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

'The Lost Peace': Evidencing the Syndemic Relationship between Neglected Tropical Diseases and Mental Distress in Liberia

Neglected Tropical Diseases (NTDs) are a group of chronic infectious diseases of poverty affecting over one billion people globally. Intersections of NTDs, disability, and mental ill-health are increasingly evidenced but are rarely studied from a mixed-methods perspective. Here, we advance syndemic understandings by further assessing and contextualising the syndemic relationship between NTDs (particularly their associated disability) and mental distress in Liberia. Participatory qualitative methods, including body mapping (56 participants), social mapping (28 participants), and in-depth interviews (12) provided space for persons affected by NTDs to narrate their experiences. Simultaneously, 201 surveys explored experiences of common mental health conditions among persons affected by skin NTDs. An intersectionality approach was applied within the analysis for both qualitative and quantitative methods informed by Meyer's minority stress model, adapted for NTDs. Qualitative data was analysed thematically and gender-disaggregated, univariable and multivariable analyses were applied to survey data for the outcome measures depression (PHQ-9) and anxiety (GAD-7). Disability was associated with higher levels of depression and anxiety (p < 0.001). An interaction between disability and being a women increased incidence risk ratio of depression (p < 0.001). In alignment with qualitative findings, persons affected experienced additional generalised (financial concerns), external (experience of stigma) and internal (experience of pain and physical symptoms) minority stressors, to varying degrees, which contributed towards their mental distress, and mental health conditions. These findings were used to co-develop a syndemic-informed person-centred health system response to address the suffering associated with NTDs and mental distress, including a focus on strengthening relationships between formal and informal community health actors and the broader health system.

Addressing the Syndemic Relationship between Lymphatic Filariasis and Mental Distress in Malawi: The Potential of Enhanced Self-Care

Lymphatic filariasis (LF) causes disfiguring and disabling lymphoedema, which can lead to mental distress and requires life-long self-care treatment. This study applies syndemic theory to understand the biosocial relationship between LF and mental distress in Malawi. Using in-depth qualitative methods, we critically evaluate experiences of mental distress and LF through 21 life-history interviews, to narrate experiences from the perspective of persons affected by LF, and to understand how enhanced self-care (ESC) for lymphoedema management disrupts the syndemic relationship. Complementary key informant interviews with Ministry of Health LF programme staff were conducted to further understand intervention and health system delivery. All interviews were recorded, transcribed, and translated, and then subject to thematic analysis. Our findings suggest that for persons affected by LF in Malawi, before being trained in ESC, absent referral pathways, inequalities in healthcare provision or available treatment, and limited knowledge of the condition (LF) drove the syndemic of LF and mental distress. Distress was often exacerbated by stigma and social exclusion, and shaped by intersections of gender, generation, poverty, and extreme climate conditions. We argue that addressing the syndemic suffering associated with LF and mental distress through interventions which center the needs of persons affected is critical in effective and equitable LF care delivery.

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.

Understanding gender and its intersection with social stratifiers on prevention and care seeking behavior of lymphatic filariasis in Nepal

BACKGROUND

Lymphatic filariasis (LF) is a debilitating and painful neglected tropical disease and is one of the leading causes of permanent disability. In many countries, the intersection of gender with various social stratifiers has influenced exposure to LF and ultimately impacting the disease burden and its elimination. This study aimed to explore the influence of gender and its intersection with other social stratifiers for the prevention and care seeking behavior of LF in Nepal.

METHODS

This study employed qualitative research methods: in-depth interviews (IDIs) and focus group discussions (FGDs) for data collection in Bardiya, Nepal. A total of 22 IDIs (11 male, 11 female) and 2 FGDs (1 male and 1 female) were conducted with the community people between January and March 2020. The participants were purposively selected to represent different social stratifiers including age, sex, ethnicity, occupation. The data collected were analyzed using a thematic framework approach with use of intersectional gender analysis matrix.

RESULTS

The study findings revealed that men spend more time outside their household compared to women while fulfilling their roles and responsibilities, largely determined by societal expectations and gender norms. This resulted in limited access to preventive health services for men, as they often missed annual mass drug administration programme in their community and limited access to preventive methods. Further traditional occupation, specific to particular ethnicity, influenced the vulnerability to LF for certain ethnic groups. The ability to prevent exposure varied among individuals. Although women made decisions regarding the use of protective methods, it was influenced by patriarchal and gender norms. They often felt a responsibility to take care and priorities males and other family members when resources are limited. The intersectionality of gender with other social stratifiers such as marital status, ethnicity, and geographical areas influenced individual's ability to access information related to LF and care seeking.

CONCLUSIONS

Overall, the findings emphasized how access to resources, division of work, norms and values and decision-making power alone and its interaction with various social stratifiers shaped peoples' vulnerability to disease, ability to prevent exposure and response to illness.

Neglected tropical diseases and disability-what is the link?

