

Lymphatic filariasis (LF) is a neglected tropical disease (NTD). In 2000 the World Health Organization (WHO) established the Global Programme to Eliminate Lymphatic Filariasis (GPELF). A key component of this programme is mass drug administration (MDA). Between 2000 and 2020, the GPELF has delivered over 8.6 billion treatments to at-risk populations. The last impact assessment of the programme evaluated the treatments provided between 2000–2014. The goal of this analysis is to provide an updated health impact assessment of the programme, based on the numbers treated between 2000–2020.

Methods

We updated and refined a previously established model that estimates the number of clinical manifestations and disability-adjusted life years (DALYs) averted by the treatments provided by the GPELF. The model comprises three different population cohorts that can benefit from MDA provided (those protected from acquiring infection, those with subclinical morbidity prevented from progressing and those with clinical disease alleviated). The treatment numbers were updated for all participating countries using data from the WHO. In addition, data relating to the estimated number of individuals initially at risk of LF infection were updated where possible. Finally, the DALY calculations were refined to use updated disability weights.

Results

Using the updated model and corresponding treatment data, we projected that the total benefit cohort of the GPELF (2000–2020) would consist of approximately 58.5 million individuals and the programme would avert 44.3 million chronic LF cases. Over the lifetime of the benefit cohorts, this corresponded to 244 million DALYs being averted.

Conclusion

This study indicates that substantial health benefits have resulted from the first 20 years of the GPELF. It is important to note that the GPELF would have both additional benefits not quantified by the DALY burden metric as well as benefits on other co-endemic diseases (such as soil-transmitted helminths, onchocerciasis and scabies)—making the total health benefit underestimated. As with the past impact assessments, these results further justify the value and importance of continued investment in the GPELF.

Graphical Abstract

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.

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 a Regimen of Antifungal Cream Use on Episodes of Acute Adenolymphangitis (ADL) among Lymphedema Patients: An Application Using Marginal Structural Models

Episodes of adenolymphangitis (ADL) are a recurrent clinical aspect of lymphatic filariasis (LF) and a risk factor for progression of lymphedema. Inter-digital entry lesions, often found on the web spaces between the toes of those suffering from lymphedema, have been shown to contribute to the occurrence of ADL episodes. Use of antifungal cream on lesions is often promoted as a critical component of lymphedema management. Our objective was to estimate the observed effect of antifungal cream use on ADL episodes according to treatment regimen among a cohort of lymphedema patients enrolled in a morbidity management program. We estimated this effect using marginal structural models for time varying confounding. In this longitudinal study, we estimate that for every one-unit increase in the number of times one was compliant to cream use through 12 months, there was a 23% (RR = 0.77 (0.62, 0.96)) decrease in the number of ADL episodes at 18 months, however the RR’s were not statistically significant at other study time points. Traditionally adjusted models produced a non-significant RR closer to the null at all time points. This is the first study to estimate the effect of a regimen of antifungal cream on the frequency of ADL episodes. This study also highlights the importance of the consideration and proper handling of time-varying confounders in longitudinal observational studies.

Stage-specific antibody response against two larval stages of Brugia malayi in different clinical spectra of brugian filariasis

Context:

T-cell hypo-responsiveness in microfilaria (Mf) carriers against the microfilarial stage antigen of Brugia malayi has been described, but no study has been carried out to assess antibody dynamics against stage-specific antigens.

Aim:

The work was carried out with the aim to assess stage-specific antibody responses against L3 and microfilarial stage antigens in brugian filariasis in an endemic area.

Setting and Design:

Patients with different clinical spectra of brugian filariasis were recruited to evaluate antibody responses to brugian antigens.

Subjects and Methods:

Serum samples were collected from patients with different clinical spectra and antibody response was evaluated for total immunoglobulin G (IgG), IgG isotypes (IgG1, IgG2, IgG3, IgG4) and immunoglobulin E (IgE) response to L3 and microfilarial stage by enzyme-linked immunosorbent assay.

Statistical Analysis:

Paired t-test and one-way analysis of variance were carried out to analyze the data.

