Impact of chronic lymphatic filariasis on quantity and quality of productive work among weavers in an endemic village from India

Implementing a Locally Made Low-Cost Intervention for Wound and Lymphedema Care in Western Kenya

In Western Kenya, the burden of chronic wounds and lymphedema has a significant impact on functionality and quality of life. Major barriers to provision of care include availability, affordability, and accessibility of bandages. At the Academic Model Providing Access to Healthcare, dermatologists and pharmacists collaborated to develop a 2-component compression bandage modeled after the Unna boot, using locally available materials, that is distributed through a revolving fund pharmacy network. In partnership with nursing, use of these bandages at a national referral hospital and a few county facilities has increased, but increasing utilization to an expanded catchment area is needed.

Economic Costs and Benefits of Community-Based Lymphedema-Management Programs for Lymphatic Filariasis in India

Lymphatic filariasis (LF) is endemic in 72 countries; 15 million persons live with chronic filarial lymphedema. It can be a disabling condition, frequently painful, leading to reduced mobility, social exclusion, and depression. The Global Program to Eliminate Lymphatic Filariasis aims to stop new infections and care for affected persons, but morbidity management has been initiated in only 38 countries. We examine economic costs and benefits of alleviating chronic lymphedema and its effects through simple limb care. We use economic and epidemiological data from 12 Indian states in which 99% of Indians with filariasis reside. Using census data, we calculate the age distribution of filarial lymphedema and predict the burden of morbidity of infected persons. We estimate lifetime medical costs and lost earnings due to lymphedema and acute dermatolymphangioadenitis (ADLA) with and without community-based limb-care programs. Programs of community-based limb care in all Indian endemic areas would reduce costs of disability by 52%, saving a per person average of US$2,721, equivalent to 703 workdays. Per-person savings are 185 times the program's per-person cost. Chronic lymphedema and ADLA impose a substantial physical and economic burden in filariasis-endemic areas. Low-cost programs for lymphedema management based on limb washing and topical medication are effective in reducing the number of ADLA episodes and stopping progression of disabling lymphedema. With reduced disability, people can work longer hours per day, more days per year, and in more strenuous, higher paying jobs, resulting in important economic benefits to themselves, their families, and their communities.

The influence of breast cancer related lymphedema on women's return-to-work

BACKGROUND

Lymphedema is one of the major treatment complications following breast cancer surgery and radiation. As the majority of women who develop breast cancer are at the age of employment, occupational functioning and employment are issues of concern. This study is novel in exploring the ways that lymphedema affects their work experience.

METHODS

A multiple-case study methodology drawn from Yin's definition was employed. A total of 13 female survivors who developed breast cancer-related lymphedema participated by completing a survey and a 60-min semi-structured interview.

RESULTS

Four main themes emerged: (1) breast cancer-related lymphedema affects physical and emotional functioning associated with work; (2) ongoing treatment for breast cancer-related lymphedema creates challenges for work; (3) environmental factors affect the return-to-work experience; and (4) personal factors play a key role in adjusting to return-to-work.

CONCLUSION

Both breast cancer-related lymphedema and its treatment have direct and indirect effects on work, with environmental and personal factors also shaping the work-return experience. This study suggests that breast cancer survivors with lymphedema who wish to return to work face potential barriers, and that gaps remain in the availability of supports.

Perceptions, knowledge, attitudes and practices for the prevention and control of lymphatic filariasis in Conakry, Republic of Guinea

Little is known about the perceptions, attitudes and practices of lymphatic filariasis in Conakry, Republic of Guinea. Yet, such knowledge is important for an optimal design and implementation of setting-specific prevention and control measures. We conducted a cross-sectional study using a mixed methods approach. Qualitative data related to people's general experience with lymphatic filariasis, their perception of the causes of the disease, the onset of elephantiasis, care-seeking behaviour and the socioeconomic impact of lymphatic filariasis were collected through in-depth interviews with 85 respondents. Quantitative data related to strategies for prevention and the knowledge of the causes of the disease were collected by interviewing 429 people. A total of 514 individuals (313 females and 201 males), aged 10-84 years, participated. Most participants were well aware of lymphatic filariasis and they recognized the disease mainly by its disfiguring manifestation, collectively termed "elephantiasis" or "leg-swelling disease". Morbidity patterns due to filarial infection showed an increase with age (from 30 to 50 years) independent of sex. Most patients with lymphatic filariasis abandoned their jobs (73.9%) or sought other work (21.7%). The main perceived causes of acquiring lymphatic filariasis were of supernatural origin (as stated by 8.7% of patients and 5.7% of healthy subjects), while mosquito bites were mentioned by fewer participants (4.3% of patients and 4.2% of healthy subjects). A number of other causes were reported that relate to both medical and non-medical conceptions. The study also identified socioeconomic impairments and stigmatization due to elephantiasis. Taken together, community perception of lymphatic filariasis in Conakry is influenced by sociocultural conceptions. Appropriate health education campaigns aimed at enhancing community understanding of the transmission of lymphatic filariasis are required to increase the success of mass drug administration implemented for the elimination of this disease. There is a need for a morbidity management programme to alleviate lymphatic filariasis-related physical and emotional burden in Conakry.

