Physical and psychosocial burden due to lymphatic filariasis as perceived by patients and medical experts

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.

Tungiasis Stigma and Control Practices in a Hyperendemic Region in Northeastern Uganda

Neglected tropical diseases are known to be highly stigmatized conditions. This study investigates tungiasis-related stigma and control practices in the impoverished Napak District in rural northeastern Uganda, where tungiasis is hyperendemic and effective treatment is unavailable. We conducted a questionnaire survey with the main household caretakers (n = 1329) in 17 villages and examined them for tungiasis. The prevalence of tungiasis among our respondents was 61.0%. Questionnaire responses showed that tungiasis was perceived as a potentially serious and debilitating condition and that tungiasis-related stigma and embarrassment were common. Among the respondents, 42.0% expressed judging attitudes, associating tungiasis with laziness, carelessness, and dirtiness, and 36.3% showed compassionate attitudes towards people with tungiasis. Questionnaire responses further indicated that people made an effort to keep their feet and house floors clean (important tungiasis prevention measures), but lack of water was a common problem in the area. The most frequent local treatment practices were hazardous manual extraction of sand fleas with sharp instruments and application of various and sometimes toxic substances. Reliable access to safe and effective treatment and water are therefore key to reducing the need for dangerous treatment attempts and breaking the vicious cycle of tungiasis stigma in this setting marked by poverty.

An analysis of social dimensions of podoconiosis and leprosy on affected households in endemic health districts of the North West Region of Cameroon

Background

Podoconiosis and leprosy are Neglected Tropical Diseases associated with low quality of life, social stigma and isolation of affected people and families. Despite the substantial social burden it imposes, podoconiosis has largely been ignored in the global health literature until recently unlike leprosy. This study assessed and compared the quality of life and social impact of podoconiosis with that of leprosy among affected households and neighborhoods in North West Cameroon.

Methods

A comparative cross-sectional design was used. Eighty-six households: 43 podoconiosis and 43 leprosy, plus household neighbours were enrolled from July and August 2015 from three health districts. Podoconiosis patients living in households within Batibo and Ndop health districts were sequentially sampled using a list of confirmed podoconioisis cases from previous studies. Leprosy patients living within communities in Mejang Health Area were sequentially sampled using the Mbingo treatment center register. WHO BREF tool was used to assess quality of life. Franklin Stigma Scale was adapted to assess felt and enacted stigma. Mann-Whitney U test was used to compare differences in stigma and QoL.

Results

Physical domain showed a significant difference in the distribution in quality of life between groups (p < 0.05, median:70; U:635, r = 0.2). Overall enacted stigma revealed significant differences with p < 0.05 and r = 0.4. Overall stigma from family members (median:17, U:627 and r = 0.3) and neighbours (median:67, U:336 and r = 0.5) showed significant differences with p < 0.05 in the distribution of scores for both diseases. Sex and age showed significant associations with QoL and stigma.

Conclusion

This study reveals the quality of life and stigma associated with podoconiosis on affected households to be comparable to that experienced by households with a leprosy patient. There is need for intensified preventive, management and control schemes to fight podoconiosis in Cameroon, just like leprosy.

•

Podoconiosis and leprosy are NTDs linked with low quality of life, stigma and isolation of affected people and families.

•

The social consequences include difficulties in finding employment, gaining education and getting married.

•

Podoconiosis impairs similar social burden on its victims like leprosy, yet remains neglected in Cameroon unlike leprosy.

•

This disparity in attention may be due to lack of evidence on the social impact of Podoconiosis likened to leprosy.

•

This paper creates scientific basis on the social effects of Podoconiosis in Cameroon to inform health policy actions.

Family-based intervention for prevention and self-management of disabilities due to leprosy, podoconiosis and lymphatic filariasis versus usual care in Ethiopia: study protocol for a cluster-randomised controlled trial

INTRODUCTION

Leprosy, podoconiosis and lymphatic filariasis (LF) are three skin-related neglected tropical diseases. All three conditions can lead to temporary and permanent impairments. These impairments progressively worsen and are major determinants of stigma, discrimination and participation restrictions. Self-care is essential to prevent disabilities and chronic disease complications. Many persons with leprosy-related, LF-related and podoconiosis-related disabilities need to practice self-management routines their entire life. This is difficult without support and encouragement of others. The objective of this study was to assess the effectiveness of a family-based intervention in terms of physical outcomes related to prevention and self-management of disabilities due to leprosy, podoconiosis and LF and family quality of life and well-being compared with usual practice and care.

METHODS AND ANALYSIS

The study will use a cluster-randomised controlled trial design with two study arms. The project will be carried out in endemic districts in East and West Gojjam zones in the Amhara region in Ethiopia. Clusters consist of kebeles (lower administrative structures in the district) that have been merged, based on their geographical proximity and the number of cases in each kebele. A total of 630 participants will be included in the study. The intervention group will consist of 105 persons affected by leprosy, 105 persons affected by LF or podoconiosis, and 210 family members. The control group will consist of 105 persons affected by leprosy and 105 persons affected by LF or podoconiosis. The family-based intervention comprises an essential care package that consists of the following three main components: (1) self-management of disabilities, (2) economic empowerment and (3) psychosocial support. Participants in the control areas will receive usual practice and care. Data analysis includes, but is not limited to, calculating the percentage of change and corresponding 95% CI of physical impairment outcomes in each group, before and after the intervention is implemented, effect sizes, intention to treat and difference in difference analysis.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Debre Markos University Health Sciences Institutional Research Ethics Review Committee. Results will be disseminated through peer-reviewed publications, conference presentations and workshops.

TRIAL REGISTRATION NUMBER

PACTR202108907851342.

Lymphatic filariasis elimination in the Dominican Republic: History, progress, and remaining steps

Lymphatic filariasis (LF) is a mosquito-transmitted parasitic disease that is a leading cause of disability globally. The island of Hispaniola, which the Dominican Republic shares with Haiti, accounts for approximately 90% of LF cases in the Americas region. In 1998, the Dominican Ministry of Public Health created the Program to Eliminate Lymphatic Filariasis (PELF) with the goal of eliminating LF transmission by 2020. Baseline mapping revealed 19 (12% of total) endemic municipalities clustered into three geographic foci (Southwest, La Ciénaga and East), with a total at-risk population of 262,395 people. Beginning in 2002, PELF sequentially implemented mass drug administration (MDA) in these foci using albendazole and diethylcarbamazine (DEC). In total, 1,174,050 treatments were given over three to five annual rounds of house-to-house MDA per focus with a median coverage of 81.7% (range 67.4%–92.2%). By 2018, LF antigen prevalence was less than 2% in all foci, thus meeting criteria to stop MDA and begin post-treatment surveillance (PTS). This success has been achieved against a shifting landscape of limited domestic funding, competing domestic public health priorities, and sporadic external donor support. Remaining steps include the need to scale-up morbidity management and disability prevention services for LF and to continue PTS until LF transmission is interrupted across Hispaniola.

Lymphatic filariasis (LF) is a neglected tropical disease caused by thin worms transmitted to humans by the bites of mosquitoes. LF is a leading cause of disability globally, resulting from the long-term physical (swelling of legs and genitals) and psycho-social impacts on affected individuals. The Dominican Republic is one of four LF-endemic countries in the Americas. This report describes the efforts to eliminate the disease in the country, including a review of disease mapping and implementation of mass drug administration (MDA)—the provision of safe and effective medicine to at-risk communities—to interrupt parasite transmission. Particular emphasis is given to program planning and community mobilization for MDA due to the divergent environments of endemic foci, which ranged from rural agricultural regions to densely populated urban neighborhoods. Impact evaluation data for each focus demonstrates interruption of LF transmission and that criteria to stop MDA have been met. Finally, plans for post-treatment surveillance and the scale-up of clinical care services for those who remain affected by chronic LF are presented—required elements for eliminating LF as a public health problem.