Neglected tropical diseases (NTDs) are a diverse group of infectious conditions that vary in their epidemiology, impact and control. They are among the most common conditions globally, affecting approximately one billion people. Many NTDs have long-term consequences, such as visual and physical impairments. As a result, people with NTDs may have difficulties in carrying out activities or participating in society—in other words, NTDs can cause disabilities. Additionally, NTDs are often strongly linked to stigma and can have mental health consequences. It is therefore important to incorporate rehabilitation within NTD programmes. Rehabilitation can be conceptualized narrowly in terms of the provision of clinical services (e.g. physiotherapy and assistive devices) or, more broadly, including efforts to improve employment, overcome stigma and enhance social participation of people with disabilities. Approximately 15% of the global population has a disability, and this large group must be considered when designing NTD programmes. Improving the inclusion of people with disabilities may require adaptations to NTD programmes, such as making them physically accessible or training staff about disability awareness. Without incorporating disability within NTD programmes, the quality of life of people with NTDs will suffer and global targets for elimination and management of NTDs will not be met.

People are neglected, not diseases: the relationship between disability and neglected tropical diseases

People with disabilities and the neglected tropical diseases (NTDs) are separately receiving increased focus. In light of this positive development, and the similarities and intersections between the negative impacts experienced by both people with disabilities and people with NTDs, we believe now is the right time to focus attention on the overlap between the two. Both people with NTDs and people with disabilities experience a myriad of overlapping negative health, financial and socio-cultural consequences. Despite this, we believe that disability is not yet properly prioritised on the development agenda, and that there are multiple opportunities to make NTD programming more inclusive, to the benefit of those at this neglected intersection and beyond. There are both opportunities and need to scale up, integrate, and invest in inclusive, health system-focused NTD programming. Realisation of the Sustainable Development Goals, Universal Health Coverage, and the control and elimination of NTDs all rely on ensuring people with disabilities are not left behind.

Gender-related factors affecting health seeking for neglected tropical diseases: findings from a qualitative study in Ethiopia

BACKGROUND

Despite known gender-specific differences in terms of prevalence, transmission and exposure to neglected tropical diseases (NTDs), there is limited discussion of the influence of gender in NTD programmes and interventions. There is a paucity of research on how gender interacts with NTD service provision and uptake. This study, part of broader implementation research in Ethiopia, applied a gender lens to health seeking for five NTDs: lymphatic filariasis, podoconiosis, schistosomiasis, soil-transmitted helminth infection and trachoma.

METHODOLOGY/PRINCIPAL FINDINGS

The study was conducted in a district of the Southern Nations, Nationalities, and Peoples' Region of Ethiopia where the five NTDs are prevalent. A qualitative methodology was adopted to explore participants' perspectives and experiences. Data generation methods included 20 interviews and four focus group discussions. Community members, volunteer Health Development Army leaders, Health Extension Workers and a range of health workers at the health post, health centre and hospital level (n = 59) were purposively sampled. Interviews and focus group discussions were audio recorded, transcribed verbatim into English then analysed through open coding, drawing on constant comparative methods. Gender related factors affected care seeking for NTDs and were described as reasons for not seeking care, delayed care seeking and treating NTDs with natural remedies. Women faced additional challenges in seeking health care due to gender inequalities and power dynamics in their domestic partnerships. Participants recommended raising community awareness about NTDs, however this remains problematic due to gender and social norms around appropriate discourse with members of the opposite gender.

CONCLUSIONS/SIGNIFICANCE

The findings from this study provide crucial insights into how gender interacts with accessing health services, at different levels of the health system. If we are committed to leaving no one behind and achieving universal health coverage, it is essential to address gender disparities to access and utilisation of interventions delivered by national NTD programmes.

Application of the Lower Extremity Functional Scale and Its Correlation with Lymphedema Health-Related Quality of Life on Lower Limb Filarial Lymphedema Patients

Introduction: This study carried out as a part of the lymphedema (LE)—osteoarthritis project to know the feasibility and applicability of lower extremity functional scale (LEFS) and LE health-related quality of life (LEHRQoL) among filarial LE patients of the lower extremity.

Materials and Methods: Following inclusion and exclusion criteria 30 LE patients and 30 controls were recruited in the study. After obtaining informed written consent, Tamil version of the two “self-reporting assessment tools” LEFS and LEHRQoL were applied to all the participants by two examiners independently. Feasibility was assessed by the time schedule. Internal consistency and the correlation between two examiners was assessed by calculating Cronbach's alpha and Karl Pearson correlation coefficient and Spearman rank correlation respectively.

Results: The mean time taken for completing the LEFS and LEHRQoL questionnaire was 5 minutes and 2 seconds and 12 minutes and 8 seconds respectively. Internal consistency reliability assessment showed good internal consistency for both the examiners (Cronbach's alpha 0.816 and 0.812). There was a strong positive correlation for the cases (r = 0.956, p < 0.001; r = 0.908, p < 0.001) and controls (r = 0.992, p < 0.001; r = 0.985, p < 0.001) between the two examiners.