Results:

L3 and microfilarial stage antigens showed almost similar antibody responses in adenolymphangitis (ADL) and chronic pathology (CP) patients, however, diminished antibody response was observed with Mf stage antigen, especially with microfilaraemia. ADL patients had minimum antibody levels of all isotypes except IgG2 on day 0 which showed an increase subsequently, indicating suppression of antibody response during filarial fever. CP patients showed increase in IgE and decrease in IgG4 antibodies on day 365 indicating that these differences may be due to recent conversion into CP.

Conclusion:

A prominent hyporesponsiveness in microfilaraemic individuals against microfilarial stage, but not against the L3 stage of the same parasite was observed, concluding stage-specificity in humoral immune response in brugian filariasis.

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.

Evaluating the Burden of Lymphedema Due to Lymphatic Filariasis in 2005 in Khurda District, Odisha State, India

BACKGROUND

Over 1.1 billion people worldwide are at risk for lymphatic filariasis (LF), and the global burden of LF-associated lymphedema is estimated at 16 million affected people, yet country-specific estimates are poor.

METHODOLOGY/PRINCIPAL FINDINGS

A house-to-house morbidity census was conducted to assess the burden and severity of lymphedema in a population of 1,298,576 persons living in the LF-endemic district of Khurda in Odisha State, India. The burden of lymphedema in Khurda is widespread geographically, and 1.3% (17,036) of the total population report lymphedema. 51.3% of the patients reporting lymphedema were female, mean age 49.4 years (1-99). Early lymphedema (Dreyer stages 1 & 2) was reported in two-thirds of the patients. Poisson regression analysis was conducted in order to determine risk factors for advanced lymphedema (Dreyer stages 4-7). Increasing age was significantly associated with advanced lymphedema, and persons 70 years and older had a prevalence three times greater than individuals ages 15-29 (aPR: 3.21, 95% CI 2.45, 4.21). The number of adenolymphangitis (ADL) episodes reported in the previous year was also significantly associated with advanced lymphedema (aPR 4.65, 95% CI 2.97-7.30). This analysis is one of the first to look at potential risk factors for advanced lymphedema using morbidity census data from an entire district in Odisha State, India.

SIGNIFICANCE

These data highlight the magnitude of lymphedema in LF-endemic areas and emphasize the need to develop robust estimates of numbers of individuals with lymphedema in order to identify the extent of lymphedema management services needed in these regions.

The health and economic benefits of the global programme to eliminate lymphatic filariasis (2000-2014)

BACKGROUND

Lymphatic filariasis (LF), also known as elephantiasis, is a neglected tropical disease (NTD) targeted for elimination through a Global Programme to Eliminate LF (GPELF). Between 2000 and 2014, the GPELF has delivered 5.6 billion treatments to over 763 million people. Updating the estimated health and economic benefits of this significant achievement is important in justifying the resources and investment needed for eliminating LF.

METHOD

We combined previously established models to estimate the number of clinical manifestations and disability-adjusted life years (DALYs) averted from three benefit cohorts (those protected from acquiring infection, those with subclinical morbidity prevented from progressing and those with clinical disease alleviated). The economic savings associated with this disease prevention was then analysed in the context of prevented medical expenses incurred by LF clinical patients, potential income loss through lost-labour, and prevented costs to the health system to care for affected individuals. The indirect cost estimates were calculated using the human capital approach. A combination of four wage sources was used to estimate the fair market value of time for an agricultural worker with LF infection (to ensure a conservative estimate, the lowest wage value was used).

RESULTS

We projected that due to the first 15 years of the GPELF 36 million clinical cases and 175 (116-250) million DALYs will potentially be averted. It was estimated that due to this notable health impact, US$100.5 billion will potentially be saved over the lifetimes of the benefit cohorts. This total amount results from summing the medical expenses incurred by LF patients (US$3 billion), potential income loss (US$94 billion), and costs to the health system (US$3.5 billion) that were projected to be prevented. The results were subjected to sensitivity analysis and were most sensitive to the assumed percentage of work hours lost for those suffering from chronic disease (changing the total economic benefit between US$69.30-150.7 billion).

CONCLUSIONS

Despite the limitations of any such analysis, this study identifies substantial health and economic benefits that have resulted from the first 15 years of the GPELF, and it highlights the value and importance of continued investment in the GPELF.

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.

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.