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.

The Socioeconomic Benefit to Individuals of Achieving the 2020 Targets for Five Preventive Chemotherapy Neglected Tropical Diseases

BACKGROUND

Lymphatic filariasis (LF), onchocerciasis, schistosomiasis, soil-transmitted helminths (STH) and trachoma represent the five most prevalent neglected tropical diseases (NTDs). They can be controlled or eliminated by means of safe and cost-effective interventions delivered through programs of Mass Drug Administration (MDA)-also named Preventive Chemotherapy (PCT). The WHO defined targets for NTD control/elimination by 2020, reinforced by the 2012 London Declaration, which, if achieved, would result in dramatic health gains. We estimated the potential economic benefit of achieving these targets, focusing specifically on productivity and out-of-pocket payments.

METHODS

Productivity loss was calculated by combining disease frequency with productivity loss from the disease, from the perspective of affected individuals. Productivity gain was calculated by deducting the total loss expected in the target achievement scenario from the loss in a counterfactual scenario where it was assumed the pre-intervention situation in 1990 regarding NTDs would continue unabated until 2030. Economic benefits from out-of-pocket payments (OPPs) were calculated similarly. Benefits are reported in 2005 US$ (purchasing power parity-adjusted and discounted at 3% per annum from 2010). Sensitivity analyses were used to assess the influence of changes in input parameters.

RESULTS

The economic benefit from productivity gain was estimated to be I$251 billion in 2011-2020 and I$313 billion in 2021-2030, considerably greater than the total OPPs averted of I$0.72 billion and I$0.96 billion in the same periods. The net benefit is expected to be US$ 27.4 and US$ 42.8 for every dollar invested during the same periods. Impact varies between NTDs and regions, since it is determined by disease prevalence and extent of disease-related productivity loss.

CONCLUSION

Achieving the PCT-NTD targets for 2020 will yield significant economic benefits to affected individuals. Despite large uncertainty, these benefits far exceed the investment required by governments and their development partners within all reasonable scenarios. Given the concentration of the NTDs among the poorest households, these investments represent good value for money in efforts to share the world's prosperity and reduce inequity.

Economic Costs and Benefits of a Community-Based Lymphedema Management Program for Lymphatic Filariasis in Odisha State, India

Lymphatic filariasis afflicts 68 million people in 73 countries, including 17 million persons living with chronic lymphedema. The Global Programme to Eliminate Lymphatic Filariasis aims to stop new infections and to provide care for persons already affected, but morbidity management programs have been initiated in only 24 endemic countries. We examine the economic costs and benefits of alleviating chronic lymphedema and its effects through a simple limb-care program. For Khurda District, Odisha State, India, we estimated lifetime medical costs and earnings losses due to chronic lymphedema and acute dermatolymphangioadenitis (ADLA) with and without a community-based limb-care program. The program would reduce economic costs of lymphedema and ADLA over 60 years by 55%. Savings of US$1,648 for each affected person in the workforce are equivalent to 1,258 days of labor. Per-person savings are more than 130 times the per-person cost of the program. Chronic lymphedema and ADLA impose a substantial physical and economic burden on the population in filariasis-endemic areas. Low-cost programs for lymphedema management based on limb washing and topical medication for infection are effective in reducing the number of ADLA episodes and stopping progression of disabling and disfiguring lymphedema. With reduced disability, people are able to work longer hours, more days per year, and in more strenuous, higher-paying jobs, resulting in an important economic benefit to themselves, their families, and their communities. Mitigating the severity of lymphedema and ADLA also reduces out-of-pocket medical expense.