Conclusions: LEFS and LEHRQoL were well accepted among filarial LE patients and the patients with low literacy were able to respond without any difficulty to both assessment tools. LEFS was found suitable for the assessment of lower extremity functions of the LE patients as in other diseases affecting the lower limb and it also indirectly brought out the impact on the QoL.

Surgical Treatment of Advanced Lymphatic Filariasis of Lower Extremity Combining Vascularized Lymph Node Transfer and Excisional Procedures

Background: Lymphatic filariasis (LF) in advanced stage is a clinically challenging disability resulting in poor quality of life. In advanced stage of filariasis, medical management is seldom effective and few surgical procedures are beneficial. In this study, we assessed clinical efficacy of a surgical technique combining vascularized lymph node transfer (VLNT) and serial excision for patients affected by advanced LF. Patients and Methods: A total of 17 patients with grades 2 and 3 lower limb lymphedema after three consecutive humanitarian missions in India between 2014 and 2018 underwent excision of excessive soft tissue of leg and supraclavicular lymph node flap transferred to dorsum of foot. Recipient vessels were prepared and microanastomosis was performed. Lymphedema was assessed by measuring leg circumferences at different levels, episodes of infectious lymphangitis, and lymphoscintigraphy. Results: A significant decrease of lower limb circumference measurements at all levels was noted postoperatively. Postoperative lymphoscintigraphy revealed reduced lymph stasis. One patient suffered of a seroma on donor site. Six patients had partial loss of skin graft over the flap at recipient site and it was managed by regrafting. Data analysis observed statistically significant reduction in feeling of heaviness (p < 0.005) and episodes of acute lymphangitis after surgery. Conclusion: Advanced LF of leg is difficult to manage using traditional medical treatment. The combination of VLNT and surgical excision provided a safe and reliable approach to treat this debilitating disease.

The role of gender relations in uptake of mass drug administration for lymphatic filariasis in Alor District, Indonesia

Background

The Global Programme to Eliminate Lymphatic Filariasis has set 2020 as a target to eliminate lymphatic filariasis (LF) as a public health problem through mass drug administration (MDA) to all eligible people living in endemic areas. To obtain a better understanding of compliance with LF treatment, a qualitative study using 43 in-depth interviews was carried out in Alor District, Indonesia to explore factors that motivate uptake of LF treatment, including the social and behavioural differences between compliant and non-compliant individuals. In this paper, we report on the findings specific to the role of family and gender relations and how they affect compliance.

Results

The sample comprised 21 men and 22 women; 24 complied with treatment while 19 did not. Gender relations emerged as a key theme in access, uptake and compliance with MDA. The view that the husband, as head of household, had the power, control, and in some cases the responsibility to influence whether his wife took the medication was common among both men and women. Gender also affected priorities for health care provision in the household as well as overall decision making regarding health in the household. Four models of responsibility for health decision making emerged: (i) responsibility resting primarily with the husband; (ii) responsibility resting primarily with the wife; (iii) responsibility shared equally by both husband and wife; and (iv) responsibility autonomously assumed by each individual for his or her own self, regardless of the course of action of the other spouse.

Conclusions

(i) Gender relations and social hierarchy influence compliance with LF treatment because they inherently affect decisions taken within the household regarding health; (ii) health care interventions need to take account of the complexity of gender roles; (iii) the fact that women’s power tends to be implicit and not overtly recognised in the household or the community has important implications for health care interventions; (iv) campaigns and other preventive interventions need to take account of the diversity of patterns of health care decision-making and responsibility in specific communities so that social mobilisation messages can be tailored appropriately.

Assessing the feasibility of integration of self-care for filarial lymphoedema into existing community leprosy self-help groups in Nepal

BACKGROUND

Lymphatic filariasis (LF) and leprosy are disabling infectious diseases endemic in Nepal. LF infection can lead to lymphoedema and hydrocoele, while secondary effects of leprosy infection include impairments to hands, eyes and feet. The disabling effects of both conditions can be managed through self-care and the supportive effects of self-help groups (SHGs). A network of SHGs exists for people affected by leprosy in four districts in Nepal's Central Development Region, however no such service exists for people affected by LF. The aim of this study was to determine the feasibility of integrating LF affected people into existing leprosy SHGs in this area.

METHODS

A survey was conducted using a semi-structured questionnaire to elicit information on: (i) participant characteristics, clinical manifestation and disease burden; (ii) participants' knowledge of management of their condition and access to services; and (iii) participants' knowledge and perceptions of the alternate condition (LF affected participants' knowledge of leprosy and vice versa) and attitudes towards integration.

RESULTS

A total of 52 LF affected and 53 leprosy affected participants were interviewed from 14 SHGs. On average, leprosy affected participants were shown to have 1.8 times greater knowledge of self-care techniques, and practiced 2.5 times more frequently than LF affected participants. Only a quarter of LF affected participants had accessed a health service for their condition, compared with 94.3% of leprosy affected people accessing a service (including SHGs), at least once a week. High levels of stigma were perceived by both groups towards the alternate condition, however, the majority of LF (79%) and leprosy (94.3%) affected participants stated that they would consider attending an integrated SHG.