Filaricidal activity of Daniellia oliveri and Psorospermum febrifugum extracts

BACKGROUND

Drugs currently used for controlling onchocerciasis and lymphatic filariasis (LF) are mainly microfilaricidal, with minimal or no effect on the adult worms. For efficient management of these diseases, it is necessary to search for new drugs with macrofilaricidal activities that can be used singly or in combination with existing ones. Daniellia oliveri and Psorospermum febrifugum are two plants commonly used in the local management of these infections in Bambui, a township in the North West Region of Cameroon, but there is currently no documented scientific evidence to support their claimed anthelmintic efficacy and safety. The aim of this study was to provide evidence in support of the search for means to eliminate these diseases by screening extracts and chromatographic fractions isolated from these plants for efficacy against the parasitic roundworms Onchocerca ochengi and Brugia pahangi.

METHODS

The viability of O. ochengi adult worms was assessed using the MTT/formazan assay. Fully confluent monkey kidney epithelial cells (LLC-MK2) served as the feeder layer for the O. ochengi microfilariae (mfs) assays. Viability of the mfs was assessed by microscopic examination for mean motility scoring (relative to the negative control) every 24 h post addition of an extract. The Worminator system was used to test the effects of the extracts on adult B. pahangi motility, and mean motility units were determined for each worm. Cytotoxicity of the active extracts on N27 cells was assessed using the MTS assay.

RESULTS

Extracts from D. oliveri and P. febrifugum were effective against the adult roundworms O. ochengi and B. pahangi. Interestingly, extracts showing macrofilaricidal activities against O. ochengi also showed activity against O. ochengi mfs. The hexane stem bark extract of D. oliveri (DO_BHEX) was more selective for adult O. ochengi than for mfs, with a half maximal and 100% inhibitory concentration (IC₅₀ and IC₁₀₀, respectively) against adult O. ochengi of 13.9 and 31.3 μg/ml, respectively. The in vitro cytotoxicity of all active extracts on N27 cells showed selective toxicity for parasites (selectivity index > 1). Bioassay-guided fractionation of the extracts yielded fractions with activity against adult B. pahangi, thus confirming the presence of bioactive principles in the plant extracts.

CONCLUSIONS

Our study supports the use of D. oliveri and P. febrifugum in the traditional treatment of onchocerciasis and LF. The further purification of active extracts from these plants could yield lead compounds for filarial drug discovery and development.

Financial burden impact quality of life among lymphatic Filariasis patients

Background

Human lymphatic filarial pathology is the leading cause of disability and poverty among people living with the infection. The second goal of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) is to manage the disease’s morbidity to improve patients’ quality of life. Consequently, the current study assessed the overall quality of life of lymphatic filariasis (LF) pathology patients in some selected endemic communities in rural Ghana.

Method

In the present study, the Lymphatic Filariasis Quality of Life Questionnaire (LFSQQ) was used to evaluate the effect of lymphatic filariasis on the quality of life of people, with the disease in nine (9) communities in the Ahanta West District of the Western Region of Ghana where mass drug administration is being implemented for the past twenty years. Pearson’s correlation, linear regression, and one-way analysis of variance (ANOVA) analyses were used to assess the associations between the LFSQQ instrument domains.

Results

Of the 155 study participants recruited, 115 (74.19%) were females, and 40 (25.81%) males. A greater proportion of the study participants (40, 25.8%) were presented with stage two (2) lymphoedema, while only two patients had stage seven (7) lymphoedema. The average of the overall quality of life scores of study participants was 68.24. There was a negative Pearson correlation (r = − 0.504, p-value < 0.001) between the stage of lymphoedema (severity of the disease) and the quality of life of the LF patients. In addition, a clear pattern of positive correlation (r = 0.71, p-value < 0.001) was observed between the disease burden and pain/discomfort domains of the study participants. Whereas the highest domain-specific score (85.03) was observed in the domain of self-care, we noted that the environmental domain, which consists of the financial status, was the lowest (45.94) among the study participants.

Conclusion

Our findings support previous works on the reduced quality of life among lymphatic filariasis patients with pathology. In this study, our results reveal a depressing financial condition among people presenting with late stages of LF pathologies, which eventually reduces their well-being.

An exploration of family quality of life in persons with leprosy-, lymphatic filariasis- and podoconiosis-related disabilities and their family members in Ethiopia

Background

Leprosy, podoconiosis and lymphatic filariasis (LF) may adversely affect the social, economic and psychological well-being of persons affected and their families. The objectives of this study were to assess and compare family quality of life of persons affected and their family members, explore the relationship between family quality of life and perceived stigma and activity limitations and explore what factors influence family quality of life.

Methods

A cross-sectional quantitative study was conducted in the Awi zone in Ethiopia. Persons affected and their family members were selected using purposive sampling. Three questionnaires were used: the Beach Center Family Quality of Life (FQOL) scale (range 25–125, with higher scores denoting higher family quality of life), the SARI Stigma Scale (range 0–63, with higher scores denoting higher levels of stigma) and the Screening of Activity Limitation and Safety Awareness (SALSA) scale (range 0–80, with higher scores denoting more activity limitations). Data analysis consisted of simple descriptive analysis and regression analysis.

Results

A total of 95 persons affected and 117 family members were included. The overall mean of the family quality of life score was 71.7. Persons affected had significantly higher mean family quality of life scores than family members on all domains. Female gender, a smaller family size and occupation were associated with lower family quality of life. We found a mean SARI Stigma score of 22.3 and a mean SALSA score of 37.6. There was no association between the FQOL and SARI scores or between the FQOL and SALSA scores.

Conclusions

Family quality of life is an important area to address because neglected tropical diseases often affect the whole family. It is therefore important in order to provide appropriate support for persons affected and their family members. Efforts to improve the quality of life of families in which a family member is affected by leprosy, podoconiosis or LF should give priority to women and families with a smaller family size.

Transcription factor FTZ-F1 regulates mosquito cuticular protein CPLCG5 conferring resistance to pyrethroids in Culex pipiens pallens

Background

Culex pipiens pallens poses a serious threat to human health because of its widespread distribution, high carrier capacity for several arboviruses, frequent human-biting, and growth in urban environments. Pyrethroid insecticides have been mainly used to control adult Cx. pipiens pallens during outbreaks of mosquito-borne diseases. Unfortunately, mosquitoes have developed resistance, rendering the insecticides ineffective. Cuticular resistance is the primary mechanism of pyrethroid resistance. Previously, we revealed that cuticular protein of low complexity CPLCG5 is a major cuticular protein associated with deltamethrin resistance in Cx. pipiens pallens, which is enriched in the cuticle of mosquitoes’ legs and participates in pyrethroid resistance by forming a rigid matrix. However, the regulatory mechanisms of its transcription remain unknown.

Results

First, qRT-PCR analysis revealed that the expression of FTZ-F1 (encoding Fushi tarazu-Factor 1) was ~ 1.8-fold higher in the deltamethrin-resistant (DR) than deltamethrin-susceptible (DS) strains at 24 h post-eclosion (PE) and ~ 2.2-fold higher in the DR strain than in the DS strain at 48 h PE. CPLCG5 and FTZ-F1 were co-expressed in the legs, indicating that they might play an essential role in the legs. Dual luciferase reporter assays and EMSA (electrophoretic mobility shift experiments) revealed that FTZ-F1 regulates the transcription of CPLCG5 by binding to the FTZ-F1 response element (− 870/− 864). Lastly, knockdown of FTZ-F1 not only affected CPLCG5 expression but also altered the cuticle thickness and structure of the legs, increasing the susceptibility of the mosquitoes to deltamethrin in vivo.

