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.

Progress and impact of 20 years of a lymphatic filariasis elimination programme in South-East Asia

Background

The South-East Asia regional programme to eliminate lymphatic filariasis (LF) was launched in 2000. This study presents the progress and impact of the programme in the region.

Methods

Mass drug administration (MDA) and morbidity management data were accessed from the WHO preventive chemotherapy databank. The status of the programme in the nine South-East Asia countries was reviewed and progress was assessed. The impact of the programme on LF disease burden was estimated on the basis of the effectiveness of the MDA drugs against microfilaraemia and chronic disease.

Results

Under the MDA programme, 8.1 billion treatments were delivered in nine countries and 5.7 billion treatments were consumed by the target population during 2001–2018. Three of nine countries eliminated LF. Bangladesh is poised to reach its elimination goal by 2021. In the other five countries, 38–76% of intervention units completed intervention and surveillance is in progress. The MDA programme prevented or cured 74.9 million infections, equivalent to an 84.2% reduction. Close to 1 million lymphoedema patients and 0.5 million hydrocele patients were reported and are being provided with the minimum package of care.

Conclusions

The South-East Asia region's LF elimination programme reduced the burden of LF appreciably and is moving towards achieving the elimination goal in the next 8–10 y.

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

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

The 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.

Information technology in morbidity management of human lymphatic filariasis-A promising tool in global programme for elimination of lymphatic filariasis

Background & objectives

India is a signatory to the 1997 World Health Assembly resolutions on lymphatic fila- riasis, and other neglected tropical diseases, and supports global elimination of lymphatic filariasis by 2020. The global programme to eliminate lymphatic filariasis (GPELF) has two main components, viz. interrupting transmission of LF through mass drug administration; and managing morbidity and preventing disability. Consorted efforts by the Public Health Department in Tamil Nadu state (India) for elimination of LF was launched in the year 1997 concentrating on both the components of the programme. The data on the prevalence of filarial morbidity and its entire management at present is based on manual reports and registers maintained by the field functionaries. To overcome the constraints in the manual reporting, an attempt was made to develop a web-based reporting system with different modules and user-friendly interface.

Methods

The Vellore and Thiruvannamalai districts were selected as a study area. The study was conducted between 2011 and 2014, which revealed that the entire morbidity management was based on the manual formats. Constraints in the present manual reporting were analysed. PHP and MySQL tools were used to generate user friendly modules. Feedback was collected from field functionaries at different health centre levels, on the adequacy in the modules and effectiveness of the web-based reporting system.

Results

The online reporting modules facilitated data entry at the health subcentre level itself. Analysis and retrieval of data was facilitated at all other levels in the public health system. The modules also covered details of surgical interventions, ex-gratia payments and other benefits extended to the lymphoedema patients by the Government.

Interpretation & conclusion

The usage and feedback of the web-based reporting system appeared very encouraging and reliable, indicating that it can be implemented in health programmes for disease management. This web-based user-friendly online reporting system can contribute largely to achieve the goals of the GPELF; specially after MDA is withdrawn.

Situational analysis of lymphatic filariasis morbidity in Ahanta West District of Ghana

OBJECTIVES

Situational analysis of lymphatic filariasis (LF) morbidity and its management in Ahanta West, Ghana, to identify potential barrier to healthcare for LF patients.

METHODS

Lymphoedema and hydrocoele patients were identified by community health workers from a subset of villages, and were interviewed and participated in focus group discussions to determine their attitudes and practices towards managing their morbidity, and their perceived barriers to accessing care. Local health professionals were also interviewed to obtain their views on the availability of morbidity management services in the district.

RESULTS

Sixty-two patients (34 lymphoedema and 28 hydrocoeles) and 13 local health professionals were included in the study. Lymphoedema patients predominantly self-managed their conditions, which included washing with soap and water (61.8%), and exercising the affected area (52.9%). Almost 65% of patients had sought medical assistance at some stage, but support was generally limited to receiving tablets (91%). Local health professionals reported rarely seeing lymphoedema patients, citing stigma and lack of provisions to assist patients as a reason for this. Almost half of hydrocoele patients (44%) chose not to seek medical assistance despite the negative impact it had on their lives. Whilst surgery itself is free with national health insurance, 63% those who had not sought treatment stated that indirect costs of surgery (travel costs, loss of earnings, etc.) were the most prohibitive factor to seeking treatment.

CONCLUSIONS

The information obtained from this study should now be used to guide future morbidity strategies in building a stronger relationship between the local health services and LF patients, to ultimately improve patients' physical, psychological and economic wellbeing.