Evaluating the Burden of Lymphedema Due to Lymphatic Filariasis in 2005 in Khurda District, Odisha State, India

BACKGROUND

Over 1.1 billion people worldwide are at risk for lymphatic filariasis (LF), and the global burden of LF-associated lymphedema is estimated at 16 million affected people, yet country-specific estimates are poor.

METHODOLOGY/PRINCIPAL FINDINGS

A house-to-house morbidity census was conducted to assess the burden and severity of lymphedema in a population of 1,298,576 persons living in the LF-endemic district of Khurda in Odisha State, India. The burden of lymphedema in Khurda is widespread geographically, and 1.3% (17,036) of the total population report lymphedema. 51.3% of the patients reporting lymphedema were female, mean age 49.4 years (1-99). Early lymphedema (Dreyer stages 1 & 2) was reported in two-thirds of the patients. Poisson regression analysis was conducted in order to determine risk factors for advanced lymphedema (Dreyer stages 4-7). Increasing age was significantly associated with advanced lymphedema, and persons 70 years and older had a prevalence three times greater than individuals ages 15-29 (aPR: 3.21, 95% CI 2.45, 4.21). The number of adenolymphangitis (ADL) episodes reported in the previous year was also significantly associated with advanced lymphedema (aPR 4.65, 95% CI 2.97-7.30). This analysis is one of the first to look at potential risk factors for advanced lymphedema using morbidity census data from an entire district in Odisha State, India.

SIGNIFICANCE

These data highlight the magnitude of lymphedema in LF-endemic areas and emphasize the need to develop robust estimates of numbers of individuals with lymphedema in order to identify the extent of lymphedema management services needed in these regions.

Filarial chyluria as a rare cause of urinary retention

We herein describe a case of Wuchereria bancrofti infection in a previously healthy 37-year-old Nepalese man. The patient presented with a history of milky urine with subsequent acute urinary retention lasting for a few days. The presence of microfilariae was confirmed on both peripheral blood and urine smears obtained at midnight. He was conservatively treated with diethylcarbamazine combined with doxycycline. Filariasis was previously endemic in southern parts of Japan, although it has been eradicated. Clinicians should remember filariasis as a potential etiology of urinary retention, especially in cases that may be associated with imported infectious disease.

Low density microfilaraemia as a causative agent in a case of unexplained ascitis of suspicious nature

It is estimated that 120 million people worldwide are affected by filariasis. In the South East and South Asian region, Wuchereria bancrofti is the most prevalent parasite causing filariais in 99.4 % of cases. In the present case the parasite was a cause of unexplained ascitis in a young female whose previous cytological report was suspicious in nature. Extensive physical and radiological assesment was not able to determine the cause of ascitis. Repeat cytological examinantion revealed a few microfilariae of Wuchereria bancrofti. The patient was diagnosed as a case of low density microfilaremia and was put on anti-filarial therapy subsequent to which ascitis of the patient regressed. In this case, the clinical picture did not give a clue regarding the aetiology of the ascites. There was no evidence suggestive of filariasis, such as lymphoedema or hydrocele except mild eosinophilia. Circumstantialtial evidence regarding the aetiology of the effusion in our patient included her recovery following antifilarial therapy. The cytological diagnosis of Mf in this patient avoided further expensive investigations and the patient responded to antifilarial therapy.

Vaccination with intestinal tract antigens does not induce protective immunity in a permissive model of filariasis