CONCLUSIONS

LF affected participants need to increase their knowledge of self-care and access to health services. Despite stigma being a potential barrier, attitudes towards integration were positive, suggesting that the SHGs may be a good platform for LF affected people to start self-care in this area.

TRIAL REGISTRATION

This is not a registered trial.

Is mass drug administration against lymphatic filariasis required in urban settings? The experience in Kano, Nigeria

Background

The Global Programme to Eliminate Lymphatic Filariasis (GPELF), launched in 2000, has the target of eliminating the disease as a public health problem by the year 2020. The strategy adopted is mass drug administration (MDA) to all eligible individuals in endemic communities and the implementation of measures to reduce the morbidity of those suffering from chronic disease. Success has been recorded in many rural endemic communities in which elimination efforts have centered. However, implementation has been challenging in several urban African cities. The large cities of West Africa, exemplified in Nigeria in Kano are challenging for LF elimination program because reaching 65% therapeutic coverage during MDA is difficult. There is therefore a need to define a strategy which could complement MDA. Thus, in Kano State, Nigeria, while LF MDA had reached 33 of the 44 Local Government Areas (LGAs) there remained eleven ‘urban’ LGAs which had not been covered by MDA. Given the challenges of achieving at least 65% coverage during MDA implementation over several years in order to achieve elimination, it may be challenging to eliminate LF in such settings. In order to plan the LF control activities, this study was undertaken to confirm the LF infection prevalence in the human and mosquito populations in three urban LGAs.

Methods

The prevalence of circulating filarial antigen (CFA) of Wuchereria bancrofti was assessed by an immuno-chromatography test (ICT) in 981 people in three urban LGAs of Kano state, Nigeria. Mosquitoes were collected over a period of 4 months from May to August 2015 using exit traps, gravid traps and pyrethrum knock-down spray sheet collections (PSC) in different households. A proportion of mosquitoes were analyzed for W. bancrofti, using dissection, loop-mediated isothermal amplification (LAMP) assay and conventional polymerase chain reaction (PCR).

Results

The results showed that none of the 981 subjects (constituted of <21% of children 5–10 years old) tested had detectable levels of CFA in their blood. Entomological results showed that An. gambiae s.l. had W. bancrofti DNA detectable in pools in Kano; W. bancrofti DNA was detected in between 0.96% and 6.78% and to a lesser extent in Culex mosquitoes where DNA was detected at rates of between 0.19% and 0.64%. DNA analysis showed that An. coluzzii constituted 9.9% of the collected mosquitoes and the remaining 90.1% of the mosquitoes were Culex mosquitoes.

Conclusion

Despite detection of W. bancrofti DNA within mosquito specimens collected in three Kano urban LGAs, we were not able to find a subject with detectable level of CFA. Together with other evidence suggesting that LF transmission in urban areas in West Africa may not be of significant importance, the Federal Ministry of Health advised that two rounds of MDA be undertaken in the urban areas of Kano. It is recommended that the prevalence of W. bancrofti infection in the human and mosquito populations be re-assessed after a couple of years.

Mass drug administration (MDA) for the control of elephantiasis in the state of Kano in Nigeria, started in the year 2010. It was estimated that by 2015, the MDA programme will be extended to 11 remaining urban Local Government Areas (LGAs). However, MDA in urban areas faces specific challenges, the most prominent being the need to achieve coverage rates of 65% and above. As such MDA alone may not be sufficient to achieve the required programme impacts of reducing LF transmission to levels below which transmission cannot be sustained, and additional interventions may be required. This study set out to confirm the LF infection prevalence in the human and mosquito populations in three urban LGAs in Kano. Individuals were tested for signs of the disease, and mosquito samples were collected and also tested for the worms that cause the disease. The study revealed that of 981 people tested, none had circulating filarial antigen in the blood. However, the mosquitoes collected revealed the presence of the disease-causing worms, but the level of infection was low. The infection in the mosquitoes was also detected in two different types of mosquitoes. Based on the outcomes of this study, and evidence from other West African cities on the transmission of LF, the Federal Ministry of Health recommended that two rounds of MDA be undertaken in urban areas of Kano. A further reassessment after a couple of years is warranted.

Social stigma towards neglected tropical diseases: a systematic review

BACKGROUND

People affected by neglected tropical diseases (NTDs) are frequently the target of social stigmatization. To date not much attention has been given to stigma in relation to NTDs. The objective of this review is to identify the extent of social stigma and the similarities and differences in the causes, manifestations, impact of stigma and interventions used between the NTDs.

METHODS

A systematic review was conducted in Pubmed, ScienceDirect, PsycINFO and Web of Knowledge. The search encompassed 17 NTDs, including podoconiosis, but not leprosy as this NTD has recently been reviewed. However, leprosy was included in the discussion.

