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

Mapping lymphatic filariasis morbidities in 24 endemic districts of Ethiopia through the health extension program

BACKGROUND

The primary strategy for achieving the second goal of the Global Program to Eliminate Lymphatic Filariasis (GPELF) is morbidity management and disability prevention (MMDP), aimed at alleviating the suffering of affected populations. A significant challenge in many LF-endemic areas is the effective registration and identification of individuals with LF, which is crucial for planning and ensuring access to MMDP services. This study seeks to map the geographical distribution of LF-related morbidities across 24 endemic districts in Ethiopia.

METHODS

A community-based cross-sectional study was conducted to identify individuals affected by LF in 24 endemic districts using primary health care units (PHCUs). The study involved 946 trained health extension workers (HEWs) conducting house-to-house visits to identify and register cases of lymphedema and hydrocele, with support from 77 trained supervisors and 87 team leaders coordinating the morbidity mapping. Certified surgeons performed confirmatory evaluations through clinical assessments on a randomly selected sample of cases to validate HEW diagnoses, ensuring accurate identification of lymphedema and hydrocele. Statistical analysis of the data, including the severity of lymphedema and acute attacks, was conducted using STATA 17.

RESULTS

This study involved 300,000 households with nearly 1.2 million individuals, leading to the identification of 15,527 LF cases-14,946 (96.3%) with limb lymphedema and 581 (3.7%) with hydrocele. Among those with lymphedema, 8396 (54.1%) were women. Additionally, 13,731 (88.4%) patients resided in rural areas. Of the 14,591 cases whose acute attack information was recorded, 10,710 (73.4%) reported experiencing at least one acute attack related to their lymphedema in the past 6 months, with a notable percentage of males (74.5%; n = 4981/6686). Among the 12,680 recorded cases of leg lymphedema, the percentage of acute attacks increased with severity: 64% (n = 5618) mild cases, 68% (n = 5169) moderate cases and 70% (n = 1893) severe cases.

CONCLUSION

This study successfully mapped the geographical distribution of LF morbidities across 24 LF-endemic districts in Ethiopia, identifying a substantial number of lymphedema and hydrocele cases, particularly in rural areas where healthcare access is limited. The findings underscore the potential of Ethiopia's health extension program to identify affected individuals and ensure they receive necessary care. The findings inform targeted interventions and access to MMDP services, contributing to Ethiopia's goal of eliminating LF by 2027.

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.

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.

The national distribution of lymphatic filariasis cases in Malawi using patient mapping and geostatistical modelling

BACKGROUND

In 2020 the World Health Organization (WHO) declared that Malawi had successfully eliminated lymphatic filariasis (LF) as a public health problem. Understanding clinical case distributions at a national and sub-national level is important, so essential care packages can be provided to individuals living with LF symptoms. This study aimed to develop a national database and map of LF clinical cases across Malawi using geostatistical modelling approaches, programme-identified clinical cases, antigenaemia prevalence and climate information.

METHODOLOGY

LF clinical cases identified through programme house-to-house surveys across 90 sub-district administrative boundaries (Traditional Authority (TA)) and antigenaemia prevalence from 57 sampled villages in Malawi were used in a two-step geostatistical modelling process to predict LF clinical cases across all TAs of the country. First, we modelled antigenaemia prevalence in relation to climate covariates to predict nationwide antigenaemia prevalence. Second, we modelled clinical cases for unmapped TAs based on our antigenaemia prevalence spatial estimates.

PRINCIPLE FINDINGS

The models estimated 20,938 (95% CrI 18,091 to 24,071) clinical cases in unmapped TAs (70.3%) in addition to the 8,856 (29.7%), programme-identified cases in mapped TAs. In total, the overall national number of LF clinical cases was estimated to be 29,794 (95% CrI 26,957 to 32,927). The antigenaemia prevalence and clinical case mapping and modelling found the highest burden of disease in Chikwawa and Nsanje districts in the Southern Region and Karonga district in the Northern Region of the country.

CONCLUSIONS

The models presented in this study have facilitated the development of the first national LF clinical case database and map in Malawi, the first endemic country in sub-Saharan Africa. It highlights the value of using existing LF antigenaemia prevalence and clinical case data together with modelling approaches to produce estimates that may be used for the WHO dossier requirements, to help target limited resources and implement long-term health strategies.

Public perceptions of genomic studies and hereditary diseases in Aari community, South Omo Zone, Ethiopia

BACKGROUND

Genetic and genomic research is revolutionizing precision medicine; however, addressing ethical and cultural aspects is crucial to ensure ethical conduct and respect for community values and beliefs. This study explored the beliefs, perceptions and concerns of the Aari community in South Ethiopia regarding genetic concepts, hereditary diseases and ethical research practices related to sample collection, storage and sharing.