Conclusions

The results revealed that FTZ-F1 regulates the expression of CPLCG5 by binding to the CPLCG5 promoter region, altering cuticle thickness and structure, and increasing the susceptibility of mosquitoes to deltamethrin in vivo. This study revealed part of the mechanism of cuticular resistance, providing a deeper understanding of insecticide resistance.

Genetic and functional diversification of chemosensory pathway receptors in mosquito-borne filarial nematodes

Lymphatic filariasis (LF) afflicts over 60 million people worldwide and leads to severe pathological outcomes in chronic cases. The nematode parasites (Nematoda: Filarioidea) that cause LF require both arthropod (mosquito) intermediate hosts and mammalian definitive hosts for their propagation. The invasion and migration of filarial worms through host tissues are complex and critical to survival, yet little is known about the receptors and signaling pathways that mediate directed migration in these medically important species. In order to better understand the role of chemosensory signaling in filarial worm taxis, we employ comparative genomics, transcriptomics, reverse genetics, and chemical approaches to identify putative chemosensory receptor proteins and perturb chemotaxis phenotypes in filarial worms. We find that chemoreceptor family size is correlated with the presence of environmental (extrahost) stages in nematode life cycles, and that filarial worms contain compact and highly diverged chemoreceptor complements and lineage-specific ion channels that are predicted to operate downstream of chemoreceptor activation. In Brugia malayi, an etiological agent of LF, chemoreceptor expression patterns correspond to distinct parasite migration events across the life cycle. To interrogate the role of chemosensation in the migration of larval worms, arthropod and mammalian infectious stage Brugia parasites were incubated in nicotinamide, an agonist of the nematode transient receptor potential (TRP) channel OSM-9. Exposure of microfilariae to nicotinamide alters intramosquito migration, and exposure of L3s reduces chemotaxis toward host-associated cues in vitro. Nicotinamide also potently modulates thermosensory responses in L3s, suggesting a polymodal sensory role for Brugia osm-9. Reverse genetic studies implicate both Brugia osm-9 and the cyclic nucleotide-gated (CNG) channel subunit tax-4 in larval chemotaxis toward host serum, and these ion channel subunits partially rescue sensory defects in Caenorhabditis elegans osm-9 and tax-4 knock-out strains. Together, these data reveal genetic and functional diversification of chemosensory signaling proteins in filarial worms and encourage a more thorough investigation of clade- and parasite-specific facets of nematode sensory receptor biology.

In vitro and in vivo studies of micro-depots using tailored microemulsion for sustained local anaesthesia

In clinical practice, lidocaine is used as local anesthetic for the management of post-operative pain. The commercial formulation including gels, injections and ointments showed short duration of action (1 to 2 h). In this paper, the efforts have being made to develop tailored lidocaine-microemulsion (o/w), which on penetration in the skin layer cause micro-depots formation due to destabilization of the microemulsion system. To identify the microemulsion region, pseudo ternary diagrams were constructed using Capmul MCM as oil, Pluronic F68 as tri-block surfactant, polyethylene glycol 200 as co-surfactant at 1:4 and 1:6 ratios (S:Co-S). The selected 5%w/v lidocaine loaded microemulsion [Ld-ME-2(1:4)] was stable in thermodynamic test and during shelf life period (3 months). In ex vivo permeability study, the lidocaine release from Ld-ME-2(1:4) microemulsion was sustained in comparison to the marketed lidocaine ointment. The skin irritation study confirmed the safety of lidocaine loaded microemulsion. Tail flick test showed improved and sustain local anaesthetic effect in comparison to the market ointment. The improved efficacy of microemulsion system, was due to high penetration in the skin layer due to local precipitation of lidocaine from microemulsion. The findings suggest that the tailored microemulsion could be a potential strategy to prolong the local anaesthesia.

The consequences of Brugia malayi infection on the flight and energy resources of Aedes aegypti mosquitoes

Evidence from experimental infection studies has shown that infected mosquitoes exhibit altered host-seeking behaviours, with suppression and activation of behaviours dependent on the parasite's development stage. The mechanisms are poorly characterised; however, infections can impact mosquito energy reserves, thereby influencing key life-history traits and behaviours. In addition, filarial infection is likely detrimental to flight due to damage caused by developing worms. This study aimed to evaluate the impacts of Brugia malayi infection on Aedes aegypti flight parameters: distance, average speed, maximum speed and number of flight bursts, using a tethered flight mill. In addition, we explored whether differences in flight capacity may be due to the effect of infection on glycogen and lipid reserves. Infection with filarial worms significantly reduced flight distance but increased the number of flight bursts. Exposure to microfilaermic blood led to a significant decrease in average and maximum flight speeds even in the absence of an established infection. Mosquitoes fed on microfilaraemic blood showed reduced levels of glycogen (-37.9%) and lipids (-49.7%) compared to controls at nine days post-exposure. However, a one-hour period of flight activity caused an increase in lipid content for both infected and control mosquitoes. Consequential flight incapacitation may serve in explaining the heterogeneous distribution of lymphatic filariasis.

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

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

The social, physical and economic impact of lymphedema and hydrocele: a matched cross-sectional study in rural Nigeria

BACKGROUND

Lymphatic filariasis (LF) is a mosquito-borne parasitic disease and a major cause of disability worldwide. To effectively plan morbidity management programmes, it is important to estimate disease burden and evaluate the needs of patients. This study aimed to estimate patient numbers and characterise the physical, social and economic impact of LF in in rural Nigeria.

METHODS

This is a matched cross-sectional study which identified lymphedema and hydrocele patients with the help of district health officers and community-directed distributors of mass drug administration programmes. A total of 52 cases were identified and matched to 52 apparently disease-free controls, selected from the same communities and matched by age and sex. Questionnaires and narrative interviews were used to characterise the physical, social and economic impact of lymphedema and hydrocele.

RESULTS

Forty-eight cases with various stages of lower limb lymphedema, and 4 with hydrocele were identified. 40% of all cases reported feeling stigma and were 36 times (95% CI: 5.18-1564.69) more likely to avoid forms of social participation. Although most cases engaged in some form of income-generating activity, these were low paid employment, and on average cases spent significantly less time than controls working. The economic effects of lower income were exacerbated by increased healthcare spending, as cases were 86 times (95% CI: 17.48-874.90) more likely to spend over US $125 on their last healthcare payment.

CONCLUSION

This study highlights the importance of patient-search as a means of estimating the burden of LF morbidity in rural settings. Findings from this work also confirm that LF causes considerable psychosocial and economic suffering, all of which adversely affect the mental health of patients. It is therefore important to incorporate mental health care as a major component of morbidity management programmes.

How lymphatic filariasis was eliminated from an urban poor setting in Santo Domingo, Dominican Republic

BACKGROUND

While progress has been made in the elimination of lymphatic filariasis, challenges that call for innovative approaches remain. Program challenges are increasingly observed in 'hard-to-reach' populations: urban dwellers, migrant populations, those living in insecurity, children who are out of school and areas where infrastructure is weak and education levels are low. 'Business-as-usual' approaches are unlikely to work. Tailored solutions are needed if elimination goals are to be reached. This article focuses on mass drug administrations (MDAs) in urban settings.

METHODS

We selected the urban poor area of Santo Domingo, Dominican Republic. With three rounds of MDA and with good coverage, elimination was achieved. We wanted to understand contributing factors to achieving good coverage. A qualitative study analyzed context, barriers and facilitators using a predefined framework based on review of the literature.