RESULTS

The 52 selected articles provided evidence on stigma related to lymphatic filariasis (LF), podoconiosis, Buruli ulcer, onchocerciasis, schistosomiasis, leishmaniasis, Chagas disease, trachoma, soil-transmitted helminthiasis (STH) and human African trypanosomiasis. The similarities predominated in stigma related to the various NTDs; only minimal differences in stigma reasons and measures were found.

CONCLUSION

These similarities suggest that joint approaches to reduce stigmatization may be feasible. Lessons from leprosy and other stigmatized health conditions can be used to plan such joint approaches. Further research will be necessary to study the efficacy of joint interventions and to investigate stigma related to NTDs for which no evidence is available yet.

The burden of mental health in lymphatic filariasis

BACKGROUND

Neglected Tropical Diseases (NTDs) afflict around one billion individuals in the poorest parts of the world with many more at risk. Lymphatic filariasis is one of the most prevalent of the infections and causes significant morbidity in those who suffer the clinical conditions, particularly lymphedema and hydrocele. Depressive illness has been recognised as a prevalent disability in those with the disease because of the stigmatising nature of the condition. No estimates of the burden of depressive illness of any neglected tropical disease have been undertaken to date despite the recognition that such diseases have major consequences for mental health not only for patients but also their caregivers.

METHODS

We developed a mathematical model to calculate the burden of Disability- Adjusted Life Years (DALY) attributable to depressive illness in lymphatic filariasis and that of their caregivers using standard methods for calculating DALYs. Estimates of numbers with clinical disease was based on published estimates in 2012 and the numbers with depressive illness from the available literature.

RESULTS

We calculated that the burden of depressive illness in filariasis patients was 5.09 million disability-adjusted life years (DALYs) and 229,537 DALYs attributable to their caregivers. These figures are around twice that of 2.78 million DALYs attributed to filariasis by the Global Burden of Disease study of 2010.

CONCLUSIONS

Lymphatic filariasis and other neglected tropical diseases, notably Buruli Ulcer, cutaneous leishmaniasis, leprosy, yaws, onchocerciasis and trachoma cause significant co morbidity associated with mental illness in patients. Studies to assess the prevalence of the burden of this co-morbidity should be incorporated into any future assessment of the Global Burden of neglected tropical diseases. The prevalence of depressive illness in caregivers who support those who suffer from these conditions is required. Such assessments are critical for neglected tropical diseases which have such a huge global prevalence and thus will contribute a significant burden of co-morbidity attributable to mental illness.

Investing in justice: ethics, evidence, and the eradication investment cases for lymphatic filariasis and onchocerciasis

It has been suggested that initiatives to eradicate specific communicable diseases need to be informed by eradication investment cases to assess the feasibility, costs, and consequences of eradication compared with elimination or control. A methodological challenge of eradication investment cases is how to account for the ethical importance of the benefits, burdens, and distributions thereof that are salient in people's experiences of the diseases and related interventions but are not assessed in traditional approaches to health and economic evaluation. We have offered a method of ethical analysis grounded in theories of social justice. We have described the method and its philosophical rationale and illustrated its use in application to eradication investment cases for lymphatic filariasis and onchocerciasis, 2 neglected tropical diseases that are candidates for eradication.

Filariasis serosurvey, New Caledonia, South Pacific, 2013

Background

Lymphatic filariasis (LF) is a major public health problem in the Pacific. As the global prevalence of infection was not known in New Caledonia (NC), a serosurvey study was conducted by determining the prevalence of circulating filarial antigens, as recommended by the World Health Organization.

Findings

A cross sectional study on a 2 degree stratified sample was carried out from June to November 2013. Inclusion criteria were: individuals aged 2 to 80 y/o, who had been hospitalized or sought medical care for a non-infectious cause and who had been living in NC for more than 6 months. LF antigenic detection was performed using the immunocromatographic BinaxNOW filariasis card test (ICT).

Among the 1,035 individuals tested, 7 were antigenic. The overall LF antigenic prevalence was 0.62% (CI 95% [0.60-0.63]).

All patients were unrelated to each other; none of them presented clinical symptoms of LF.

Four of the 7 ICT positive patients reported having travelled to LF endemic areas, 2 patients had never traveled outside NC and the last one had only traveled in non-endemic areas.

For the 7 ICT positive patients, the research of microfilariae in blood smears and filarial DNA by PCR was negative.

Conclusion

The prevalence of filarial antigenemia in NC is less than 1%, the threshold that defines the filarial endemic areas for WHO. Nevertheless, as two patients who had never travelled outside NC and one who had only travelled to non-endemic areas were antigenic, we cannot conclude that NC is totally free of LF.