METHODS

In-depth interviews and focus group discussions were conducted with community elders, health officials, tuberculosis patients and apparently healthy individuals. Data were thematically analysed using MAXQDA software.

RESULTS

Participants identified diseases such as podoconiosis, leprosy, goitre and epilepsy as hereditary and perceived some as 'curses' due to generational impact and social stigma. Disease susceptibility was attributed to divine intervention or factors such as malnutrition and sanitation. Although hereditary diseases were considered unavoidable, in some cases environmental factors were acknowledged. Participants shared personal examples to demonstrate inheritance concepts. Blood held cultural significance, and concerns about its potential misuse resulted in scepticism towards giving samples.

CONCLUSIONS

This study emphasizes the significance of comprehending local beliefs and perceptions and stresses the need to establish effective communication, build trust and address underlying causes of hesitancy to improve recruitment and ensure ethical conduct.

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.

From Neglected to Public Health Burden: Factors Associated with Podoconiosis in Resource Limited Setting in Case of Southwest Ethiopia: A Community Based Cross Sectional Study

Background

Even though podoconiosis can cause physical, financial, and social impairments, it is commonly overlooked by organizations, and one-fourth of the predicted worldwide burden will fall on Ethiopia. In spite of this, there are only a few attempts for prevention and control in certain areas in Ethiopia. Updated statistics on prevalence and contributing factors could make local efforts at prevention, control, and rehabilitation more effective. Thus, this study was aimed to assess the prevalence of podoconiosis and its associated factors among Ilu Aba Bor zone residents, South West Ethiopia.

Methods

A community-based cross-sectional study was conducted on 491 participants from March 25 to April 25, 2022. Data were entered into Epi-Data version 4.6.0, then exported to SPSS version 25 for final analysis. In the bi-variable regression, variables with P-values less than 0.25 were included in the multivariable model. Finally, multivariable logistic regression was performed to identify factors associated with podoconiosis at a 5% level of significance.

Results

In this study area, podoconiosis prevalence was found to be 5.7% [3.6-7.2]. In multivariable regression model, lower tertile wealth status [AOR=2.09; (95% CI (1.384, 5.343)], no formal education [AOR=2.23; (95% CI; 1.179-3.820)] and average distance to reach water source to home [AOR=2.061; (95% CI: 1.78-7.35)] were significantly associated podoconiosis.

Conclusion and Recommendation

According to this study, one in every seventeen individuals had podoconiosis, which is a significant prevalence when compared to earlier studies. Podoconiosis was observed to be associated with factors like wealth status, educational attainment, and distance from water source. To address this public health issue, strong preventive and therapeutic treatments should be used.

Effect of a Community-Based Holistic Care Package on Physical and Psychosocial Outcomes in People with Lower Limb Disorder Caused by Lymphatic Filariasis, Podoconiosis, and Leprosy in Ethiopia: Results from the EnDPoINT Pilot Cohort Study

Lymphatic filariasis (LF), podoconiosis, and leprosy are highly stigmatized neglected tropical diseases that can cause lower limb swelling and deformity. Simple interventions to support self-care can reduce their physical impacts, but little is known about how to address the psychosocial needs of people living with the diseases, and about how to scale-up morbidity reduction programs. EnDPoINT is a multistage implementation study designed to address these knowledge gaps by developing and evaluating a holistic care package that can be integrated into the Ethiopian health system. This article presents the quantitative results from the EnDPoINT pilot, in which the effectiveness of the care package was assessed in 251 participants from one district in northern Ethiopian using a pre-post design. Reductions 12 months after care package initiation were seen in attacks of acute adenolymphangitis (adjusted odds ratio for attack in last month 0.005; 95% CI 0.001, 0.02; P < 0.001), lower limb and foot circumference (mean difference lower limb circumference -2.0 cm; 95% CI -2.3, -1.8; P < 0.001; foot circumference -2.3 cm; 95% CI -2.5, -2.0; P < 0.001), and lymphedema stage (mean reduction in stage -0.27; 95% CI -0.37, -0.19; P < 0.001). Significant improvements were also observed in scores assessing disability, quality-of-life, depression, stigma, discrimination, and social support. This study thus suggests that the EnDPoINT care package is highly effective in reducing morbidity in people living with LF, podoconiosis, and leprosy in northern Ethiopia.

Knowledge, attitudes and practices of health professionals towards people living with lymphoedema caused by lymphatic filariasis, podoconiosis and leprosy in northern Ethiopia

BACKGROUND

Podoconiosis, lymphatic filariasis and leprosy are highly stigmatised neglected tropical diseases that cause lymphoedema. Their enormous impacts on health-related quality of life, mental health and economic productivity can be significantly reduced by morbidity management and disability prevention (MMDP) services, but to deliver such services requires appropriate training of healthcare professionals. The aim of this study was to assess the knowledge, attitudes and practices (KAP) of rural Ethiopian healthcare professionals towards people with lymphoedema as a way to assess training needs.