RESULTS

Results show that barriers commonly reported in urban settings were present (population density, lack of organization in household layout, population mobility, violence, shortage of human resources and challenges in monitoring treatment coverage). Tactics used included strong visibility in the community leading to high levels of awareness, the use of laminated photo sheets during house-to-house visits and a 1:4 supervision strategy. The importance of working through community leadership structures and building relationships with the community was evident.

DISCUSSION

The approach developed here has applications for large-scale treatment programs for lymphatic filariasis and other diseases in urban settings.

Functional Status in Hemodialysis - A Comparative Study with FIM, ADLQ and 7D5L Instruments

There is only limited information on the functional status (FS) of patients receiving hemodialysis (HD) from developing countries where the etiology of chronic kidney disease (CKD) and demographic profile are different. The study aims to assess the FS in patients with CKD using three validated generic instruments. A total of 116 adult patients on HD with a dialysis vintage >3 months were enrolled. FS was assessed using three generic tools – Functional Independence Measure (FIM) (scores 18–126), Seven domains and five levels (7D5L) (scores 0–28), and Activities of Daily Living Questionnaire (ADLQ) (scores 0–6) scales. A higher FIM and ADLQ scores and lower 7D5L score indicated good FS. The mean age of patients was 41.28 ± 15.44 years. About 77.6% were males and 80.2% were unemployed. About 67.2% were receiving twice-weekly HD, and 28.4% were receiving thrice-weekly dialysis. The mean scores were 119.05 ± 11.42 with FIM, 6.44 ± 4.26 with 7D5L, and 5.51 ± 1.19 with ADL instruments. More than 80% showed full functional independence with ADLQ instrument. With FIM, the overall scores showed a tendency for functional independence, but the subdomains involving locomotion/mobility were impaired to a greater extent. The proportion of patients with full independence was less with 7D5L. We observed an inferior FS in individuals <40 years. Patients on HD were functionally independent as assessed by FIM and ADLQ instruments. However, 7D5L appeared to be better in identifying mild to moderate limitations in daily activities. The domains involving motor tasks seem to be affected to a greater extent. The current scales for assessing FS do not incorporate a time-dependent component.

Morbidity management and disability prevention for lymphatic filariasis in Sri Lanka: Current status and future prospects

Background

Sri Lanka was acknowledged to have eliminated lymphatic filariasis (LF) as a public health problem in 2016, largely due to its success in Mass Drug Administration (MDA) to interrupt disease transmission. Analysis of the Strengths, Weaknesses, Opportunities and Threats (SWOT) of the national Morbidity Management and Disability Prevention (MMDP) program, the other pillar of the LF control program, was carried out with the objective of evaluating it and providing recommendations to optimize the use of available resources.

Methodology

A situation analysis of the MMDP activities provided by the state health sector was carried out using published records, in-depth interviews with key informants of the Anti Filariasis Campaign, site-visits to filariasis clinics with informal discussions with clinic workforce and personal communications to identify strengths and weaknesses; and opportunities to overcome weaknesses and perceived threats to the program were explored.

The principal strength of the MMDP program was the filariasis clinics operational in most endemic districts of Sri Lanka, providing free health care and health education to clinic attendees. The weaknesses identified were the low accessibility of clinics, incomplete coverage of the endemic region and lack of facilities for rehabilitation. The perceived threats were diversion of staff and resources for control of other vector-borne infections, under-utilization of clinics and non-compliance with recommended treatment. Enhanced high level commitment for MMDP, wider publicity and referral systems, integration of MMDP with other disease management services and collaboration with welfare organizations and research groups were identified as opportunities to overcome weaknesses and challenges.

Conclusions

The recommended basic package of MMDP was functional in most of the LF-endemic region. The highlighted weaknesses and challenges, unless addressed, may threaten program sustainability. The identified opportunities for improvement of the programme could ensure better attainment of the goal of the MMDP program, namely access to basic care for all affected by lymphatic filarial disease.

Lymphatic filariasis (LF) is a tropical disease causing swelling of limbs (lymphoedema, elephantiasis) and male genitalia (hydrocele). It is a disabling and deforming disease caused by parasitic worms transmitted by mosquitoes. The Sri Lankan Anti Filariasis Campaign was successful in reducing LF transmission to very low levels by annual mass drug administration, resulting in recent achievement of elimination status. The other pillar of LF elimination is the management of morbidity and disability prevention (MMDP) among those with lymphatic filarial disease. The strengths, weaknesses and threats of the MMDP program were evaluated and opportunities for improvement were explored in June 2017. The filariasis clinics established in the endemic area, providing care for patients with lymphoedema and elephantiasis, were identified as the main strength. Hospital surgical units were important in the treatment of hydrocele. The weaknesses were low accessibility of clinics, incomplete coverage of endemic districts, lack of facilities for rehabilitation and lack of morbidity targets. The threats were diversion of staff and resources, under-utilization of clinics, social stigma and loss of alliances. Enhanced commitment to improve coverage and access to clinics in the endemic areas, wider publicity, referral systems, integration of MMDP into other disease management services, collaborations with welfare organizations and research groups were the opportunities identified.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

This is not a registered trial.

Lymphatic filariasis patient identification in a large urban area of Tanzania: An application of a community-led mHealth system

BACKGROUND

Lymphatic filariasis (LF) is best known for the disabling and disfiguring clinical conditions that infected patients can develop; providing care for these individuals is a major goal of the Global Programme to Eliminate LF. Methods of locating these patients, knowing their true number and thus providing care for them, remains a challenge for national medical systems, particularly when the endemic zone is a large urban area.

METHODOLOGY/PRINCIPLE FINDINGS

A health community-led door-to-door survey approach using the SMS reporting tool MeasureSMS-Morbidity was used to rapidly collate and monitor data on LF patients in real-time (location, sex, age, clinical condition) in Dar es Salaam, Tanzania. Each stage of the phased study carried out in the three urban districts of city consisted of a training period, a patient identification and reporting period, and a data verification period, with refinements to the system being made after each phase. A total of 6889 patients were reported (133.6 per 100,000 population), of which 4169 were reported to have hydrocoele (80.9 per 100,000), 2251 lymphoedema-elephantiasis (LE) (43.7 per 100,000) and 469 with both conditions (9.1 per 100,000). Kinondoni had the highest number of reported patients in absolute terms (2846, 138.9 per 100,000), followed by Temeke (2550, 157.3 per 100,000) and Ilala (1493, 100.5 per 100,000). The number of hydrocoele patients was almost twice that of LE in all three districts. Severe LE patients accounted for approximately a quarter (26.9%) of those reported, with the number of acute attacks increasing with reported LE severity (1.34 in mild cases, 1.78 in moderate cases, 2.52 in severe). Verification checks supported these findings.

CONCLUSIONS/SIGNIFICANCE

This system of identifying, recording and mapping patients affected by LF greatly assists in planning, locating and prioritising, as well as initiating, appropriate morbidity management and disability prevention (MMDP) activities. The approach is a feasible framework that could be used in other large urban environments in the LF endemic areas.

Measuring the physical and economic impact of filarial lymphoedema in Chikwawa district, Malawi: a case-control study

BACKGROUND

Lymphatic filariasis (LF) is one of the primary causes of lymphoedema in sub-Saharan Africa, and has a significant impact on the quality of life (QoL) of those affected. In this paper we assess the relative impact of lymphoedema on mobility and income in Chikwawa district, Malawi.

METHODS

A random sample of 31 people with lymphoedema and 31 matched controls completed a QoL questionnaire from which both an overall and a mobility-specific score were calculated. Two mobility tests were undertaken, namely the 10 m walking test [10MWT] and timed up and go [TUG] test, and a subset of 10 cases-control pairs wore GPS data loggers for 3 weeks to measure their mobility in a more natural setting. Retrospective economic data was collected from all 31 case-control pairs, and each participant undertaking the GPS activity recorded daily earnings and health expenditure throughout the observation period.