Health-seeking behaviors and self-care practices of people with filarial lymphoedema in Nepal: a qualitative study

Background. Lymphatic filariasis is endemic in Nepal. This study aimed to investigate health-seeking behaviors and self-care practices of people with filarial Lymphoedema in Nepal. Methods. A cross-sectional study was conducted using qualitative methods in three endemic districts. Twenty-three patients with current Lymphoedema were recruited in the study. Results. Hydrocele was found to be a well-known condition and a major health problem in the studied communities. People with Lymphoedema primarily sought health care from traditional healers, whereas sometimes home-based care was their first treatment. Later Ayurvedic and allopathic hospital-based care were sought. Respondents reported various psychological problems such as difficulty in engaging in sexual intercourse, anxiety, worry and stress, depression, low self-esteem, feeling weak, fear of being abandoned, and fear of transmitting disease to the children. Standard foot care practices except washing were largely absent. Conclusions. Lymphoedema in the limbs and hydrocele were found to be major health problems. The traditional health care providers were the first contact of care for the majority of respondents. Only a few patients had been practicing standard foot care practices.

A review of factors that influence individual compliance with mass drug administration for elimination of lymphatic filariasis

Background

The success of programs to eliminate lymphatic filariasis (LF) depends in large part on their ability to achieve and sustain high levels of compliance with mass drug administration (MDA). This paper reports results from a comprehensive review of factors that affect compliance with MDA.

Methodology/Principal Findings

Papers published between 2000 and 2012 were considered, and 79 publications were included in the final dataset for analysis after two rounds of selection. While results varied in different settings, some common features were associated with successful programs and with compliance by individuals. Training and motivation of drug distributors is critically important, because these people directly interact with target populations, and their actions can affect MDA compliance decisions by families and individuals. Other important programmatic issues include thorough preparation of personnel, supplies, and logistics for implementation and preparation of the population for MDA. Demographic factors (age, sex, income level, and area of residence) are often associated with compliance by individuals, but compliance decisions are also affected by perceptions of the potential benefits of participation versus the risk of adverse events. Trust and information can sometimes offset fear of the unknown. While no single formula can ensure success MDA in all settings, five key ingredients were identified: engender trust, tailor programs to local conditions, take actions to minimize the impact of adverse events, promote the broader benefits of the MDA program, and directly address the issue of systematic non-compliance, which harms communities by prolonging their exposure to LF.

Conclusions/Significance

This review has identified factors that promote coverage and compliance with MDA for LF elimination across countries. This information may be helpful for explaining results that do not meet expectations and for developing remedies for ailing MDA programs. Our review has also identified gaps in understanding and suggested priority areas for further research.

Lymphatic filariasis (LF, also known as “elephantiasis”) is a deforming and disabling disease that is caused by roundworm parasites that are transmitted by mosquitoes. The Global Programme to Eliminate Lymphatic Filariasis is the largest public health intervention program attempted to date based on mass drug administration (MDA). MDA does not cure filarial infections, but it can reduce or interrupt transmission of new infections by clearing larval parasites from human blood so that they are not available for mosquitoes. High levels of participation are required for this strategy to work; guidelines from the World Health Organization call for at least 65% of the eligible population to take the medications annually for four to six years. MDA presents logistical challenges that require cooperation between donors, health ministries, and communities. The success of MDA depends on coverage (drug delivery) and compliance (people ingesting antifilarial drugs), which depends on individual interactions between drug distributors and the people who live in LF-endemic areas. This paper focuses on this last step of implementation with a comprehensive review of published and unpublished information on factors that affect compliance with MDA at the level of the individual. We have also provided an outline of current gaps in understanding and recommendations for further research.

Socioeconomic burden of lymphatic filariasis in Georgetown, Guyana

OBJECTIVE

To assess the socioeconomic impact of lymphatic filariasis (LF) in Guyana.

METHODS

Observational, cross-sectional study of 50 persons with chronic LF attending the Filariasis Clinic who were selected as the cases; and 50 persons with chronic skin conditions but no chronic LF, attending the Skin Clinic who were selected as the controls. The two groups were assessed using semi-structured interviews.

RESULTS

Socioeconomic impact was statistically significant, especially with respect to 'having to change jobs' and experiencing major emotional and financial changes (P < 0.05). Fifty-six per cent of cases reported a major change since their diagnosis, whereas only 32% of controls did. Cases were less likely to be able to dress themselves and walk inside and outside the house than controls; they were three times more likely to spend money on transportation than controls (OR, 3.04 95% CI 1.11, 8.44).

CONCLUSION

Patients with chronic LF face a considerable burden, which should be addressed as part of the Elimination Programme. One way in which this can be done is to provide free transportation for patients with chronic LF to and from Filariasis Clinics.

Impaired quality of life in adults and children with scabies from an impoverished community in Brazil

BACKGROUND

Scabies is highly prevalent in resource-poor communities in developing countries and is associated with considerable morbidity in this setting. How the parasitic skin disease impairs the quality of life of patients has rarely been investigated.

METHODOLOGY

A modified Dermatology Life Quality Index (mDLQI) was developed to assess the quality of life in adults and children with scabies living in an urban slum in Fortaleza, capital of Ceará State, Brazil. A total of 105 patients with scabies (58 children and 57 adults) were included in the study. The diagnosis was made by dermatoscopy, skin scraping, and adhesive film test.