METHODS

This study used questionnaires to quantitatively assess KAP towards people with lymphoedema among rural healthcare professionals in northwest Ethiopia before and 12 months after a short training intervention.

RESULTS

Questionnaires were administered to 14 health professionals at baseline and 21 at follow-up. At baseline, 71% (10/14) were found to hold at least one stigmatising attitude towards lymphoedema patients, compared with 66% (14/21) at follow-up. Large gaps in knowledge were noted, with many unable to identify ways of treating/preventing the diseases.

CONCLUSIONS

This study showed high proportions of healthcare workers holding stigmatising views and lacking essential knowledge about lymphoedema. To maximise the impact of MMDP interventions, further research is urgently needed to understand how to address these issues.

A qualitative study on the implementation of a holistic care package for control and management of lymphoedema: experience from a pilot intervention in northern Ethiopia

Background

Neglected Tropical Diseases (NTDs) such as podoconiosis, lymphatic filariasis (LF) and leprosy mainly affect communities in low resource settings. These diseases are associated with physical disability due to lymphoedema as well as poor mental health and psychosocial outcomes. Integration of care across these NTDs at primary health care level, which includes mental health and psychosocial care alongside physical health care, is increasingly recommended.

Methods

A holistic integrated care package was developed and piloted as part of the EnDPoINT project in Gusha district, Awi zone, Ethiopia. The intervention was conducted at the health care organization, health facility and community levels. To assess the impact of the care package in terms of acceptability, scalability, sustainability and barriers to implementation, a qualitative study was conducted in January 2020. This included four focus group discussions (29 participants) and ten key informant interviews with decision makers, health professionals, patients, and community representatives.

Results

The integrated lymphoedema care package was found to be efficient compared to vertical programs in saving time and resources. It also resulted in improved awareness of the causes, treatment and prevention of lymphoedema, in marked improvements in the lymphoedema, and in reduced stigma and discrimination. The care package was found to be acceptable to patients, health professionals and decision makers. The barriers to integrated care were unrealistic patient expectations, inadequate dissemination across health workers, and poor transportation access. Health professionals, decision makers and patients believed the integrated lymphoedema care package to be scalable and sustainable.

Conclusion

The integrated holistic care package was found to be acceptable to patients, health professionals and decision makers. We recommend its scale-up to other endemic districts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07088-7.

Insights on Lymphedema Self-Care Knowledge and Practice in Filariasis and Podoconiosis-Endemic Communities in Bangladesh and Ethiopia

Lymphedema is a life-long sequelae to several neglected tropical diseases (NTD). In Bangladesh the main cause is lymphatic filariasis (LF) and Ethiopia is endemic for both LF and podoconiosis. The World Health Organization (WHO) recommends daily self-care including meticulous washing and drying of affected skin and attention to entry lesions, limb exercises and elevation. Adherence to this regime reduces secondary infections which cause disabling episodes of acute dermato-lymphangitis (ADL). Self-care practices must be integrated into family life, supported by community and monitored by health staff; however, little is known about the influence of personal and socio-demographic factors on adherence. People affected by lymphedema (n=272), adult caregivers (n=272), and health workers (n=68) in Bangladesh and Ethiopia were trained in lymphedema management according to WHO recommendations. Surveys on the causes and management of lymphedema were collected at baseline and 24-weeks, and patients completed a daily journal of self-care activities and symptoms. At baseline knowledge on causes and management of lymphedema was greater among health workers (&gt;70%) than patients and caregivers (&lt;20%) in both countries, and there were significant between-country differences in patient reported use of limb washing (Bangladesh = 7.7%. Ethiopia = 51.1%, p = 0.001). At 24-weeks knowledge on lymphedema causes and management had increased significantly among patients and caregivers, there was &lt;70% adherence to limb washing and exercises, but lesser use of limb elevation in both countries. A range of patient characteristics were associated with significant variation in self-care, except for limb washing. Performance of fewer leg exercises was significantly associated with increased age or severe lymphedema in Bangladesh, and with being female or in paid work in Ethiopia. Patient journals recorded ADL symptoms and working days lost due to lymphedema more frequently than were reported by recall during the 24-week survey. Core elements of lymphedema self-care education, training and monitoring are the same for multiple etiologies. This creates opportunities for cross-cutting implementation of integrated service delivery across several skin NTDs. Sustainability will depend on community level ownership and research on factors affecting adherence to lymphedema self-care are urgently needed.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Infrared Thermal Imaging as a Novel Non-Invasive Point-of-Care Tool to Assess Filarial Lymphoedema