RESULTS

Cases had a significantly poorer overall QoL (cases = 32.2, controls = 6.0, P < 0.01) and mobility-specific (cases = 43.1, controls = 7.4, P < 0.01) scores in comparison to controls. Cases were also significantly slower (P < 0.01) at completing the timed mobility tests, e.g. mean 10MWT speed of 0.83 m/s in comparison to 1.10 m/s for controls. An inconsistent relationship was observed between mobility-specific QoL scores and the timed test results for cases (10MWT correlation = -0.06, 95% CI = (-0.41, 0.30)), indicating that their perceived disability differed from their measured disability, whereas the results were consistent for controls (10MWT correlation = -0.61, 95% CI = (-0.79, -0.34)). GPS summaries indicated that cases generally walk shorter distances at slower speeds than control, covering a smaller geographical area (median area by kernel smoothing: cases = 1.25 km², controls = 2.10 km², P = 0.16). Cases reported earning less than half that earned by controls per week (cases = $0.70, controls = $1.86, P = 0.064), with a smaller proportion of their earnings (16% vs 22%, P = 0.461) being spent on healthcare.

CONCLUSIONS

Those affected by lymphoedema are at a clear disadvantage to their unaffected peers, experiencing a lower QoL as confirmed by both subjective and objective mobility measures, and lower income. This study also indicates that objective measures of mobility may be a useful supplement to self-assessed QoL questionnaires when assessing the future impact of lymphoedema management interventions.

Dermal Structure in Lymphedema Patients with History of Acute Dermatolymphangioadenitis Evaluated by Histogram Analysis of Ultrasonography Findings: A Case-Control Study

BACKGROUND

Acute dermatolymphangioadenitis (ADLA) is a risk factor for increasing of edema and worsening severity. Reducing ADLA frequency is an important objective of lymphedema management because ADLA episodes are strongly associated with poor quality of life. Lymphedema changes dermal and subcutaneous structure, favoring ADLA; ADLA recurrence may be caused by structural change of the dermis. However, the structure of the skin following ADLA episodes has not been studied in depth. The aim of this study was to examine changes in the skin after episodes of ADLA in breast cancer-related lymphedema (BCRL) using histogram analysis of ultrasonography findings.

METHODS AND RESULTS

This was a case-control study with matching for the duration of lymphedema. We compared 10 limbs (5 BCRL patients, Cases) with a history of ADLA and 14 limbs (7 BCRL patients, Controls) without. Ultrasonography was performed using a 20-MHz probe, and measurements were made at a site 10 cm proximal to the ulnar styloid process. We compared "skewness" of the images in the dermis from the histogram analysis. This study was approved by the Ethics Committee of Kanazawa University. Skewness was significantly different between the affected and unaffected limbs (p = 0.02). Cases showed a positive value (median 0.74, range -0.18 to 1.26), whereas Controls showed a negative value (median -0.21, range -0.45 to 0.31).

CONCLUSIONS

Episodes of ADLA changed the distribution of echogenicity on imaging, which indicates a change in the collagen fibers in the dermis. These findings might contribute to improving the management of lymphedema and prevention of recurrent ADLA.

Social stigma towards neglected tropical diseases: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical case estimates of lymphatic filariasis in an endemic district of Bangladesh after a decade of mass drug administration

BACKGROUND

Bangladesh has a high burden of lymphatic filariasis (LF) disease. This survey estimated the current number of clinical cases in a historically endemic district after a decade of mass drug administration (MDA).

METHODS

A cluster survey was conducted in 30 villages of Nilphamari District. Ten households per village were randomly selected, and individuals with LF clinical conditions identified. Hydrocoele and lymphoedema (leg, arm, breast) cases were quantified and mapped, and differences by sex, age, severity of disease and episodes of acute dermatolymphangioadenitis attacks (ADLA) examined.

RESULTS

From 1242 surveyed >10 years old 55 individuals (4.4%) with LF clinical conditions were identified. Males were mostly affected by hydrocoeles, and females by leg lymphoedema. Higher prevalence and more advanced stages of disease were found in older age groups.

CONCLUSIONS

Overall low prevalence of severe clinical disease was found, which has positive implications for the elimination goal. Future planning of MMDP strategies will need to address the varying clinical conditions, severity of disease and impact of ADLAs affecting different sub-groups of the population. It will also be important to monitor for new cases, and examine the shift in age distribution of cases over time.

Experiences of a Community-Based Lymphedema Management Program for Lymphatic Filariasis in Odisha State, India: An Analysis of Focus Group Discussions with Patients, Families, Community Members and Program Volunteers

Background

Globally 68 million people are infected with lymphatic filariasis (LF), 17 million of whom have lymphedema. This study explores the effects of a lymphedema management program in Odisha State, India on morbidity and psychosocial effects associated with lymphedema.

Methodology/Principal Findings

Focus groups were held with patients (eight groups, separated by gender), their family members (eight groups), community members (four groups) and program volunteers (four groups) who had participated in a lymphedema management program for the past three years. Significant social, physical, and economic difficulties were described by patients and family members, including marriageability, social stigma, and lost workdays. However, the positive impact of the lymphedema management program was also emphasized, and many family and community members indicated that community members were accepting of patients and had some improved understanding of the etiology of the disease. Program volunteers and community members stressed the role that the program had played in educating people, though interestingly, local explanations and treatments appear to coexist with knowledge of biomedical treatments and the mosquito vector.

Conclusions/Significance

Local and biomedical understandings of disease can co-exist and do not preclude individuals from participating in biomedical interventions, specifically lymphedema management for those with lymphatic filariasis. There is a continued need for gender-specific psychosocial support groups to address issues particular to men and women as well as a continued need for improved economic opportunities for LF-affected patients. There is an urgent need to scale up LF-related morbidity management programs to reduce the suffering of people affected by LF.

Around the world 68 million people are infected with lymphatic filariasis (LF), a mosquito-borne disease caused by filarial worms. The parasite can damage patients’ lymphatic systems causing pain, infections and swollen limbs, known as lymphedema or, in more advanced stages, elephantiasis. Lymphedema management programs can help patients to deal with the physical and emotional effects of lymphedema and elephantiasis. We held a total of 24 focus groups to discuss the experiences of people with lymphedema in Odisha State, India who participate in such a program. Discussions were held with patients, family members of patients, community members and program volunteers. Significant social, physical and economic difficulties were described by patients and family members, including marriage-related issues, social stigma, and lost workdays. However, the positive impacts of the lymphedema management program were also emphasized, and many family and community members indicated that community members were accepting of patients and had some improved understanding of the cause of the disease. People were able to hold both a ‘scientific’ and a ‘traditional’ understanding of LF at the same time. The financial hardships that people described highlight the need for improved economic opportunities for lymphedema-affected patients. Support programs based in the community also have clear social and emotional benefits. There is an urgent need to scale up LF management programs to reduce the suffering of people affected by LF.

The Effect of In Vitro Cultivation on the Transcriptome of Adult Brugia malayi

BACKGROUND

Filarial nematodes cause serious and debilitating infections in human populations of tropical countries, contributing to an entrenched cycle of poverty. Only one human filarial parasite, Brugia malayi, can be maintained in rodents in the laboratory setting. It has been a widely used model organism in experiments that employ culture systems, the impact of which on the worms is unknown.

METHODOLOGY/PRINCIPAL FINDINGS

Using Illumina RNA sequencing, we characterized changes in gene expression upon in vitro maintenance of adult B. malayi female worms at four time points: immediately upon removal from the host, immediately after receipt following shipment, and after 48 h and 5 days in liquid culture media. The dramatic environmental change and the 24 h time lapse between removal from the host and establishment in culture caused a globally dysregulated gene expression profile. We found a maximum of 562 differentially expressed genes based on pairwise comparison between time points. After an initial shock upon removal from the host and shipping, a few stress fingerprints remained after 48 h in culture and until the experiment was stopped. This was best illustrated by a strong and persistent up-regulation of several genes encoding cuticle collagens, as well as serpins.

