Geographical distribution and prevalence of podoconiosis in Rwanda: a cross-sectional country-wide survey

"We all think boots are meant for men": A community-based participatory assessment of rural women's barriers to preventing podoconiosis in Rwanda

Podoconiosis is a debilitating neglected tropical disease (NTD) that is possibly caused by prolonged exposure to irritant alkaline clay soil. It is endemic to East Africa and disproportionately affects rural female farmers. The condition can be prevented through foot hygiene and regular wearing of protective shoes. In Rwanda, there is limited information on the factors impacting rural female farmers' access to and utilization of boots while farming. Therefore, this community-based participatory study was conducted to explore the cultural, economic, and ergonomic factors affecting rural farmers' use of protective footwear. Sixteen audio-recorded focus group discussions were conducted with female and male farmers in four villages with the highest podoconiosis prevalence across four provinces of Rwanda. Transcripts were coded inductively using Dedoose (version 9.0.86) and analyzed through thematic content analysis. Participants expressed that wearing shoes protects against diseases and injuries but ability to afford a pair of protective footwear was a major barrier to accessing and wearing them. There were differences in women and men's shoe-wearing behaviors while farming, largely driven by the fact that women who wear boots face rumors and backlash. Findings highlight barriers hindering effective podoconiosis prevention among rural female farmers in Rwanda. Opportunities exist to strengthen podoconiosis and NTD prevention programs, through the integration of gender into existing community-based interventions and the inclusion of local communities into the co-designing of contextualized interventions.

'We no longer experience the same pain': a cross-sectional study assessing the impact of Heart and Sole Africa's podoconiosis prevention education program

BACKGROUND

Podoconiosis is a non-infectious neglected tropical disease caused by long-term exposure to irritant volcanic soils. It results in severe physical, psychological and financial consequences. Heart and Sole Africa (HASA) is a non-governmental, community-based organization providing management to podoconiosis patients in Rwanda. We sought to analyze the impact of their program on the lives of patients.

METHODS

Quantitative surveys recorded the participants' demographics, adherence to HASA's management recommendations and changes in quality of life (QOL). Qualitative questions were used to gather respondent perspectives on HASA programming.

RESULTS

We interviewed 127 patients from HASA's Musanze (n=47) and Burera (n=80) clinics. Almost all participants (98.4%) reported statistically significant (p<0.01) improvements in their QOL, and more than one-half (51.2%) had a favorable adherence score of >80%. Qualitative feedback identified specific challenges to adherence and recognition of program success in symptom management.

CONCLUSIONS

Our study demonstrated the value of community-based podoconiosis programming in improving the lives of patients. Practices such as regular feet washing, emollient application, shoe wearing and limb raising can result in a marked reduction of morbidity. Our findings support the argument for scaling up these management practices across Rwanda.

'My feet cannot stand on their own': podoconiosis patient healthcare expenditures and income impacts in Rwanda

BACKGROUND

Podoconiosis is a progressive and debilitating form of tropical lymphoedema endemic to Rwanda. Although the physical and psychological consequences are well known, few studies have evaluated the financial burden of podoconiosis.

METHODS

This cross-sectional, quantitative study aimed to characterize direct treatment costs and impacts on annual earnings among individuals living with podoconiosis. Participants from two highly endemic districts were invited to complete a survey focused on health-seeking history, insurance status, out-of-pocket costs and income changes. Direct treatment costs included medical expenditures (consultation, diagnostics, medication) and non-medical expenditures (food, transportation, accommodation).

RESULTS

Overall, 226 adults (≥18 y of age) diagnosed with podoconiosis participated. Most had access to community-based health insurance (91.6%) but were unable to work (71.7%). Respondents sought care from health centres/posts (61.9%), hospitals (25.1%), traditional healers (5.8%) and/or community health workers (4.0%). On average, study participants paid US$32.50 (range US$0-779.23) annually, or 11.7% of their household salary, on podoconiosis treatments.

CONCLUSIONS

This study demonstrates the significant financial burden of podoconiosis on individuals and their communities. Increased attention on integrating podoconiosis management into primary care systems and testing cost-effective solutions is needed to protect those who are most vulnerable.

Epidemiology of podoconiosis in sub-Saharan Africa: A systematic review and meta-analysis

Objective

Podoconiosis, one of the neglected tropical diseases (NTDs), affects barefoot people in impoverished regions and contributes to poverty by having negative impacts on economic output, education, and disability. People who have the disease waste nearly half of all of their productive workdays. There is limited evidence available on prevalence of podoconiosis in sub-Saharan Africa (SSA). Therefore, the aim of this research was to determine the pooled prevalence of podoconiosis in the SSA over the last 10 years.