Antigens obtained from the intestinal tract of filarial nematodes have been proposed as potential safe and effective vaccine candidates. Because they may be 'hidden' from the immune response during natural infection, yet accessible by antibodies induced by vaccination, intestinal antigens may have a low potential for eliciting allergic responses when vaccinating previously infected individuals. Despite prior promising data, vaccination with intestinal antigens has yet to be tested in a permissive model of filariasis. In this study we investigated the efficacy of vaccination with filarial intestinal antigens in the permissive Litomosoides sigmodontis BALB/c model of filariasis, and we evaluated the extent to which these antigens are recognized by the immune system during and after infection. Infected BALB/c mice developed lower IgG antibody responses to soluble intestinal antigens (GutAg) than to soluble antigens of whole worms (LsAg). Similarly, GutAg induced less proliferation and less production of IL-4 and IFNγ from splenocytes of infected mice than LsAg. In contrast to these differences, active infection resulted in equivalent levels of circulating GutAg-specific IgE and LsAg-specific IgE levels. Consistent with this, basophil activation, as assessed by flow cytometric staining of intracellular basophil IL-4 expression, was equivalent in response to GutAg and LsAg. Vaccination with GutAg adsorbed to CpG/alum induced GutAg specific IgG1 and IgG2A production, with GutAg specific IgG titers greater than 5-fold higher than those measured in previously infected animals. Despite this response to GutAg vaccination, vaccinated mice harbored similar parasite burdens 8 weeks post infection when compared to non-vaccinated controls. These studies demonstrate that soluble antigens obtained from the intestinal tracts of L. sigmodontis have some qualities of 'hidden' antigens, but they still sensitize mice to allergic reactions and fail to protect against future infection when given as a vaccine adsorbed to alum/CPG.

Marriage, sex, and hydrocele: an ethnographic study on the effect of filarial hydrocele on conjugal life and marriageability from Orissa, India

Background

Lymphatic filariasis (LF), a leading cause of permanent and long-term disability, affects 120 million people globally. Hydrocele, one of the chronic manifestations of LF among 27 million people worldwide, causes economic and psychological burdens on patients and their families. The present study explores and describes the impact of hydrocele on sexual and marital life as well as on marriageability of hydrocele patients from rural areas of Orissa, an eastern state of India.

Methodology/Principal Findings

This paper is based on ethnographic data collected through focus group discussions and in-depth interviews with hydrocele patients, wives of hydrocele patients, and other participants from the community. The most worrisome effect of hydrocele for patients and their wives was the inability to have a satisfactory sexual life. The majority of patients (94%) expressed their incapacity during sexual intercourse, and some (87%) reported pain in the scrotum during intercourse. A majority of hydrocele patients' wives (94%) reported dissatisfaction in their sexual life. As a result of sexual dissatisfaction and physical/economic burden, communication has deteriorated between the couples and they are not living happily. This study also highlights the impact on marriageability. The wives of hydrocele patients said that a hydrocele patient is the “last choice” and that girls show reluctance to marry hydrocele patients. In some cases, the patients were persuaded by their wives to remove hydrocele by surgery (hydrocelectomy).

Conclusions/Significance

The objective of the morbidity management arm of the Global Programme to Eliminate LF should be to increase access to hydrocelectomy, as hydrocelectomy is the recommended intervention. Though the study area is covered by the programme, like in other endemic areas, hydrocelectomy has not been emphasised by the national LF elimination programme. The policy makers and programme managers should be sensitised by utilising this type of research finding.

Lymphatic filariasis, the second leading cause of permanent and long-term disability, affects 120 million people globally. Hydrocele, an accumulation of fluid in the scrotum that causes it to swell, is one of the chronic manifestations of LF among men and there are about 27 million men with hydrocele worldwide. We conducted ethnographic interviews and discussions with patients, women whose husbands have hydrocele, and the general public in a rural community of eastern India. The study describes how hydrocele impacts patients' sexual and marital life. It reveals the most worrisome effect of hydrocele for patients and their wives due to the inability to have a satisfactory sexual life. Patients expressed their incapacity during sexual intercourse. A majority of hydrocele patients' wives reported that their married life became burdened and couples were not living happily. This study also highlights the impact on marriageability, and some women expressed that a hydrocele patient is the “last choice”. In some cases, the patients were persuaded by their wives to remove hydrocele by surgery (hydrocelectomy). Hence, access to hydrocelectomy has to be strengthened under the Global Programme to Eliminate Lymphatic Filariasis, which is operational in several endemic areas in the world. Also, this activity may be integrated with primary healthcare services and interventions of other neglected tropical diseases.

Triple co-administration of ivermectin, albendazole and praziquantel in zanzibar: a safety study

BACKGROUND

Public health interventions based on distribution of anthelminthic drugs against lymphatic filariasis (LF), onchocerciasis, soil-transmitted helminthiasis (STH) and schistosomiasis have been implemented separately to date. A better use of available resources might be facilitated by a more coordinated approach to control such infections, including the possibility of co-administering the three recommended anthelminthic drugs through a single, large-scale intervention.