CONCLUSIONS/SIGNIFICANCE

These findings suggest that B. malayi can be maintained in culture as a valid system for pharmacological and biological studies, at least for several days after removal from the host and adaptation to the new environment. However, genes encoding several stress indicators remained dysregulated until the experiment was stopped.

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.

Autophagy protects monocytes from Wolbachia heat shock protein 60-induced apoptosis and senescence

Monocyte dysfunction by filarial antigens has been a major mechanism underlying immune evasion following hyporesponsiveness during patent lymphatic filariasis. Recent studies have initiated a paradigm shift to comprehend the immunological interactions of Wolbachia and its antigens in inflammation, apoptosis, lymphocyte anergy, etc. Here we showed that recombinant Wolbachia heat shock protein 60 (rWmhsp60) interacts with TLR-4 and induces apoptosis in monocytes of endemic normal but not in chronic patients. Higher levels of reactive oxygen species (ROS) induced after TLR-4 stimulation resulted in loss of mitochondrial membrane potential and caspase cascade activation, which are the plausible reason for apoptosis. Furthermore, release in ROS owing to TLR-4 signaling resulted in the activation of NF-κB p65 nuclear translocation which leads to inflammation and apoptosis via TNF receptor pathway following the increase in IL-6 and TNF-α level. Here for the first time, we report that in addition to apoptosis, rWmhsp60 antigen in filarial pathogenesis also induces molecular senescence in monocytes. Targeting TLR-4, therefore, presents a promising candidate for treating rWmhsp60-induced apoptosis and senescence. Strikingly, induction of autophagy by rapamycin detains TLR-4 in late endosomes and subverts TLR-4-rWmhsp60 interaction, thus protecting TLR-4–mediated apoptosis and senescence. Furthermore, rapamycin-induced monocytes were unresponsive to rWmhsp60, and activated lymphocytes following PHA stimulation. This study demonstrates that autophagy mediates the degradation of TLR-4 signaling and protects monocytes from rWmhsp60 induced apoptosis and senescence.

Despite knowing the significance of Wolbachia in helminth infections, our understanding of immunity and pathogenesis remains incomplete. Therefore, considering the gravity of the problem, the present study provides evidence that Wolbachia heat shock protein 60 induces apoptosis and senescence through TLR-4. Also, binding of rWmhsp60 to TLR-4 triggered caspase cascade activation following, ROS-mediated mitochondrial potential loss. Moreover, we found that nuclear translocation of NF-κB p65 was predominantly related to TLR-4 expression and resulted in apoptosis- and senescence-mediated inflammation via TNF-α and IL-6. Hence, we hypothesized that modifying TLR-4 expression may provide a plausible target for designing antiparasitic drugs. Here we have shown that induction of autophagy by rapamycin destabilizes TLR-4 expression and protects monocytes from rWmhsp60-induced apoptosis and senescence. In addition, rapamycin-induced monocytes were unresponsive to rWmhsp60 and triggered lymphocyte activation after PHA stimulation. Thus, synergistic usage of rapamycin with existing anti-filarial drugs might reduce the TLR-mediated inflammatory reactions following microfilaricidal treatment.

Filariasis serosurvey, New Caledonia, South Pacific, 2013

Background

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

Findings

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

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

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

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

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

Conclusion

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

Exploring hydrocoele surgery accessibility and impact in a lymphatic filariasis endemic area of southern Malawi

BACKGROUND

Hydrocoele surgery is the recommended treatment for the common clinical manifestation of lymphatic filariasis in men. This study determined the geographical differences in surgery accessibility, and improvements in the quality of life of patients in Chikwawa district, Malawi.

METHODS

Surgery records from Chikwawa District Hospital (CDH), between 2008 and 2013, were used to map surgery rates by village, spatial dependence by census enumeration area and relationship of distance (kilometres) to CDH. A subset of patients were selected to quantify and compare their physical and socio-economic well-being and level of disability pre- and post-surgery using a standardised questionnaire.

RESULTS

A total of 476 hydrocoele surgical cases were identified with 260 cases geo-referenced and mapped. A significant negative relationship between village-level surgery rates and distance to CDH (r=-0.137; 95% CI: -0.47 to -0.26) was found, and clusters of enumeration areas with high surgery rates identified around the CDH. Significant improvements in patients' ability to walk and work were found and the overall level of disability was reduced post-surgery.

CONCLUSIONS

Hydrocoele surgery positively impacted on patients, improving their physical and socio-economic output. Surgical services need to scale-up and expand to reach cases that have less access to the best treatment currently available.

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

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

Quantifying the physical and socio-economic burden of filarial lymphoedema in Chikwawa District, Malawi

BACKGROUND

Lymphatic filariasis (LF) is a disfiguring parasitic disease and one of the leading causes of disability in the world. This study aimed to assess the severity of lymphoedema, the physical restrictions and socio-economic impact on affected individuals living in an endemic community in Malawi.

METHODS

In a single health centre catchment area, a follow-up survey was conducted to assess 69 lymphoedema cases, and the impact of their condition in eight different areas of their lives. Differences were examined by sex, age and severity of disease. The overall level of disability was quantified and the impact of acute dermatolymphangioadenitis (ADLA) attacks was examined.

RESULTS

Lymphoedema cases were most affected by pain/discomfort and anxiety/depression, which also had an economic impact. Male and older (>60 years) individuals reported more problems. Higher disability levels based on a quantified score were significantly associated with decreased walking distance and working hours. ADLA significantly increased pain/discomfort and reduced cognition, and also affected the individuals' self-care, social participation and ability to work.

CONCLUSIONS

Filarial lymphoedema causes significant hardship, particularly in relation to ADLAs, and the scale of the problem needs to be better defined with new specific tools so that the best support and care can be provided to those in greatest need.

Comparison of three quality of life instruments in lymphatic filariasis: DLQI, WHODAS 2.0, and LFSQQ

Background

The Global Program to Eliminate Lymphatic Filariasis aims to interrupt transmission of lymphatic filariasis and manage morbidity in people currently living with the disease. A component of morbidity management is improving health-related quality of life (HRQoL) in patients. Measurement of HRQoL in current management programs is varied because of the lack of a standard HRQoL tool for use in the lymphatic filariasis population.

Methodology/Principal Findings

In this study, the psychometric properties of three health status measures were compared when used in a group of lymphatic filariasis patients and healthy controls. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), the Dermatology Life Quality Index (DLQI), and the Lymphatic Filariasis Quality of Life Questionnaire (LFSQQ) were administered to 36 stage II and stage III lymphatic filariasis subjects and 36 age and sex matched controls in Kerala, India. All three tools yielded missing value rates lower than 10%, suggesting high feasibility. Highest internal consistency was seen in the LFSQQ (α = 0.97). Discriminant validity analysis demonstrated that HRQoL was significantly lower in the LF group than in controls for the WHODAS 2.0, DLQI, and LFSQQ, but total HRQoL scores did not differ between stage II and stage III lymphedema subjects. The LFSQQ total score correlated most strongly with the WHODAS 2.0 (r = 0.91, p<0.001) and DLQI (r = 0.81, p<0.001).

Conclusions/Significance

The WHODAS 2.0, DLQI, and LFSQQ demonstrate acceptable feasibility, internal consistency, discriminate validity, and construct validity. Based on our psychometric analyses, the LFSQQ performs the best and is recommended for use in the lymphatic filariasis population.