Methods

Studies were retrieved from PubMed, Embase, Web of Science, Scopus, Google Scholar, and Google by using a combination of search terms with Boolean operators. All authors independently assessed each study's quality using the modified Newcastle-Ottawa Scale for cross-sectional studies. STATA Version 14 was used to conduct the statistical analysis. The random-effect approach of meta-analysis was used. To test for heterogeneity, I-Squared (I2) statistics were employed and sensitivity analysis with a leave-one-out was done.

Result

In this systematic review and meta-analysis, a total of 16 publications with 2,195,722 individuals were included. The pooled prevalence of podoconiosis was 2.66 (95% confidence interval (CI): 2.24, 3.10) with heterogeneity index (I2) of 99.9%. Walking barefoot adjusted odd ratio (AOR) 5.35 (95% CI: 1.65, 9.05), p = 0.001, not washing feet with soap and water regularly AOR 2.8 (95% CI: 1.16, 4.44, p = 0.001), and an increased age AOR 2.23 (95% CI: 1.25, 5.58) were factors significantly associated with the prevalence of podoconiosis.

Conclusion

This study revealed that pooled prevalence of podoconiosis was considerable in SSA. Age, being barefoot, and failing to wash one's feet with soap and water have been identified to be factors that were significantly associated with the prevalence of podoconiosis. Therefore, creating awareness on shoe wearing and providing shoes in communication with supporting organizations in podoconiosis prevalent areas, and early diagnosis based on family history are needed for the prevention of podoconiosis.

Determinants of Podoconiosis in Bensa District, Sidama Region, Ethiopia: A case control study

BACKGROUND

Podoconiosis is one of the neglected tropical diseases (NTD) with the greatest potential for elimination. Despite its public health importance, podoconiosis is a poorly understood disease which led to a widespread misconception about its cause, prevention, and treatment. Even though the exact global burden is still to be measured, it is estimated that at least 4 million people are affected with podoconiosis worldwide, of which more than 1.5 million people are in Ethiopia. The objective of this study was to identify the determinants of podoconiosis in Bensa District, Sidama Regional State, Ethiopia.

METHODOLOGY/PRINCIPAL FINDINGS

A community-based unmatched case-control study was used to identify the determinants of podoconiosis. The sample size was estimated using the double population proportion formula. An interviewer-administered structured questionnaire was used for data collection. Blood specimens collected from cases were tested by Filariasis Test Strip to exclude lymphatic filariasis. Data were checked for completeness, coded and entered into Epi-data Version 4.6, and exported to the SPSS version 22 software. Variables with a p<0.2 in the bivariate analysis were further analyzed using multivariable binary logistic regression. Multivariable logistic regression analysis was used to examine determinants that could be associated with podoconiosis with a 95% confidence interval. A total of 459 (153 cases and 306 controls) participants were included with a response rate of 100%. Factors such as the age of participant [AOR = 0.34, 95% CI (0.13-0.87)], being female [AOR = 2.90, 95% CI (1.40-6.10)], age at which shoe wearing started [AOR = 0.7, 95% CI (0.03-0.16)], not wearing shoe daily [AOR = 2.26, 95% CI (1.05-4.86)], wearing hard plastic shoe [AOR = 3.38, 95% CI (1.31-10.89)], and family history with a similar disease (leg swelling) [AOR = 10.2, 95% CI (3.97-26.37)] were significantly associated with the occurrence of podoconiosis.

CONCLUSIONS/SIGNIFICANCE

The age of the participants, gender, the age at which shoe wearing started, type of shoe the participants' wear, frequency of shoe wearing, traveling barefoot, and family history with similar disease (leg swelling) were significantly associated with the occurrence of podoconiosis. Sidama regional health bureau along with non-governmental organizations working on the neglected tropical disease should plan modalities on awareness creation and comprehensive health education on shoe wearing and foot hygiene.

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.

Geostatistical modelling of the distribution, risk and burden of podoconiosis in Kenya

BACKGROUND

Understanding and accurately predicting the environmental limits, population at risk and burden of podoconiosis are critical for delivering targeted and equitable prevention and treatment services, planning control and elimination programs and implementing tailored case finding and surveillance activities.

METHODS

This is secondary analysis of a nationwide podoconiosis mapping survey in Kenya. We combined national representative prevalence survey data of podoconiosis with climate and environmental data, overlayed with population figures in a geostatistical modelling framework, to predict the environmental suitability, population living in at-risk areas and number of cases of podoconiosis in Kenya.