High prevalence of Wuchereria bancrofti infection as detected by immunochromatographic card testing in five districts of Orissa, India, previously considered to be non-endemic

India accounts for over one-third of the world's burden of lymphatic filariasis (LF). Although most coastal districts of Orissa state (eastern India) are LF-endemic, the western districts of Orissa are considered non-endemic. During a large-scale insecticide-treated bed net/microfinance trial, we tested one randomly selected adult (age 15-60 years) for LF from a random sample of microfinance-member households in five districts of western Orissa, using immunochromatographic card testing (ICT). Overall, 354 (adjusted prevalence 21%, 95%CI 17-25%) of 1563 persons were ICT positive, with district-wide prevalence rates ranging from 15-32%. This finding was not explained by immigration, as only 3% of subjects had ever lived in previously known LF-endemic districts. These results therefore suggest ongoing autochthonous transmission in districts where LF control programs are not operational. Our results highlight the importance of broad, systematic surveillance for LF in India and call for the implementation of LF control programs in our study districts.

The economic benefits resulting from the first 8 years of the Global Programme to Eliminate Lymphatic Filariasis (2000-2007)

BACKGROUND

Between 2000-2007, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) delivered more than 1.9 billion treatments to nearly 600 million individuals via annual mass drug administration (MDA) of anti-filarial drugs (albendazole, ivermectin, diethylcarbamazine) to all at-risk for 4-6 years. Quantifying the resulting economic benefits of this significant achievement is important not only to justify the resources invested in the GPELF but also to more fully understand the Programme's overall impact on some of the poorest endemic populations.

METHODOLOGY

To calculate the economic benefits, the number of clinical manifestations averted was first quantified and the savings associated with this disease prevention then analyzed in the context of direct treatment costs, indirect costs of lost-labor, and costs to the health system to care for affected individuals. Multiple data sources were reviewed, including published literature and databases from the World Health Organization, International Monetary Fund, and International Labour Organization

PRINCIPAL FINDINGS

An estimated US$21.8 billion of direct economic benefits will be gained over the lifetime of 31.4 million individuals treated during the first 8 years of the GPELF. Of this total, over US$2.3 billion is realized by the protection of nearly 3 million newborns and other individuals from acquiring lymphatic filariasis as a result of their being born into areas freed of LF transmission. Similarly, more than 28 million individuals already infected with LF benefit from GPELF's halting the progression of their disease, which results in an associated lifetime economic benefit of approximately US$19.5 billion. In addition to these economic benefits to at-risk individuals, decreased patient services associated with reduced LF morbidity saves the health systems of endemic countries approximately US$2.2 billion.

CONCLUSIONS/SIGNIFICANCE

MDA for LF offers significant economic benefits. Moreover, with favorable program implementation costs (largely a result of the sustained commitments of donated drugs from the pharmaceutical industry) it is clear that the economic rate of return of the GPELF is extremely high and that this Programme continues to prove itself an excellent investment in global health.

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.

Marriage, sex, and hydrocele: an ethnographic study on the effect of filarial hydrocele on conjugal life and marriageability from Orissa, India

Background

Lymphatic filariasis (LF), a leading cause of permanent and long-term disability, affects 120 million people globally. Hydrocele, one of the chronic manifestations of LF among 27 million people worldwide, causes economic and psychological burdens on patients and their families. The present study explores and describes the impact of hydrocele on sexual and marital life as well as on marriageability of hydrocele patients from rural areas of Orissa, an eastern state of India.

Methodology/Principal Findings

This paper is based on ethnographic data collected through focus group discussions and in-depth interviews with hydrocele patients, wives of hydrocele patients, and other participants from the community. The most worrisome effect of hydrocele for patients and their wives was the inability to have a satisfactory sexual life. The majority of patients (94%) expressed their incapacity during sexual intercourse, and some (87%) reported pain in the scrotum during intercourse. A majority of hydrocele patients' wives (94%) reported dissatisfaction in their sexual life. As a result of sexual dissatisfaction and physical/economic burden, communication has deteriorated between the couples and they are not living happily. This study also highlights the impact on marriageability. The wives of hydrocele patients said that a hydrocele patient is the “last choice” and that girls show reluctance to marry hydrocele patients. In some cases, the patients were persuaded by their wives to remove hydrocele by surgery (hydrocelectomy).