Lymphatic filariasis causes disfiguring and disabling lymphoedema, which is commonly and frequently exacerbated by acute dermatolymphangioadenitis (ADLA). Affected people require long-term care and monitoring but health workers lack objective assessment tools. We examine the use of an infrared thermal imaging camera as a novel non-invasive point-of-care tool for filarial lower-limb lymphoedema in 153 affected adults from a highly endemic area of Bangladesh. Temperature differences by lymphoedema stage (mild, moderate, severe) and ADLA history were visualised and quantified using descriptive statistics and regression models. Temperatures were found to increase by severity and captured subclinical differences between no lymphoedema and mild lymphoedema, and differences between moderate and severe stages. Toes and ankle temperatures detected significant differences between all stages other than between mild and moderate stages. Significantly higher temperatures, best captured by heel and calf measures, were found in participants with a history of ADLA, compared to participants who never had ADLA, regardless of the lymphoedema stage. This novel tool has great potential to be used by health workers to detect subclinical cases, predict progression of disease and ADLA status, and monitor pathological tissue changes and stage severity following enhanced care packages or other interventions in people affected by lymphoedema.

Caring for patients in the global programme to eliminate lymphatic filariasis

Clinical lymphatic filariasis (LF) is a debilitating, disfiguring medical condition with severe psychosocial consequences for patients and their families. Addressing these patients’ medical needs is a major component of the global programme to eliminate lymphatic filariasis (GPELF). In the 20 y of providing a minimal package of care many thousands of surgical operations to correct LF hydrocoeles been performed and national programmes in >90% of LF endemic countries have received the training needed to care for their patients. The creation of educational materials detailing appropriate patient care, together with increased funding, have been key catalysts in increasing awareness of clinical LF in recent years. Nevertheless, the implementation of care for these patients has often faced challenges that have led to delays in fully implementing the patient care component of GPELF; these include locating these often stigmatised individuals, maintaining provision of the necessary consumables (e.g. soaps and creams) and maintaining programme support within already overstretched national LF teams. As the LF global programme moves to achieve success by 2030 it will be vital to continue to focus efforts on the care and rehabilitation of those suffering from lymphoedema and hydrocoeles, learning from the experiences of the past 20 y.

Assessment of Etiology of Elephantiasis and Its Associated Risk Factors in Jeldu District, West Shoa, Ethiopia

Elephantiasis is the main cause of tropical lymphoedema in Ethiopia. The aim of the current study was to assess the etiology of elephantiasis and its associated risk factors. Cross-sectional community-based study was carried out from March to May 2020 in seven purposively selected villages of Jeldu district. Identified suspected cases of elephantiasis in those villages were interviewed, clinically observed, and serologically examined using filariasis test strip kits at their respective houses during day time. A midnight blood sample was obtained from all FTS positive cases for microscopic examination of Wuchereria bancrofti larva, microfilariae. From a total of 105 identified elephantiasis cases, 69.5% were podoconiosis cases and 30.5% were LF cases. Among 32 serologically positive cases, only 15.6% cases were found positive by parasitological blood diagnosis. Considerable cases of podoconiosis (37%) were at age range 26-40 years, whereas smallest cases (16.4%) were at 10-25 years. Among cases of podoconiosis and LF, 77 subjects have been developed overt chronic leg(s) swelling; 85.7% of them showed bilateral swelling below knee and 14.3% of them showed unilateral swelling with stage II swelling 41.1%. Regarding risk factors, odds of podoconiosis was greatly lower in participants who washed their legs daily when compared to those who washed their legs sometimes (P=0.002). Odds of LF was higher in people who used bed nets/IRS and they were more protected than those who did not use bed nets/IRS (P=0.03). Odds of LF was high in cases farming besides rivers and/or perform irrigation work (P=0.003). The highest silicon concentration 4.65 mg/10 gm in Urgaha is coinciding with the highest podoconiosis cases (23.3%) of the village. Family history was a significant risk factor for the disease (P ≤ 0.001). Age (26-40 years), sex, and leg hygiene were also strong risk factors. Both etiologies of elephantiasis, LF and podoconiosis, are geographically overlapped in Jeldu district.

Addition of Lymphatic Stimulating Self-Care Practices Reduces Acute Attacks among People Affected by Moderate and Severe Lower-Limb Lymphedema in Ethiopia, a Cluster Randomized Controlled Trial

Lymphedema causes disability and exacerbates poverty in many countries. The management of lymphatic filariasis (LF) and podoconiosis-related lymphedema involves daily hygiene to reduce secondary infections, but self-massage and deep-breathing, which have proven beneficial in cancer-related lymphedema, are not included. A cluster randomized trial in northern Ethiopia investigated the effects of lymphatic stimulation for people affected by moderate to severe lymphedema. Participants were allocated to either standard (control n = 59) or enhanced (intervention n = 67) self-care groups. Primary outcomes were lymphedema stage, mid-calf circumference, and tissue compressibility. Secondary outcomes were the frequency and duration of acute attacks. After 24 weeks, fewer patients were assessed as severe (control −37.8%, intervention −42.4%, p = 0.15) and there were clinically relevant changes in mid-calf tissue compressibility but not circumference. There was a significant between-group difference in patients who reported any acute attacks over the study period (control n = 22 (38%), intervention n = 7 (12%), p = 0.014). Daily lymphedema self-care resulted in meaningful benefits for all participants with a greater reduction in acute episodes among people performing lymphatic stimulation. Observations of a change in lymphedema status support earlier findings in Bangladesh and extend the demonstrated benefits of enhanced self-care to people affected by podoconiosis.