RESULTS

In 2020, the number of people living with podoconiosis in Kenya was estimated to be 9344 (95% uncertainty interval 4222 to 17 962). The distribution of podoconiosis varies by geography and three regions (Eastern, Nyanza and Western) represent >90% of the absolute number of cases. High environmental suitability for podoconiosis was predicted in four regions of Kenya (Coastal, Eastern, Nyanza and Western). In total, 2.2 million people live in at-risk areas and 4.2% of the total landmass of Kenya is environmentally predisposed for podoconiosis.

CONCLUSIONS

The burden of podoconiosis is relatively low in Kenya and is mostly restricted to certain small geographical areas. Our results will help guide targeted prevention and treatment approaches through local planning, spatial targeting and tailored surveillance activities.

Quantifying Population Burden and Effectiveness of Decentralized Surveillance Strategies for Skin-Presenting Neglected Tropical Diseases, Liberia

We evaluated programmatic approaches for skin neglected tropical disease (NTD) surveillance and completed a robust estimation of the burden of skin NTDs endemic to West Africa (Buruli ulcer, leprosy, lymphatic filariasis morbidity, and yaws). In Maryland, Liberia, exhaustive case finding by community health workers of 56,285 persons across 92 clusters identified 3,241 suspected cases. A total of 236 skin NTDs (34.0 [95% CI 29.1–38.9]/10,000 persons) were confirmed by midlevel healthcare workers trained using a tailored program. Cases showed a focal and spatially heterogeneous distribution. This community health worker‒led approach showed a higher skin NTD burden than prevailing surveillance mechanisms, but also showed high (95.1%) and equitable population coverage. Specialized training and task-shifting of diagnoses to midlevel health workers led to reliable identification of skin NTDs, but reliability of individual diagnoses varied. This multifaceted evaluation of skin NTD surveillance strategies quantifies benefits and limitations of key approaches promoted by the 2030 NTD roadmap of the World Health Organization.

Podoconiosis instruction at nursing schools in Kenya, Rwanda, and Uganda

BACKGROUND

Podoconiosis is a preventable, progressive, and non-infectious form of elephantiasis that can contribute to significant disability and economic burden when not treated early. Nurses play a critical role in early detection and response in rural Africa, but it is unclear if they receive adequate training on podoconiosis. We aimed to characterize podoconiosis instruction at all government accredited, post-secondary nursing institutions in three African countries.

METHODS

Data for this cross-sectional study was collected through a quantitative survey with several open-answer questions. Through a rigorous online search, we identified all post-secondary institutions in Kenya, Rwanda and Uganda accredited to teach human nursing. A total of 289 accredited programs, including 85 certificate, 56 degree and 148 diploma programs were invited to participate. Respondents completed surveys online or by telephone. Measures focused on podoconiosis knowledge, perceptions of quality/quantity of podoconiosis instruction, and barriers to sufficient podoconiosis education.

RESULTS

We obtained information about 212 curricula across 149 nursing institutions in the three countries (participation rate: 73.4%). Podoconiosis coverage was limited across programs (certificate-24.1%; diploma-55.6%; degree-30.3%). Most respondents felt that the quality and quantity of instruction were insufficient (60.6%, 62.9%), respectively. Exclusion from government curricula, low priority and faculty lack of knowledge were commonly reported barriers to podoconiosis inclusion.

CONCLUSIONS

This study demonstrated clear gaps in podoconiosis training for nurses across the three countries and highlights a serious challenge in eliminating podoconiosis as a public health problem. Interventions to improve nurses' knowledge could include the development and free distribution of podoconiosis teaching materials, designed for integration into pre-existing courses.

Prevalence of podoconiosis and its associated factors in Gamo zone, Southern Ethiopia, 2021

Background

Podoconiosis is a chronic non-infectious preventable disease. Though not fatal, it may cause social, economic and physical disability. Ethiopia is projected to bear one-fourth (25%) of the global burden of podoconiosis. Despite its huge economic impact and chronic morbidity and disability, podoconiosis seems to be neglected. Therefore, the aim of this study was to assess the prevalence of podoconiosis and its associated factors in Gamo zone, Southern Ethiopia.

Methods

A community based cross sectional study was conducted among 683 household members. A multistage sampling method was used to select study participants. Binary logistic regression model was fitted to identify factors associated with podoconiosis. Odds ratio with 95% confidence interval was computed to determine the level of significance; in multivariable analysis, variables with a P value less than 0.05 were considered as statistically significant.