RESULTS

Feelings of shame was the restriction most frequently noted (adults 77.2% and children 46.6%). Other types of quality of life impairment were the need to dress differently (35.1 vs. 29.3%), restriction on leisure activities (24.6 vs. 36.8%), social exclusion (24.6 vs. 17.9%), stigmatization (21.1 vs. 25.0%), teasing (only children: 26.3%), and problems with sexual partners (only adults: 10.9%). Women and girls perceived more restrictions than men and boys. mDLQI scores indicated that 13.9% of the patients noticed a large or very large effect on their life, 65.2% considered their quality of life lightly or moderately reduced by scabies, and 20.9% did not feel any restrictions. The degree of impairment increased parallel to the degree of itching and severity of scabies (P=0.003).

LIMITATIONS

Owing to active case finding, most of the patients were in an early phase of scabies, and clinical pathology was not very pronounced.

CONCLUSION

Scabies considerably impaired the quality of life in adults and children living in poverty in an urban slum. Females particularly suffered from restrictions.

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.

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

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

The emerging story of disability associated with lymphatic filariasis: a critical review

Globally, 40 million people live with the chronic effects of lymphatic filariasis (LF), making it the second leading cause of disability in the world. Despite this, there is limited research into the experiences of people living with the disease. This review summarises the research on the experiences of people living with LF disability. The review highlights the widespread social stigma and oppressive psychological issues that face most people living with LF-related disability. Physical manifestations of LF make daily activities and participation in community life difficult. The findings confirm the need for the Global Programme to Eliminate Lymphatic Filariasis (GPELF) to support morbidity management activities that address the complex biopsychosocial issues that people living with LF-related disability face.

Efficacy of home-based lymphoedema management in reducing acute attacks in subjects with lymphatic filariasis in Burkina Faso

One of the two main goals of the Global Programme to Eliminate Lymphatic Filariasis (LF) is to provide care for those suffering from the devastating clinical manifestations of this filarial infection. Among the 120 million infected people worldwide, up to 16 million have lymphoedema. The WHO strategy for managing lymphoedema is based on rigorous skin hygiene, exercise, antibiotics and antifungals when indicated. The aim is to reduce acute attacks of adenolymphangitis and cellulitis responsible for lymphoedema progression and disability. The objective of our study was to assess the effectiveness of home-based lymphoedema management implemented by the national health system of Burkina Faso. Any patient was eligible to participate in the study if suffering from LF-related lymphoedema of a lower limb at any stage, and receiving care as part of the health education and washing project between April 2005 and December 2007. The primary readout was the occurrence of an acute attack in the month preceding the consultation reported by the patient or observed by the care-giver. In all, 1089 patients were enrolled in the study. Before lymphoedema management intervention, 78.1% (95%CI: 75.5-80.5) of the patients had an acute attack in the month preceding the consultation; after four and half months of lymphoedema management, this was reduced to 39.1% (95%CI: 36.2-42.1). A reduction of acute attacks related to the number of consultations or related to the patients' age and gender was not observed. Our results suggest that the home-based lymphoedema management programme in the primary health care system of Burkina Faso is effective in reducing morbidity due to LF in the short-term (4.5 months). The lymphoedema management requires no additional human resources, but whether its effect can be sustained remains to be seen.

Rapid community identification, pain and distress associated with lymphoedema and adenolymphangitis due to lymphatic filariasis in resource-limited communities of North-eastern Nigeria

Identification of communities with people that could benefit from adenolymphangitis (ADL) and lymphoedema morbidity management within Lymphatic Filariasis Elimination Programmes (NLFEP) in many African countries is a major challenge to programme managers. Another challenge is advocating for proportionate allocation of funds to alleviating the suffering that afflicted people bear. In this study we developed a rapid qualitative technique of identifying communities where morbidity management programme could be situated and documenting the pain and distress that afflicted persons endure. Estimates given by health personnel and by community resource persons were compared with systematic household surveys for the number of persons with lymphoedema of the lower limb. Communities in Northeastern Nigeria, with the largest number of lymphoedema cases were selected and a study of local knowledge, physical, psychosocial burden and intervention-seeking activities associated with the disease documented using an array of techniques (including household surveys, key informant interviews, group discussions and informal conversations). Health personnel gave a more accurate estimate of the number of lymphoedema patients in their communities than either the community leader or the community directed ivermectin distributor (CDD). Community members with lymphoedema preferred to confide in health personnel from other communities. The people had a well developed local vocabulary for lymphoedema and are well aware of the indigenous transmission theories. Although the people associated the episodic ADL attacks with the rains which were more frequent at that period they did not associate the episodes with gross lymphoedema. There were diverse theories about lymphoedema causation with heredity, accidental stepping on charmed objects and organisms, breaking taboos. The most popular belief about causation, however, is witchcraft (60.9%). The episodic attacks are dreaded by the afflicted, since they are accompanied by severe pain (18%). The emotional trauma included rejection (27.5%) by family, friends and other community members to the extent that divorce and isolation are common. Holistic approach to lymphoedema morbidity management should necessarily be an integral component of the ongoing transmission elimination programme. Any transmission prevention effort that ignores the physical and psychological pain and distress that those already afflicted suffer is unethical and should not be promoted.