Economic assessment of a community-based care package for people with lower limb disorder caused by lymphatic filariasis, podoconiosis and leprosy in Ethiopia

We conducted an implementation research study to integrate a holistic package of physical health, mental health and psychosocial care for podoconiosis, lymphatic filariasis and leprosy into routine healthcare in Gusha cluster, Guagusa Shikudad district, northwest Ethiopia. The healthcare package included training patients in lower limb hygiene and skin care and provision of shoes, hygiene supplies and medication. The implementation activities included training events, workshops, awareness raising, self-help groups, supportive supervision, staff secondments and advisory board meetings. The cost of implementing the care package in Gusha cluster, with a population of 30 558 people, was 802 655 Ethiopian birr (ETB) (£48 159) and the cost of delivering care to 235 participants was 204 388 ETB (£12 263), or 870 ETB (£52) per person. There was a 35% decrease in the mean disability scores (measured using the World Health Organization Disability Assessment Schedule 2.0) and a 45% improvement in the dermatology-specific quality of life (measured using the Dermatology Life Quality Index) at the 3-month follow-up compared with baseline. There were reductions in the number of days with symptoms, days off usual activities/work and days with reduced activity due to illness, all of which were statistically significant. Our pilot suggests that integration of the care package into routine healthcare in Ethiopia may be effective in improving health-related quality of life and disability and reducing time out of economic activity due to illness.

Developing consensus of evidence to target case finding surveys for podoconiosis: a potentially forgotten disease in India

BACKGROUND

Podoconiosis is a non-infectious geochemical lymphoedema of the lower legs associated with a significant burden of morbidity. There are historical reports of podoconiosis in India, but its current endemicity status is uncertain. In this investigation we aimed to prioritise the selection of districts for pilot mapping of podoconiosis in India.

METHODS

Through a consultative workshop bringing together expert opinion on podoconiosis with public health and NTDs in India, we developed a framework for the prioritisation of pilot areas. The four criteria for prioritisation were predicted environmental suitability for podoconiosis, higher relative poverty, occurrence of lymphoedema cases detected by the state health authorities and absence of morbidity management and disability prevention (MMDP) services provided by the National Programme for Elimination of Lymphatic Filariasis.

RESULTS

Environmental suitability for podoconiosis in India was predicted to be widespread, particularly in the mountainous east and hilly southwest of the country. Most of the districts with higher levels of poverty were in the central east and central west. Of 286 districts delineated by state representatives, lymphoedema was known to the health system in 189 districts and not recorded in 80. Information on MMDP services was unavailable for many districts, but 169 were known not to provide such services. We identified 35 districts across the country as high priority for mapping based on these criteria.

CONCLUSIONS

Our results indicate widespread presence of conditions associated with podoconiosis in India, including areas with known lymphoedema cases and without MMDP services. This work is intended to support a rational approach to surveying for an unrecognised, geographically focal, chronic disease in India, with a view to scaling up to inform a national strategy if required.

Integration of Management Strategies for Skin-Related Neglected Tropical Diseases

The concept of skin neglected tropical diseases has been widely adopted into the policy and strategy of various organizations, governments, nongovernmental organizations, and health agencies. By pooling information and resources across different diseases, whose primary manifestations affect the skin, it is possible to deliver integrated surveillance and control programs and promote advocacy and reduction of disability and stigma. A further key part of the skin neglected tropical diseases program is the development and validation of training methods for front-line health workers. Networks that allow those involved in this work to share and compare expertise are being developed through various organizations.

EnDPoINT: protocol for an implementation research study to integrate a holistic package of physical health, mental health and psychosocial care for podoconiosis, lymphatic filariasis and leprosy into routine health services in Ethiopia

INTRODUCTION

Neglected tropical diseases (NTDs) causing lower limb lymphoedema such as podoconiosis, lymphatic filariasis (LF) and leprosy are common in Ethiopia. Routine health services for morbidity management and disability prevention (MMDP) of lymphoedema caused by these conditions are still lacking, even though it imposes a huge burden on affected individuals and their communities in terms of physical and mental health, and psychosocial and economic outcomes. This calls for an integrated, holistic approach to MMDP across these three diseases.