Results

The prevalence of podoconiosis was 6.2% (95%CI: 4.3–8%). The significantly contributed factors for the prevalence of podoconiosis were wealth index (AOR = 0.249, 95%CI = 0.073–0.845), number of shoes owned (AOR = 6.199, 95% CI = 1.281–29.98), times when individual do not wear shoes (AOR = 2.448, 95%CI = 1.041–5.754), soap utilization during foot washing (AOR = 2.773, 95%CI = 1.210–6.355) and family history of leg swelling (AOR = 4.69, 95%CI = 2.215–9.935).

Conclusions

This study showed that there was significant burden of podoconiosis in the study area. Wealth index, times when individual do not wear shoes, number of shoes owned, soap utilization during foot washing, and family history of leg swelling were significantly associated with podoconiosis. It is recommended to practice secondary prevention which includes regular foot hygiene and wearing shoes, and the use of antiseptic soaks.

Self-Care Practice and Its Associated Factors Among Podoconiosis Patients in East Gojjam Zone, North West Ethiopia

INTRODUCTION

Podoconiosis is endemic non-filarial elephantiasis of the lower legs swelling caused by barefoot exposure to red clay soil. The burden of disability occurs among the poorest populations. Self-care practice is the most cost-effective prevention strategy practiced at home to improve lymphedema, working functionality, and quality of life. Despite this, there is a scarce of knowledge about self-care practices and associated factors among podoconiosis patients in Ethiopia.

OBJECTIVE

To determine self-care practice and its associated factors among podoconiosis patients in East Gojjam zone North West, Ethiopia.

METHODS

Community-based cross-sectional study design was used among 633 podoconiosis patients. Computer-generated simple random sampling technique was used to recruit participants. All patients who started podoconiosis treatment were the source population. Data were entered using Epidata version 3.1 and exported to SPSS version 25 for cleaning and analysis. Variables with 95% CI corresponding AOR were used to identify statistically significant factors for self-care practice.

RESULTS

In this study, the self-care practice of podoconiosis patient was 64%. Females [AOR: 0.38 (95% CI: 0.22, 0.65)], 55-65 years age [AOR: 0.41 (95% CI: 0.22, 0.74)], above 65 years age [AOR: 0.22 (95% CI: 0.11, 0.450)], 4-6 km distance from water source [AOR: 0.06 (95% CI: 0.03, 0.12)], above 6 km distance from water source [AOR: 0.03 (95% CI: 0.01, 0.09)], educational level [AOR: 0.05 (95% CI: 0.01, 0.40)], marital status [AOR: 5.40 (95% CI: 2.30, 12.90)], and distance from health institution [AOR: 0.35 (95% CI: 0.23, 0.54)] were statistically identified associated factors for self-care practice of podoconiosis patient.

CONCLUSION

In this study, the self-care practice of podoconiosis patients was not well practiced. Socio-demographic factors are identified as associated factors for self-care practice. Strengthening health education and behavioral changes are required to improve self-care practice.

Podoconiosis: A Possible Cause of Lymphedema in Micronesia

Podoconiosis is a type of tropical lymphedema sharing some clinical characteristics with lymphatic filariasis. Also referred to as endemic non-filarial elephantiasis, podoconiosis is a non-infectious disease from barefoot exposure to irritant red clay soil of volcanic origins. Podoconiosis is most common in Ethiopia and has also been reported in many other countries, but not in the Pacific Islands. Lymphatic filariasis is endemic in the Pacific Islands and was historically reported as elephantiasis in Micronesia. It was considered to have been eradicated in Guam and the Northern Mariana Islands following World War II. A small number of patients in Saipan exhibited characteristics of lymphatic filariasis but were seronegative for filariasis. Clinical examination of these patients matched podoconiosis much more closely than filariasis. Moreover, these patients reported a history of chronic barefoot exposure to irritant red clay soil and a prodrome characteristic of podoconiosis. While this study is limited to several cases, the results suggest that podoconiosis could be considered a cause of non-filarial lymphedema in Saipan and perhaps other islands in Micronesia. Preventive patient education is focused on discouraging barefoot exposure to red clay soils, particularly in those with a family history of lymphedema. Early recognition of the possibility of podoconiosis would allow appropriate treatment and prevent progression to later debilitating stages of the disease.

Podoconiosis - From known to unknown: Obstacles to tackle

Podoconiosis is a non-filarial and non-communicable disease leading to lymphedema of the lower limbs. Worldwide, 4 million individuals live with podoconiosis, which is accompanied by disability and painful intermittent acute inflammatory episodes that attribute to significant disability adjusted life years (DALYs). Different risk factors like contact with volcanic red clay soil, high altitude (above 1000 m), high seasonal rainfall (above 1000 mm/year) and occupation (e.g., subsistence farmer) are associated with the risk of podoconiosis. Although podoconiosis was described to be endemic in 32 countries in Africa, parts of Latin America and South East Asia, knowledge about related genetics, pathophysiology, immunology and especially the causing molecule(s) in the soil remain uncertain. Thus, podoconiosis can be considered as one of the most neglected diseases. This review provides an overview about this non-filarial related geochemical disease and aim to present perspectives and future directions that might be important for better understanding of the disease, prospect for point-of-care diagnosis, achieving protection and developing novel treatment strategies.