Do the filarial lymphoedema patients''3 months recall' on acute dermato-lymphangio-adenitis (ADLA) correlate with streptococcal serology?

AIM

The aim of this study was to know the correlation of patients' 3 months recall on acute dermato-lymphangio-adenitis (ADLA) with anti-streptolysin O (ASO) serology and its application as a tool to know the burden of ADLA in the community.

METHODS

Fifty-nine lymphoedema (LE) patients and 27 age matched controls were clinically assessed for LE and the occurrence of ADLA during the previous 3 months was obtained by recall. After obtaining the informed consent, 2 mL of venous blood sample was collected and ASO was quantified in Olympus AU400 auto-analyzer.

RESULTS

When the results were computed as two groups, controls and LE patients with no reported ADLA and LE patients with reported ADLA (by 3 months recall), the ASO positivity and ASO titre was significantly higher in the later group (P < 0.05). When the results were computed as three groups, controls with no reported ADLA, LE patients with no reported ADLA and LE patients with reported ADLA, the ASO titre was significantly higher in LE patients reported ADLA (P < 0.05).

CONCLUSION

As ASO was measured in post-infection phase, we relied on the ASO titre for making conclusion. Patients' 3 months recall on ADLA correlates with the ASO titre and therefore, it could be considered as a tool to measure the burden of ADLA in the community. Multicentre community-based studies are needed to ascertain the findings.

Clinical epidemiology of lymphatic filariasis and community practices and perceptions amongst the ado people of benue state, Nigeria

As part of efforts to initiate lymphatic filariasis elimination activities in Benue State, this study employed the use of lymphatic filariasis-related clinical signs as rapid diagnostic features, immunochromatographic card test (ICT) to detect circulating filarial antigen (CFA) and questionnaire to investigate community perceptions and beliefs. 81 (32.6%) out of the 248 persons were positive for circulating filarial antigen (CFA). Infection rates denoted by CFA ranged from 41 (46.1%) in Uffia to 1(6.6%) in Ijigbam districts. Distribution of community ICT prevalence showed a significant variation (X(2), P < 0.05). The prevalence of clinical signs and/or symptoms in the communities also showed significant variations (X(2), P < 0.05). Community hydrocoele prevalence ranged from 8 (9.0%) in Uffia to 1(6.6%) in Ijigbam. The overall hydrocoele prevalence was 21 (8.5%), while the overall lymphoedema prevalence was 16 (6.4%) and women accounted for 14 (87.5%) of persons with swollen limbs. Only about 14 (15.9%) of unaffected respondents knew that lymphatic filariasis is transmitted through mosquito bites, this differ significantly from affected respondents 10 (66.6%) (X(2), P < 0.05). The communities' capacity to protect themselves is hindered by a lack of understanding of the true cause, symptoms, transmission route and prevention of the disease. Our study demonstrates the need for the development of health education programmes that will enable people to protect themselves against mosquito bites. As Nigeria commence her lymphatic filariasis elimination programmes, there is an urgent need to develop morbidity management activities that will alleviate the burden of patients.

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.

Lessons from the Pacific programme to eliminate lymphatic filariasis: a case study of 5 countries

BACKGROUND

Lymphatic Filariasis (LF) is an important Neglected Tropical Disease, being a major cause of disability worldwide. The Global Programme to Eliminate Lymphatic Filariasis aims to eliminate LF as a public health problem by the year 2020, primarily through repeated Mass Drug Administration (MDA). The Pacific region programme commenced in 1999. By June 2007, five of the eleven countries classified as endemic had completed five MDA campaigns and post-MDA prevalence surveys to assess their progress. We review available programme data and discuss their implications for other LF elimination programs in developing countries.

METHODS

Reported MDA coverage and results from initial surveys and post-MDA surveys of LF using the immunochromatographic test (ICT) from these five Pacific Island countries (Tonga, Niue, Vanuatu, Samoa and Cook Islands) were analysed to provide an understanding of their quality and programme progress towards LF elimination. Denominator data reported by each country programme for 2001 was compared to official sources to assess the accuracy of MDA coverage data.

RESULTS

Initial survey results from these five countries revealed an ICT prevalence of between 2.7 and 8.6 percent in individuals tested prior to commencement of the programme. Country MDA coverage results varied depending on the source of denominator data. Of the five countries in this case study, three countries (Tonga, Niue and Vanuatu) reached the target prevalence of <1% antigenaemia following five rounds of MDA. However, endpoint data could not be reliably compared to baseline data as survey methodology varied.

CONCLUSION

Accurate and representative baseline and post-campaign prevalence data is crucial for determining program effectiveness and the factors contributing to effectiveness. This is emphasised by the findings of this case study. While three of the five Pacific countries reported achieving the target prevalence of <1% antigenaemia, limitations in the data preclude identification of key determinants of this achievement.

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.