METHODS AND ANALYSIS

The 'Excellence in Disability Prevention Integrated across NTDs' (EnDPoINT) implementation research study aims to assess the integration and scale-up of a holistic package of care-including physical health, mental health and psychosocial care-into routine health services for people with lymphoedema caused by podoconiosis, LF and leprosy in selected districts in Awi zone in the North-West of Ethiopia. The study is being carried out over three phases using a wide range of mixed methodologies. Phase 1 involves the development of a comprehensive holistic care package and strategies for its integration into the routine health services across the three diseases, and to examine the factors that influence integration and the roles of key health system actors. Phase 2 involves a pilot study conducted in one subdistrict in Awi zone, to establish the care package's adoption, feasibility, acceptability, fidelity, potential effectiveness, its readiness for scale-up, costs of the interventions and the suitability of the training and training materials. Phase 3 involves scale-up of the care package in three whole districts, as well as its evaluation in regard to coverage, implementation, clinical (physical health, mental health and psychosocial) and economic outcomes.

ETHICS AND DISSEMINATION

Ethics approval for the study has been obtained in the UK and Ethiopia. The results will be disseminated through publications in scientific journals, conference presentations, policy briefs and workshops.

Quantifying the socio-economic impact of leg lymphoedema on patient caregivers in a lymphatic filariasis and podoconiosis co-endemic district of Ethiopia

Background

Lymphoedema caused by lymphatic filariasis (LF) or podoconiosis can result in physical disability and social exclusion, which is exacerbated by painful acute dermatolymphangioadenitis (ADLA) episodes. These conditions have a significant impact on patients, however, little is known about the indirect effects on their caregivers. This study, therefore, aimed to determine the impact on caregivers for patients with leg lymphoedema in a co-endemic district of Ethiopia.

Methodology/Principal findings

A cross-sectional survey of lymphoedema patients and their caregivers was conducted using semi-structured questionnaires in the Southern Nation Nationalities Peoples Region (SNNPR) of Ethiopia. Lymphoedema patient information on clinical severity (mild, moderate, severe), frequency of ADLAs, their socio-demographic characteristics and the identity of main caregiver(s) was collected. Caregiver information on socio-demographic characteristics, types of care provided, their quality of life (QoL) measured across nine domains, and productivity was collected, with key indicators compared in the presence and absence of patients’ ADLAs.

A total of 73 patients and 76 caregivers were included. Patients were grouped by mild/moderate (n = 42, 57.5%) or severe (n = 31, 42.5%) lymphoedema, and reported an average of 6.1 (CI± 2.18) and 9.8 (CI± 3.17) ADLAs respectively in the last six months. A total of 48 (65.8%) female and 25 (34.2%) male patients were interviewed. Caregivers were predominately male (n = 45, 59.2%), and spouses formed the largest caregiving group for both female and male patients.

In the absence of an ADLA, most caregivers (n = 42, 55.2%) did not provide care, but only one caregiver did not provide care during an ADLA. In the absence of an ADLA, the average time (hour:minute) spent by mild/moderate (00:17, CI: ± 00:08) and severe (00:10, CI: ± 00:07) patient caregiver per task was minimal. The time mild/moderate (00:47, CI: ± 00:11) and severe (00:51, CI: ± 00:16) patient caregivers spent per task significantly increased in the presence of an ADLA. In addition, caregivers’ QoL was negatively impacted when patients experienced an ALDA, and they had to forfeit an average of 6 to 7 work/school days per month.

Conclusion/Significance

Lymphoedema and ADLAs impact negatively on patients’ and their caregivers’ lives. This emphasises the importance of increasing access to effective morbidity management and disability prevention services to reduce the burden and help to address the Sustainable Development Goal (SDG) 5, target 5.4, which seeks to recognise and value unpaid care and domestic work.

Lymphatic filariasis and podoconiosis can result in chronic severe lymphoedema of the limbs, which is aggravated by frequent painful episodes of acute bacterial infection known as ‘acute attacks’. The debilitating impact of these conditions on patients are well documented, however, the extent to which the hardship extends to their caregivers is unknown. To address this knowledge gap, a survey of 73 lymphoedema patients and their caregivers was conducted in an endemic region of Ethiopia. Patients were found to be predominately female and caregivers predominately male, mostly spouses. Caregivers provided a wide range of care, and the type, frequency and time spent on tasks significantly increased when patients experienced an acute attack. Caregivers reported a negative impact on their quality of life and provided care for an average of 15 days and forfeited an average of 7 days of work or school per month. This study has revealed a previously hidden burden of lymphoedema that not only affects patients, but their caregivers who are mostly family members. This emphasises the importance of increasing access to effective morbidity management and disability prevention programmes to reduce the burden and help to address the Sustainable Development Goal (SDG) 5, target 5.4, which seeks to recognise and value unpaid and domestic work.