Podoconiosis: key priorities for research and implementation

Podoconiosis is a non-infectious tropical lymphoedema causing swelling of the lower legs. Podoconiosis is associated with stigma, depression and reduced productivity, resulting in significant socio-economic impacts for affected individuals, families and communities. It is caused by barefoot exposure to soils and affects disadvantaged populations. Evidence from the past 5 y suggests that podoconiosis is amenable to public health interventions, e.g. footwear and hygiene-based morbidity management, which reduce acute clinical episodes. Although much has been learned in recent years, advances in care for these patients and worldwide control requires further reliable and relevant research. To develop a comprehensive global control strategy, the following key research priorities are important: better understanding of the global burden of podoconiosis through extended worldwide mapping, development of new point-of-care diagnostic methods and approaches to define the presence of the environmental characteristics that contribute to the development of the condition, improving treatment through an increased understanding of the pathogenesis of dermal changes over time, improved understanding of optimal ways of providing patient care at the national level, including research to optimize behavioural change strategies, determine the optimum package of care and integrate approaches to deliver robust surveillance, monitoring and evaluation of control programmes.

Developing and validating a clinical algorithm for the diagnosis of podoconiosis

BACKGROUND

Difficulties in reliably diagnosing podoconiosis have severely limited the scale-up and uptake of the World Health Organization-recommended morbidity management and disability prevention interventions for affected people. We aimed to identify a set of clinical features that, combined into an algorithm, allow for diagnosis of podoconiosis.

METHODS

We identified 372 people with lymphoedema and administered a structured questionnaire on signs and symptoms associated with podoconiosis and other potential causes of lymphoedema in northern Ethiopia. All individuals were tested for Wuchereria bancrofti-specific immunoglobulin G4 in the field using Wb123.

RESULTS

Based on expert diagnosis, 344 (92.5%) of the 372 participants had podoconiosis. The rest had lymphoedema due to other aetiologies. The best-performing set of symptoms and signs was the presence of moss on the lower legs and a family history of leg swelling, plus the absence of current or previous leprosy, plus the absence of swelling in the groin, plus the absence of chronic illness (such as diabetes mellitus or heart or kidney diseases). The overall sensitivity of the algorithm was 91% (95% confidence interval [CI] 87.6 to 94.4) and specificity was 95% (95% CI 85.45 to 100).

CONCLUSIONS

We developed a clinical algorithm of clinical history and physical examination that could be used in areas suspected or endemic for podoconiosis. Use of this algorithm should enable earlier identification of podoconiosis cases and scale-up of interventions.

The health and economic burden of podoconiosis in Ethiopia

Background

Podoconiosis is one of the leading causes of lymphoedema-related morbidity in low-income settings, but little is known about the scale of its health and economic impact. This information is required to inform control programme planning and policy. In this study, we estimated the health and economic burden of podoconiosis in Ethiopia.

Methods

We developed a model to estimate the health burden attributed to podoconiosis in terms of the number of disability-adjusted life years (DALYs) and the economic burden. We estimated the economic burden by quantifying the treatment and morbidity-management costs incurred by the healthcare system in managing clinical cases, patients' out-of-pocket costs and their productivity costs.

Results

In 2017, there were 1.5 million cases of podoconiosis in Ethiopia, which corresponds to 172 073 DALYs or 182 per 100 000 people. The total economic burden of podoconiosis in Ethiopia is estimated to be US$213.2 million annually and 91.1% of this resulted from productivity costs. The average economic burden per podoconiosis case was US$136.9.

Conclusions

The national cost of podoconiosis is formidable. If control measures are scaled up and the morbidity burden reduced, this will lead to Ethiopia saving millions of dollars. Our estimates provide important benchmark economic costs to programme planners, policymakers and donors for resource allocation and priority setting.

'Far from the views of decision-makers': podoconiosis instruction at medical schools across endemic countries in Africa

BACKGROUND

Podoconiosis is a neglected tropical disease that causes significant physical, emotional and financial suffering, especially among impoverished rural farmers. Sufficient physician training is integral to optimizing patient outcomes through timely diagnosis and appropriate management. Therefore we sought to characterize podoconiosis instruction offered to medical students in endemic African countries.