Lymphatic filariasis affects approximately 120 million people and is the second leading cause of life-long disability worldwide. Because lymphatic filariasis is one of the World Health Organization's six eradicable diseases, much effort has been placed into reducing transmission of the disease and managing morbidity. Novel interventions frequently use health-related quality of life as an outcome measure to monitor efficacy of the intervention. In an effort to delineate the strengths and weaknesses of health status measures and recommend use of a single tool in the lymphatic filariasis population, we compared the use of three health status tools (The World Health Organization Disability Assessment Schedule 2.0, the Dermatology Life Quality Index, and the Lymphatic Filariasis Quality of Life Questionnaire) in lymphatic filariasis subjects and healthy controls in Kerala, India. The Lymphatic Filariasis Quality of Life Questionnaire performed the best by discriminating well between subjects and controls, possessing significant content overlap with the other two tools, yielding a low missing value rate, and being internally consistent. This is the first study to compare health status measures in lymphatic filariasis subjects and provides insight into the use of the tools in quality of life analysis.

Stigma towards a neglected tropical disease: felt and enacted stigma scores among podoconiosis patients in Northern Ethiopia

Background

Podoconiosis, or non-filarial elephantiasis, is a neglected tropical disease (NTD) characterised by swelling of the lower legs. When left untreated, this disfiguring condition has a significant social impact. This study aimed to describe the stigma experience among podoconiosis patients in Dembecha, Northern Ethiopia and assess potential associations between stigma and sociodemographic determinants.

Methods

The study was conducted in May 2012 in Northern Ethiopia. A questionnaire-based cross-sectional study design was used and stigma was assessed using a validated podoconiosis stigma scale including 'felt’ and 'enacted’ stigma domains. Enacted stigma includes the experience of discrimination such as abuse, loss of employment or prejudicial attitudes, while felt stigma is the perceived fear of enacted stigma. A multivariable linear regression model was used to explore determinants that may be associated with stigma.

Results

A total of 346 clinically confirmed podoconiosis patients participated in the study. The total mean score of all stigma scale items was 30.7 (Range = 0 to 96). There was a higher mean score of scale items in domains of felt stigma (21.7; Range = 0 to 45) as compared to enacted stigma (9.0; Range = 0 to 51). The total mean score of all stigma scale items appeared to increase with disease stage. A final adjusted linear regression model found an association between stigma and factors including monthly income, duration lived in the current residence, and disease stage, after controlling for confounders.

Conclusion

Podoconiosis is a stigmatized disease with a clear social impact. This paper documented the burden of podoconiosis-related stigma and identified associated factors. Programs aimed at preventing and treating podoconiosis should incorporate interventions to mitigate both felt and enacted stigma. Interventions targeting patients should prioritize those with advanced disease.

Psychosocial and spiritual problems of terminally ill patients in Kerala, India

AIM

To investigate psychosocial and spiritual problems of terminally ill patients in Kerala, India.

MATERIALS & METHODS

Semi-structured qualitative interviews of terminally ill patients were carried out at the Trivandrum Institute of Palliative Sciences Palliative Care Clinic in Trivandrum, Kerala, India and in patients' homes in the surrounding area.

RESULTS

Interviews with 37 terminally ill patients in Kerala showed several problems regarding their emotional state, faith, knowledge about the disease, family life and the major impact of financial issues.

CONCLUSION

This study shows that more effort should be focused on the reduction of the problems terminally ill patients have to face. While many of these problems are a result of financial troubles and could be eliminated if sufficient funds were available, others are a consequence of tradition and culture. Solutions for the improvement of patients' situations in accord with tradition and culture have to be found.

Socioeconomic burden of lymphatic filariasis in Georgetown, Guyana

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Disability measurement for lymphatic filariasis: a review of generic tools used within morbidity management programs

Lymphatic filariasis (LF)-related disability affects 40 million people globally, making LF the leading cause of physical disability in the world. Despite this, there is limited research into how the impacts of LF-related disability are best measured. This article identifies the tools currently being used to measure LF-related disability and reviews their applicability against the known impacts of LF. The findings from the review show that the generic disability tools currently used by LF programs fail to measure the majority of known impacts of LF-related disability. The findings from the review support the development of an LF-specific disability measurement tool and raise doubt about the suitability of generic disability tools to assess disability related to neglected tropical diseases (NTDs) globally.

Neglected tropical diseases and mental health: a perspective on comorbidity

Mental health conditions will be the largest contributor to the global health burden by 2030. Our review suggests that neglected tropical diseases (NTDs) predispose individuals to poor mental health. Factors predisposing to poor mental health include stigma and discrimination, exclusion from participating fully in society, reduced access to health and social services, lack of educational opportunities, exclusion from income-generation and employment opportunities, and restrictions in exercising civil and political rights. These characteristics are all features of NTDs, but the mental health of these sufferers has been ignored. This review raises an issue of concern and highlights the opportunities for research by psychiatrists and psychologists on NTDs.

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

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

The association between giant hydrocele and depression in a rural clinic in Nigeria

One of the dreaded disfiguring disease conditions among the Andoni tribesmen in the Nigerian Niger delta region is hydrocele, especially when its size is large (giant hydrocele) and it cannot be concealed. This case-control study was designed to evaluate the prevalence of depression among patients with giant hydrocele presenting to Bethesda Clinic Ngo, Andoni, Nigeria. A total of 52 patients were recruited into this study: 26 in the giant hydrocele group and 26 in the control group. Their age range was 23 to 78 years, with a mean age of 53.4 ± 15.5 years for the giant hydrocele group and 53.6 ± 14.2 years for the control group. The difference between the prevalence of depression among patients that presented with giant hydrocele (61.54%) and the controls (15.38%) was statistically significant (p = .0015). The authors conclude that depression is common among patients with giant hydrocele when compared with patients with other disease conditions.

Midgut barrier imparts selective resistance to filarial worm infection in Culex pipiens pipiens

Mosquitoes in the Culex pipiens complex thrive in temperate and tropical regions worldwide, and serve as efficient vectors of Bancroftian lymphatic filariasis (LF) caused by Wuchereria bancrofti in Asia, Africa, the West Indies, South America, and Micronesia. However, members of this mosquito complex do not act as natural vectors for Brugian LF caused by Brugia malayi, or for the cat parasite B. pahangi, despite their presence in South Asia where these parasites are endemic. Previous work with the Iowa strain of Culex pipiens pipiens demonstrates that it is equally susceptible to W. bancrofti as is the natural Cx. p. pipiens vector in the Nile Delta, however it is refractory to infection with Brugia spp. Here we report that the infectivity barrier for Brugia spp. in Cx. p. pipiens is the mosquito midgut, which inflicts internal and lethal damage to ingested microfilariae. Following per os Brugia exposures, the prevalence of infection is significantly lower in Cx. p. pipiens compared to susceptible mosquito controls, and differs between parasite species with <50% and <5% of Cx. p. pipiens becoming infected with B. pahangi and B. malayi, respectively. When Brugia spp. mf were inoculated intrathoracically to bypass the midgut, larvae developed equally well as in controls, indicating that, beyond the midgut, Cx. p. pipiens is physiologically compatible with Brugia spp. Mf isolated from Cx. p. pipiens midguts exhibited compromised motility, and unlike mf derived from blood or isolated from the midguts of Ae. aegypti, failed to develop when inoculated intrathoracically into susceptible mosquitoes. Together these data strongly support the role of the midgut as the primary infection barrier for Brugia spp. in Cx. p. pipiens. Examination of parasites recovered from the Cx. p. pipiens midgut by vital staining, and those exsheathed with papain, suggest that the damage inflicted by the midgut is subcuticular and disrupts internal tissues. Microscopic studies of these worms reveal compromised motility and sharp bends in the body; and ultrastructurally the presence of many fluid or carbohydrate-filled vacuoles in the hypodermis, body wall, and nuclear column. Incubation of Brugia mf with Cx. p. pipiens midgut extracts produces similar internal damage phenotypes; indicating that the Cx. p. pipiens midgut factor(s) that damage mf in vivo are soluble and stable in physiological buffer, and inflict damage on mf in vitro.