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

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

Lymphedema in three previously Wuchereria bancrofti-endemic health districts in Mali after cessation of mass drug administration

Background

Lymphedema is a public health problem in countries with lymphatic filariasis (LF) including Mali. We studied the epidemiology and clinical presentation of lymphedema in three previously LF-endemic health districts of Mali after at least five consecutive rounds of mass drug administration (MDA) with albendazole and ivermectin.

Methods

From 2016 to 2018, we used passive and active case finding methods to identify lymphedema cases in three health districts with high pre-MDA LF prevalence: Kolondieba (66%), Bougouni (44%) and Kolokani (34%).

Results

Three hundred and thirty nine cases of lymphedema were identified, 235 (69.32%) through active case finding. Their median age was 56 years (range 2–90) and 286 (84.36%) were women. Lymphedema was reported in 226 (78.5%) people aged 41 years and older compared to 73 (21.5%) people below the age of 41 years (Chi² = 17.28, df = 5, p = 0.004). One hundred and seventy five cases of lymphedema were found in Kolondieba (66 per 100,000 people), 116 in Bougouni (19 per 100,000) and 48 in Kolokani (16 per 100,000). Stage III lymphedema was observed in 131 (38.64%), stage II in 108 (31.86%), stage IV in 46 (13.57%), stage I in 23 (6.78%), stage V in 21 (6.19%) and stage VI in ten (2.95%). In the three study districts, lymphedema affected the legs in 281 (82.89%), the arms in 42 (12.39%) and both in 16 (4.72%) (Chi2 = 13.63, p = 0.008).

Conclusion

Health districts in Mali with the highest pre-MDA LF prevalences had the highest prevalence of lymphedema. Efforts to actively identify lymphedema cases should be scaled up in previous LF-endemic areas, and should be supplemented by a morbidity management and disability prevention plan at the peripheral health system level.

Epidemiology of podoconiosis in Ethiopia: a systematic review and meta-analysis protocol

INTRODUCTION

Podoconiosis is a non-filarial swelling of the lower extremity endemic in tropical regions, North America and India. The aetiology and pathophysiology of the disease remain unknown. We propose conducting a systematic review and meta-analysis to evaluate the burden and risk factors of podoconiosis in Ethiopia reported in studies from 2009 to 2019.

METHODS AND ANALYSIS

We will search the following electronic databases: PubMed (MEDLINE), EMBASE, Hinari, Cumulative Index to Nursing and Allied Health Literature, ISI (Web of Science) and Google Scholar. Medical subject headings will be used to extensively search relevant literature on electronic databases using related keywords such as epidemiology or prevalence, magnitude or burden, podoconiosis, and Ethiopia. Grey literature and manual search will also be performed to retrieve unindexed research articles. Two reviewers will screen all retrieved articles, conduct data extraction and then critically appraise all identified studies. We will analyse data using STATA V.14 statistical software. We will demonstrate pooled estimates of podoconiosis and associated factors with effect size and 95% CI. The presence of heterogeneity among studies will be examined by forest plot as well as the I² heterogeneity test. Potential causes of heterogeneity will be explored by carrying out sensitivity and subgroup analyses. The presence of publication bias will also be examined by observing funnel plots and objectively by Egger's regression test. If the funnel plot is asymmetric and/or Egger's test was found to be statistically significant (p<0.05), the trim and fill (Duval and Tweedie's) analysis will be performed.

ETHICS AND DISSEMINATION

The study will use publicly available data and will not identify the authors of the publication by name. In light of these and as has been indicated, research ethics clearance is not required for evidence syntheses in such reviews. The results of this study will be published in a peer-reviewed journal and presented at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42019127459.

Developing the first national database and map of lymphatic filariasis clinical cases in Bangladesh: Another step closer to the elimination goals

Background

The Bangladesh Lymphatic Filariasis (LF) Elimination Programme has made significant progress in interrupting transmission through mass drug administration (MDA) and has now focussed its efforts on scaling up managing morbidity and preventing disability (MMDP) activities to deliver the minimum package of care to people affected by LF clinical conditions. This paper highlights the Bangladesh LF Programme’s success in conducting a large-scale cross-sectional survey to determine the number of people affected by lymphoedema and hydrocoele, which enabled clinical risk maps to be developed for targeted interventions across the 34 endemic districts (19 high endemic; 15 low endemic).