METHODS

We invited faculty from 170 medical schools in all podoconiosis-endemic African countries to provide information about podoconiosis inclusion in medical curricula. Surveys were available in French and English and captured podoconiosis knowledge, quantity/quality of instruction, ranking of importance relative to other diseases and barriers for improvement. Respondents voluntarily shared responses online or by telephone.

RESULTS

Study participants provided information about curricula at 97 medical schools across 14 countries. In total, 42.6% of schools across nine countries offered podoconiosis-specific instruction; most respondents felt that the quality (60.4%) and quantity (61.5%) of instruction was insufficient. Common barriers to sufficient training included exclusion from government curricula, prioritization according to caseload and scarce epidemiological data.

CONCLUSIONS

Our study demonstrates widespread neglect in podoconiosis training for physicians in endemic countries. Government support is needed to ensure curricula match the needs of health workers practicing in rural, low-income regions.

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.

Severely stigmatised skin neglected tropical diseases: a protocol for social science engagement

More than one billion people are affected by neglected tropical diseases (NTDs) and many of these diseases are preventable. While the grouping of these conditions as NTDs has generated vast mapping, mass drug administration and surveillance programmes, there is growing evidence of gaps and weaknesses in purely biomedical approaches, and the need for responses that also recognise the social determinants of health. In order to unpack the social and political determinants of NTDs, it is important to view the problem from a social science perspective. Given this background, the Social Sciences for Severe Stigmatizing Skin Diseases (5S) Foundation has recently been established by the Centre for Global Health Research at Brighton and Sussex Medical School. The broad aim of the 5S Foundation is to incorporate social science perspectives in understanding and addressing the problems around three NTDs, namely, podoconiosis, mycetoma and scabies. This protocol paper sets out the aims and approaches of the 5S Foundation while activities such as research, public engagement, training and capacity building get underway.

Linking soils and human health: geospatial analysis of ground-sampled soil data in relation to community-level podoconiosis data in North West Cameroon

Background

Podoconiosis is a form of leg swelling, which arises when individuals are exposed over time to red clay soil formed from alkaline volcanic rock. The exact causal agent of the disease is unknown. This study investigates associations between podoconiosis disease data and ground-sampled soil data from North West Cameroon.

Methods

The mineralogy and elemental concentrations were measured in the soil samples and the data were spatially interpolated. Mean soil values were calculated from a 3 km buffer region around the prevalence data points to perform statistical analysis. Analysis included Spearman's rho correlation, binary logistic regression and principal component analysis (PCA).

Results

Six elements, barium, beryllium, potassium, rubidium, strontium and thallium, as well as two minerals, potassium feldspar and quartz, were identified as statistically related to podoconiosis. PCA did not show distinct separation between the spatial locations with or without recorded cases of podoconiosis, indicating that other factors such as shoe-wearing behaviour and genetics may significantly influence podoconiosis occurrence and prevalence in North West Cameroon.

Conclusion

Several soil variables were statistically significantly related to podoconiosis. To further the current study, future investigations will look at the inflammatory pathway response of cells after exposure to these variables.

Individual and familial characteristics of patients with podoconiosis attending a clinic in Musanze District, Rwanda: A retrospective study

Background

Podoconiosis is a progressive swelling of the legs affecting genetically susceptible people who live in areas with irritant red clay soils and walk barefoot. The disease is a public health concern in many countries, including Rwanda.

Methods

This retrospective study described individual and familial characteristics of patients with podoconiosis attending the Heart and Sole Africa (HASA) clinics in Rwanda. Data on patient characteristics and family history were retrieved from electronic medical records (January 2013 – August 2019). A multiple regression analysis was used to explore factors influencing age of onset of podoconiosis.

Results

Among 467 patients with podoconiosis, the mean (standard deviation) age of onset was 34.4 (19.6) years, 139 (29.8%) patients developed podoconiosis at <20 years of age, 417 (89%) came from Musanze or neighboring Burera Districts, and 238 (51.0%) had a family history of podoconiosis. Increasing patient age was associated with older age at onset of disease (p<0.001), while an increased number of relatives with podoconiosis (p<0.002) was significantly associated with earlier disease onset.

Conclusion

Most patients with podoconiosis were women, and more than half had a family history of podoconiosis. An increased number of relatives with podoconiosis was associated with a significantly younger age at disease onset.

High levels of depressive symptoms among people with lower limb lymphoedema in Rwanda: a cross-sectional study

BACKGROUND

There is a growing body of evidence that mental distress and disorder are common among people with lower limb lymphoedema, although no research has been conducted on this subject in Rwanda.