METHODOLOGY/PRINCIPAL FINDINGS

Ivermectin, albendazole and praziquantel were co-administered to 5,055 children and adults living in areas endemic for LF, STH and schistosomiasis in Zanzibar, United Republic of Tanzania, during a pilot intervention aimed at elucidating and quantifying possible side-effects. Subsequently, these drugs were co-administered to about 700,000 individuals during a countrywide intervention targeting a large part of the total population of Zanzibar. Passive and active surveillance measures carried out during both interventions showed that side-effects attributable to the three drugs given at the same time were mild and self-limiting events.

CONCLUSIONS/SIGNIFICANCE

Our data suggest that co-administration of ivermectin, albendazole and praziquantel is safe in areas where lymphatic filariasis, soil-transmitted helminthiasis and schistosomiasis are co-endemic and where several rounds of treatment with one or two drugs have been implemented in the past. Passive surveillance measures, however, should be continued and detection, management and reporting of possible side-effects should be considered a key component of any health intervention administering drugs.

Clinicians' practices related to management of filarial adenolymphangitis and lymphoedema in Orissa, India

The Global Programme to Eliminate Lymphatic Filariasis (GPELF), which includes alleviation of disability and suffering of patients, is implemented primarily in India by primary health care system. The present study assesses the current practices related to lymphoedema care among clinicians of primary healthcare system in three filarial endemic districts of Orissa, India. The results are based on the data obtained through in-depth interviews with 50 clinicians from primary health centres (PHCs) and private clinics located in 22 PHCs sampled from three districts. All clinicians are aware of common as well as atypical manifestations of LF and offered treatment to them. The most commonly dealt complaints are lymphoedema of chronic LF and acute lymphangitis. All the clinicians reported that they prescribed diethylcarbamazine (DEC) for the treatment of patients with acute episodes, and only 50% of them prescribed antibiotics along with DEC. However, there is no uniform pattern either in the dosage of DEC or in the use of antibiotics. In this study, all the clinicians are aware that repeated acute episodes leads to lymphoedema. Majority of clinicians (94%) prescribed DEC to prevent this progression. For reduction of oedema, they offered a variety of treatments and more than half of the clinicians prescribed DEC. The study districts have been covered by the mass drug administration (MDA) of DEC under the GPELF. In order for the GPELF as a whole to prove successful and sustainable, those persons who are already suffering from LF need to be cared for and their suffering is to be relieved. Current practices of clinicians, both at government and private health institutions should be improved. With the revised knowledge that bacterial infections play a key role in the progression of disease, the attitude of clinicians towards the treatment of LF has to be changed.

Morbidity management in the Global Programme to Eliminate Lymphatic Filariasis: a review of the scientific literature

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) has two major goals: to interrupt transmission of the parasite and to provide care for those who suffer the devastating clinical manifestations of the disease (morbidity control). This latter goal addresses three filariasis-related conditions: acute inflammatory episodes; lymphoedema; and hydrocele. Research during the last decade has confirmed the importance of bacteria as a cause of acute inflammatory episodes in filariasis-endemic areas, known as acute dermatolymphangioadenitis (ADLA). Current lymphoedema management strategies are based on the central role of ADLA as a trigger for lymphoedema progression. Simple intervention packages are in use that have resulted in dramatic reductions in ADLA rates, a lower prevalence of chronic inflammatory cells in the dermis and subdermis, and improvement in quality of life. During the past decade, the socioeconomic impact of ADLA and lymphoedema in filariasis-endemic areas has received increasing attention. Numerous operational research questions remain to be answered regarding how best to optimize, scale up, monitor, and evaluate lymphoedema management programmes. Of the clinical manifestations targeted by the GPELF, hydrocele has been the focus of the least attention. Basic information is lacking on the effectiveness and complications of hydrocele surgery and risk of post-operative hydrocele recurrence in filariasis-endemic areas. Data on the impact of mass administration of antifilarial drugs on filarial morbidity are inconsistent. Several studies report reductions in acute inflammatory episodes, lymphoedema, and/or hydrocele following mass drug administration, but other studies report no such association. Assessing the public health impact of mass treatment with antifilarial drugs is important for programme advocacy and morbidity control strategies. Thus, although our knowledge of filariasis-related morbidity and its treatment has expanded in recent years, much work remains to be done to address the needs of more than 40 million persons who suffer worldwide from these conditions.