Culex pipiens complex mosquitoes transmit numerous diseases that affect humans and other animals. In many parts of the tropics they transmit Bancroftian lymphatic filariasis caused by the filarial nematode Wuchereria bancrofti. However, in parts of South Asia where Brugian lymphatic filariasis caused by Brugia spp. is endemic, this group of mosquitoes is present but does not play a role in transmission. The differential susceptibility of Cx. p. pipiens mosquitoes for Wuchereria but not Brugia species occurs as a result of the mosquito midgut environment. W. bancrofti larvae ingested with a bloodmeal can penetrate the Culex midgut, however Brugia larvae ingested by Cx. p. pipiens are unable to penetrate the midgut epithelium and die within the lumen. These observations suggest that toxic factor(s) exist within the lumen of the Cx. p. pipiens midgut that physically and lethally damage Brugia parasites. Understanding natural mechanisms of resistance to parasites in arthropod vectors is critical if we are to gain a complete understanding of the transmission dynamics and epidemiology of LF and other vector-borne diseases.

Feasibility and effectiveness of basic lymphedema management in Leogane, Haiti, an area endemic for bancroftian filariasis

Background

Approximately 14 million persons living in areas endemic for lymphatic filariasis have lymphedema of the leg. Clinical studies indicate that repeated episodes of bacterial acute dermatolymphangioadenitis (ADLA) lead to progression of lymphedema and that basic lymphedema management, which emphasizes hygiene, skin care, exercise, and leg elevation, can reduce ADLA frequency. However, few studies have prospectively evaluated the effectiveness of basic lymphedema management or assessed the role of compressive bandaging for lymphedema in resource-poor settings.

Methodology/Principal Findings

Between 1995 and 1998, we prospectively monitored ADLA incidence and leg volume in 175 persons with lymphedema of the leg who enrolled in a lymphedema clinic in Leogane, Haiti, an area endemic for Wuchereria bancrofti. During the first phase of the study, when a major focus of the program was to reduce leg volume using compression bandages, ADLA incidence was 1.56 episodes per person-year. After March 1997, when hygiene and skin care were systematically emphasized and bandaging discouraged, ADLA incidence decreased to 0.48 episodes per person-year (P<0.0001). ADLA incidence was significantly associated with leg volume, stage of lymphedema, illiteracy, and use of compression bandages. Leg volume decreased in 78% of patients; over the entire study period, this reduction was statistically significant only for legs with stage 2 lymphedema (P = 0.01).

Conclusions/Significance

Basic lymphedema management, which emphasized hygiene and self-care, was associated with a 69% reduction in ADLA incidence. Use of compression bandages in this setting was associated with an increased risk of ADLA. Basic lymphedema management is feasible and effective in resource-limited areas that are endemic for lymphatic filariasis.

Lymphatic filariasis is a parasitic disease that is spread by mosquitoes. In tropical countries where lymphatic filariasis occurs, approximately 14 million people suffer from chronic swelling of the leg, known as lymphedema. Repeated episodes of bacterial skin infection (acute attacks) cause lymphedema to progress to its disfiguring form, elephantiasis. To help achieve the goal of eliminating lymphatic filariasis globally, the World Health Organization recommends basic lymphedema management, which emphasizes hygiene, skin care, exercise, and leg elevation. Its effectiveness in reducing acute attack frequency, as well as the role of compressive bandaging, have not been adequately evaluated in filariasis-endemic areas. Between 1995 and 1998, we studied 175 people with lymphedema of the leg in Leogane, Haiti. During Phase I of the study, when compression bandaging was used to reduce leg volume, the average acute attack rate was 1.56 episodes per year; it was greater in people who were illiterate and those who used compression bandages. After March 1997, when hygiene and skin care were emphasized and bandaging discouraged, acute attack frequency significantly decreased to 0.48 episodes per year. This study highlights the effectiveness of hygiene and skin care, as well as limitations of compressive bandaging, in managing lymphedema in filariasis-endemic areas.

The experience of living with chronic manifestations of Lymphatic Filariasis among patients 15 years and older in developing countries: a systematic review

BACKGROUND

Lymphatic filariasis is considered a disease of the poor with painful and profoundly disfiguring consequences. It is transmitted by the mosquito. Lymphatic filariasis is found among persons residing in rural areas and at the periphery of communities predominantly in developing countries in the tropics.

OBJECTIVES

To present the best evidence regarding the experiences of persons living with chronic manifestations of lymphatic filariasis, their experiences of treatment strategies and how the condition influences their social relationships within the context of developing countries.

INCLUSION CRITERIA

Study subjects were persons 15 years and older with chronic lymphatic filariasis living in developing countries.Phenomena of interest Publications that were selected considered the experiences of persons living with chronic lymphatic filariasis, their experiences of treatment measures and their social relationships.Types of studies Qualitative research papers (including but not limited to: phenomenology, grounded theory, action research, narrative studies, descriptive studies, ethnographies, cultural studies, behavioral studies, case studies and feminist research) exploring the experiences of persons living with chronic manifestations of lymphatic filariasis within the context of developing countries SEARCH STRATEGY: A three-step search strategy was utilised to search for published and unpublished studies over the period of 1980-2007. MEDLINE and CINAHL were initially searched for keywords and index terms that were then used to search across all the other data bases and finally the reference list of identified studies.

METHODOLOGICAL QUALITY

Eligible publications were assessed by two independent reviewers for methodological validity using the standardised critical appraisal tools of the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) DATA EXTRACTION: Data extraction was conducted using the standardised data extraction tools of the JBI-QARI. Extracted information consisted of details on relevant aspects of the identified studies.

DATA SYNTHESIS

Study findings were categorised according to the JBI-QARI degrees of credibility scale, and placed in categories of similar meaning. Categories were finally meta-synthesised.

RESULTS

Six (6) included studies yielded 41 findings that were placed in 8 categories and finally meta-synthesised into 3 synthesised findings: CONCLUSION: Policy guidelines on chronic lymphatic filariasis management need to provide a holistic approach with the involvement of communities.

IMPLICATIONS FOR RESEARCH

Much more research into elephantiasis management should be encouraged; so should qualitative research with rigorous methodological approaches into all aspects of lymphatic filariasis.

IMPLICATIONS FOR PRACTICE

Interventions should address in concert with other needs the psycho-emotional health of patients. Counseling should be incorporated into surgical management of hydroceles to allay fears of death.

Quality of life in filarial lymphoedema patients in Colombo, Sri Lanka

The quality of life (QOL) was assessed in 141 filarial lymphoedema patients and 128 healthy people in the Colombo district of Sri Lanka. Information was gathered by administering the validated translated version of the WHO 100-item QOL questionnaire (WHOQOL-100), which ascertains an individual's perception of QOL in the physical, psychological, level of independence, environmental and spiritual domains, as well as the general QOL. Healthy controls had a better QOL in all domains as well as in the overall general QOL, when compared to patients with lymphoedema. Several facets such as pain and discomfort, sleep and rest, activities of daily living, dependence on medication and treatment, working capacity and social support were significantly affected by the acute adenolymphangitis attack/s patients had suffered. The environmental and spiritual domains were significantly affected by the maximum grade of lymphoedema. The significant difference in the QOL as perceived by patients suffering from filarial lymphoedema and apparently healthy individuals reiterates the importance of morbidity control in patients already affected by filarial lymphoedema.