METHODS

This research was embedded within a mapping study to determine the national prevalence and geographical distribution of podoconiosis in Rwanda. Using a cluster sampling design, adult members of households within 80 randomly selected sectors in all 30 districts of Rwanda were first screened and 1143 patients were diagnosed with either podoconiosis (n=914) or lower limb lymphoedema of another cause (n=229). These 1143 participants completed the Patient Health Questionnaire (PHQ)-9 to establish the prevalence of depressive symptoms.

RESULTS

Overall, 68.5% of participants reported depressive symptoms- 34.3% had mild depressive symptoms, 24.2% had moderate, 8.8% moderately severe and 1.2% severe depressive symptoms. The mean PHQ-9 score was 7.39 (SD=5.29) out of a possible 0 (no depression) to 27 (severe depression). Linear regression showed unemployment to be a consistently strong predictor of depressive symptoms; the other predictors were region (province), type of lymphoedema and, for those with podoconiosis, female gender, marital status and disease stage.

CONCLUSIONS

Levels of depressive symptoms were very high among people with lower limb lymphoedema in Rwanda, which should be addressed through holistic morbidity management and disability prevention services that integrate mental health, psychosocial and economic interventions alongside physical care.

Podoconiosis in Rwanda: Knowledge, attitudes and practices among health professionals and environmental officers

Background

Podoconiosis is a neglected tropical disease commonly found in volcanic regions, where soil is rich in silica. It usually manifests as bilateral lower limb edema. The majority of people affected by podoconiosis are farmers who do not wear shoes. The condition was recently documented in all 30 districts in Rwanda but knowledge, attitudes and practices (KAP) of Rwandan health professionals and environmental officers towards podoconiosis are unknown.

Methodology/Findings

The objective of this study was to assess the knowledge, attitudes and practices (KAP) of Rwandan health providers and environmental officers towards podoconiosis in order to improve patient healthcare experiences and health outcomes, and to reduce stigma against affected individuals. To achieve this goal, we administered a KAP assessment to physicians (N = 13), nurses/midwives (N = 59), community health workers (N = 226), and environmental officers (N = 38) in the third highest podoconiosis prevalence district in Rwanda (Musanze).

All 336 respondents had heard of podoconiosis, but 147 (44%) respondents correctly identified soil as the only direct cause of podoconiosis. The awareness of signs and symptoms and risk groups was lower than any other category (31.5% and 47.5%, respectively). The overall attitude toward podoconiosis was positive (86.1%), with CHWs least likely to harbor negative beliefs against podoconiosis patients. One particular area where most respondents (76%) expressed negative attitude was that they saw people with podoconiosis as a threat to their own health and their family’s health. Prescription of antibiotics and use of ointments/soap to manage wounds was low (5% and 32.2%, respectively), in part due to supply shortages at health facilities.

Conclusions

This study identified clear gaps in health provider knowledge and practices that affect patient care for those with podoconiosis. Improved access to essential medicines at health facilities and podoconiosis-focused training sessions for practicing health providers are necessary to minimize the burden and stigma of affected individuals.

Podoconiosis is a foot disease that progressively affects genetically susceptible people who do not wear shoes in volcanic soil. This disease causes disability, stigma, and impinges on people’s economic productivity. In Rwanda, it is estimated that 6429 people live with podoconiosis, but health services for these particular patients are almost nonexistent. We evaluated knowledge, attitudes and practice among 298 health professionals and 38 environmental officers and found that only 44% of all respondents knew that soil is the only direct cause of podoconiosis. Few health professionals (6%) reported having treated a podoconiosis patient and most health professionals (79%) identified shortages of critical drugs and supplies as an important barrier to providing treatment. Three quarters of environmental officers (74%) did not know that farmers are the people most vulnerable to this condition. The poor knowledge of all respondents toward podoconiosis and the lack of medical supplies suggest that podoconiosis patients likely receive substandard medical care and receive little credible information on prevention. We recommend a multi-sectoral approach to training, as well as the engagement of governments and the World Health Organization, to avail medications and treatment materials in the community.