Methodology/Principal findings

In the 19 high endemic districts, 8,145 community clinic staff were trained to identify and report patients in their catchment area. In the 15 low endemic districts, a team of 10 trained field assistants conducted active case finding with cases reported via a SMS mHealth tool. Disease burden and prevalence maps were developed, with morbidity hotspots identified at sub-district level based on a combination of the highest prevalence rates per 100,000 and case-density rates per square kilometre (km²). The relationship between morbidity and baseline microfilaria (mf) prevalence was also examined. In total 43,678 cases were identified in the 19 high endemic districts; 30,616 limb lymphoedema (70.1%; female 55.3%), 12,824 hydrocoele (29.4%), and 238 breast/female genital swelling (0.5%). Rangpur Division reported the highest cases numbers and prevalence of lymphoedema (26,781 cases, 195 per 100,000) and hydrocoele (11661 cases, 169.6 per 100,000), with lymphoedema predominately affecting females (n = 21,652). Rangpur and Lalmonirhat Districts reported the highest case numbers (n = 11,199), and prevalence (569 per 100,000) respectively, with five overlapping lymphoedema and hydrocoele sub-district hotspots. In the 15 low endemic districts, 732 cases were identified; 661 lymphoedema (90.2%; female 39.6%), 56 hydrocoele (7.8%), and 15 both conditions (2.0%). Spearman’s correlation analysis found morbidity and mf prevalence significantly positively correlated (r = 0.904; p<0.01).

Conclusions/Significance

The Bangladesh LF Programme has developed one of the largest, most comprehensive country databases on LF clinical conditions in the world. It provides an essential database for health workers to identify local morbidity hotspots, deliver the minimum package of care, and address the dossier elimination requirements.

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) requires lymphatic filariasis (LF) endemic countries, such as Bangladesh, to estimate the number of lymphoedema and hydrocoele cases in order to deliver the minimum package of care required to control morbidity and reduce patient suffering. This paper highlights the Bangladesh LF Elimination Programme’s progress in training more than 8000 community health workers to identify more than 44,000 cases across 34 endemic districts where approximately 70 million people are at risk. The morbidity data collected enabled the creation of a national database and a series of risk maps of lymphoedema and hydrocoele to be developed, which highlighted the significant burden in northern Rangpur Division, especially of lymphoedema among female patients. The Bangladesh LF Elimination Programme’s efforts to identify LF cases across all endemic districts represents one of the most comprehensive national databases on LF clinical cases in the world. It provides an informative database for health workers to use in the delivery of the minimum package of care and a template for other countries to adopt and develop national strategies to manage morbidity and prevent disability as recommended by GPELF.

A comparison between paper-based and m-Health tools for collating and reporting clinical cases of lymphatic filariasis and podoconiosis in Ethiopia

BACKGROUND

Lymphatic filariasis (LF) and podoconiosis are disabling diseases, endemic in Ethiopia. The main clinical manifestations include lymphoedema from LF and podoconiosis, and hydrocoele from LF. To ensure access to morbidity management and disability prevention (MMDP) services, data on patient numbers in each implementation unit (IU) is required. House-to-house census is considered the gold standard for determining patient numbers, and data are usually collated and reported using paper-based methods. However, often there are delays in data reaching the regional and central level, which leads to subsequent delays in rolling out and prioritising MMDP services. The increase in mobile phone mHealth tools offers an alternative, potentially more rapid and cost-effective approach.

METHODS

As part of an LF and podoconiosis burden assessment conducted in Hawella Tula and Bensa districts in Ethiopia, this study compared the standard paper-based methods with the new MeasureSMS-Morbidity tool for clinical cases data collation and reporting. Health extension workers (HEWs) were trained on both methods. Comparisons were made on patient information; age, gender, location (i.e., kebele), condition, severity of condition and acute attacks. Data were analysed for trends, including the differences in ranking the villages in each district based on the highest to lowest number of cases. In addition, financial and human resource requirements were compared.

RESULTS

In total, 59 HEWs (19 from Hawella Tula; 40 from Bensa) collated and reported a similar number of cases by paper-based (n=2,377) and SMS (n=2,372) methods. Significant correlations were found between the two methods for all cases and lymphoedema cases in both districts, and for hydrocoele cases in Bensa district only. The total cost of paper-based reporting was 13.7% more expensive than SMS reporting due to costs associated with data collection and entry.

CONCLUSIONS

The rank correlation showed the same villages would be prioritised for delivery of MMDP services, with time and cost-savings observed using SMS reporting, suggesting it is an effective and efficient alternative tool to help facilitate care to those who need it most.

The Skin-A Common Pathway for Integrating Diagnosis and Management of NTDs

Many of the neglected tropical diseases (NTDs) have major skin manifestations. These skin-related NTDs or ‘skin NTDs’ cause significant morbidity and economic hardship in some of the poorest communities worldwide. We draw attention to the collective burden of skin disease and suggest that the skin be used as a platform for the integration of control activities for NTDs. The opportunities for integration are numerous, ranging from diagnosis and disease mapping to mass drug administration and morbidity management. The dermatology community has an important role to play, and will be expected to support research and control activities globally.