Conclusions/Significance

The objective of the morbidity management arm of the Global Programme to Eliminate LF should be to increase access to hydrocelectomy, as hydrocelectomy is the recommended intervention. Though the study area is covered by the programme, like in other endemic areas, hydrocelectomy has not been emphasised by the national LF elimination programme. The policy makers and programme managers should be sensitised by utilising this type of research finding.

Lymphatic filariasis, the second leading cause of permanent and long-term disability, affects 120 million people globally. Hydrocele, an accumulation of fluid in the scrotum that causes it to swell, is one of the chronic manifestations of LF among men and there are about 27 million men with hydrocele worldwide. We conducted ethnographic interviews and discussions with patients, women whose husbands have hydrocele, and the general public in a rural community of eastern India. The study describes how hydrocele impacts patients' sexual and marital life. It reveals the most worrisome effect of hydrocele for patients and their wives due to the inability to have a satisfactory sexual life. Patients expressed their incapacity during sexual intercourse. A majority of hydrocele patients' wives reported that their married life became burdened and couples were not living happily. This study also highlights the impact on marriageability, and some women expressed that a hydrocele patient is the “last choice”. In some cases, the patients were persuaded by their wives to remove hydrocele by surgery (hydrocelectomy). Hence, access to hydrocelectomy has to be strengthened under the Global Programme to Eliminate Lymphatic Filariasis, which is operational in several endemic areas in the world. Also, this activity may be integrated with primary healthcare services and interventions of other neglected tropical diseases.

Clinicians' attitude on mass drug administration under the program to eliminate lymphatic filariasis: a qualitative study from Orissa, India

The global program to eliminate lymphatic filariasis (LF) is currently based on mass drug administration (MDA) with annual single dose of antifilarials. In India, the MDA is implemented by primary health centers (PHC) of the district health system. The aim of the present study was to explore the attitudes of clinicians working at PHC level in three districts of Orissa, India. The data are obtained from interviews of 50 clinicians (35 from PHCs and 15 private). Only 11 PHC clinicians and 1 private clinician opined that the elimination of LF is possible through MDA of diethylcarbamazine (DEC); and 40% PHC and 87% private clinicians strongly felt that the elimination is not feasible through MDA and that the yearly single dose of DEC was not efficacious. The remaining clinicians were unable to comment on the feasibility and efficacy of MDA. The indifferent attitudes arise from lack of knowledge or erroneous beliefs. A good understanding of the program through reorientation and rigorous training should be emphasized to make the MDA successful.

Clinicians' practices related to management of filarial adenolymphangitis and lymphoedema in Orissa, India

The Global Programme to Eliminate Lymphatic Filariasis (GPELF), which includes alleviation of disability and suffering of patients, is implemented primarily in India by primary health care system. The present study assesses the current practices related to lymphoedema care among clinicians of primary healthcare system in three filarial endemic districts of Orissa, India. The results are based on the data obtained through in-depth interviews with 50 clinicians from primary health centres (PHCs) and private clinics located in 22 PHCs sampled from three districts. All clinicians are aware of common as well as atypical manifestations of LF and offered treatment to them. The most commonly dealt complaints are lymphoedema of chronic LF and acute lymphangitis. All the clinicians reported that they prescribed diethylcarbamazine (DEC) for the treatment of patients with acute episodes, and only 50% of them prescribed antibiotics along with DEC. However, there is no uniform pattern either in the dosage of DEC or in the use of antibiotics. In this study, all the clinicians are aware that repeated acute episodes leads to lymphoedema. Majority of clinicians (94%) prescribed DEC to prevent this progression. For reduction of oedema, they offered a variety of treatments and more than half of the clinicians prescribed DEC. The study districts have been covered by the mass drug administration (MDA) of DEC under the GPELF. In order for the GPELF as a whole to prove successful and sustainable, those persons who are already suffering from LF need to be cared for and their suffering is to be relieved. Current practices of clinicians, both at government and private health institutions should be improved. With the revised knowledge that bacterial infections play a key role in the progression of disease, the attitude of clinicians towards the treatment of LF has to be changed.

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.