Predicting the environmental suitability and population at risk of podoconiosis in Africa

Podoconiosis is a type of tropical lymphedema that causes massive swelling of the lower limbs. The disease is associated with both economic insecurity, due to long-term morbidity-related loss of productivity, and intense social stigma. The geographical distribution and burden of podoconiosis in Africa are uncertain. We applied statistical modelling to the most comprehensive database compiled to date to predict the environmental suitability of podoconiosis in the African continent. By combining climate and environmental data and overlaying population figures, we predicted the environmental suitability and human population at risk of podoconiosis in Africa. Environmental suitability for podoconiosis was predicted in 29 African countries. In the year 2020, the total population in areas suitable for podoconiosis is estimated at 114.5 million people, (95% uncertainty interval: 109.4-123.9) with 16.9 million in areas suitable for both lymphatic filariasis and podoconiosis. Of the total 5,712 implementation units (typically second administrative-level units, such as districts) defined by the World Health Organization in Africa, 1,655 (29.0%) were found to be environmentally suitable for podoconiosis. The majority of implementation units with high environmental suitability are located in Angola (80, 4.8%), Cameroon (170, 10.3%), the DRC (244, 14.7%), Ethiopia (495, 29.9%), Kenya (217, 13.1%), Uganda (116, 7.0%) and Tanzania (112, 6.8%). Of the 1,655 environmentally suitable implementation units, 960 (58.0%) require more detailed community-level mapping. Our estimates provide key evidence of the population at risk and geographical extent of podoconiosis in Africa, which will help decision-makers to better plan more integrated intervention programmes.

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.

Measuring the spatial heterogeneity on the reduction of vaginal fistula burden in Ethiopia between 2005 and 2016

Vaginal fistula is a shattering maternal complication characterized by an anomalous opening between the bladder and/or rectum and vagina resulting in continuous leakage of urine or stool. Although prevalent in Ethiopia, its magnitude and distribution is not well studied. We used statistical mapping models using 2005 and 2016 Ethiopia Demographic Health Surveys data combined with a suite of potential risk factors to estimate the burden of vaginal fistula among women of childbearing age. The estimated number of women of childbearing age with lifetime and untreated vaginal fistula in 2016 were 72,533 (95% CI 38,235-124,103) and 31,961 (95% CI 11,596-70,309) respectively. These figures show reduction from the 2005 estimates: 98,098 (95% CI 49,819-170,737) lifetime and 59,114 (95% CI 26,580-118,158) untreated cases of vaginal fistula. The number of districts having more than 200 untreated cases declined drastically from 54 in 2005 to 6 in 2016. Our results show a significant subnational variation in the burden of vaginal fistula. Overall, between 2005 and 2016 there was substantial reduction in the prevalence of vaginal fistula in Ethiopia. Our results help guide local level tracking, planning, spatial targeting of resources and implementation of interventions against vaginal fistula.

Mapping the global distribution of podoconiosis: Applying an evidence consensus approach

Background

Podoconiosis is a type of elephantiasis characterised by swelling of the lower legs. It is often confused with other causes of tropical lymphedema and its global distribution is uncertain. Here we synthesise the available information on the presence of podoconiosis to produce evidence consensus maps of its global geographical distribution.

Methods and findings

We systematically searched available data on podoconiosis in SCOPUS and MEDLINE from inception, updated to 10 May, 2019, and identified observational and population-based studies reporting podoconiosis. To establish existence of podoconiosis, we used the number of cases reported in studies and prevalence data with geographical locations. We then developed an index to assess evidence quality and reliability, assigning each country an evidence consensus score. Using these summary scores, we then developed a contemporary global map of national-level podoconiosis status.

There is evidence of podoconiosis in 17 countries (12 in Africa, three in Latin America, and two in Asia) and consensus on presence in six countries (all in Africa). We have identified countries where surveillance is required to further define the presence or absence of podoconiosis. We have highlighted areas where evidence is currently insufficient or conflicting, and from which more evidence is needed.

Conclusion

The global distribution of podoconiosis is not clearly known; the disease extent and limits provided here inform the best contemporary map of the distribution of podoconiosis globally from available data. These results help identify surveillance needs, direct future mapping activities, and inform prevention plans and burden estimation of podoconiosis.

The global distribution of podoconiosis is uncertain. With our current understanding of its distribution still incomplete, many of the countries suspected to be endemic for podoconiosis are based on expert opinion and lack published evidence of confirmed cases. In this study, we used multiple data sources and health metrics to identify countries with presence and absence of podoconiosis with appropriate uncertainties. After assembling a database of different evidence types we constructed a weighted score for each country called ‘evidence consensus scores’. We used these scores to measure the certainty of the presence and absence of podoconiosis. The maps produced help to identify evidence gaps and uncertainties in the current global distribution of podoconiosis. Countries with evidence of podoconiosis are mostly clustered in Africa, and a few in Asia and Latin America. We have also identified countries with indeterminate status on the presence and absences of podoconiosis. These countries are characterised by weak health systems and multiple co-endemic diseases causing lower leg swelling, potentially leading to misdiagnosis of podoconiosis. Given these challenges, we recommend intensified disease surveillance and active case searching be implemented in areas where evidence is lacking.