Integrated morbidity management for lymphatic filariasis and podoconiosis, Ethiopia

Problem Lymphatic filariasis and podoconiosis are the major causes of tropical lymphoedema in Ethiopia. The diseases require a similar provision of care, but until recently the Ethiopian health system did not integrate the morbidity management. Approach To establish health-care services for integrated lymphoedema morbidity management, the health ministry and partners used existing governmental structures. Integrated disease mapping was done in 659 out of the 817 districts, to identify endemic districts. To inform resource allocation, trained health extension workers carried out integrated disease burden assessments in 56 districts with a high clinical burden. To ensure standard provision of care, the health ministry developed an integrated lymphatic filariasis and podoconiosis morbidity management guideline, containing a treatment algorithm and a defined package of care. Experienced professionals on lymphoedema management trained government-employed health workers on integrated morbidity management. To monitor the integration, an indicator on the number of lymphoedema-treated patients was included in the national health management information system.Local setting In 2014, only 24% (87) of the 363 health facilities surveyed provided lymphatic filariasis services, while 12% (44) provided podoconiosis services.Relevant changes To date, 542 health workers from 53 health centres in 24 districts have been trained on integrated morbidity management. Between July 2013 and June 2016, the national health management information system has recorded 46 487 treated patients from 189 districts.Lessons learnt In Ethiopia, an integrated approach for lymphatic filariasis and podoconiosis morbidity management was feasible. The processes used could be applicable in other settings where these diseases are co-endemic

Risk factors for Podoconiosis: Kamwenge District, Western Uganda, 2015

Introduction: Podoconiosis, a form of non-infectious elephantiasis, is a disabling Neglected Tropical Disease. In August 2015, a non-government organization reported an increase in elephantiasis cases in Kamwenge District. We conducted an investigation to confirm the diagnosis, identify causes and risk factors, and guide control efforts. Methods: we defined a suspect case-person as a Kamwenge resident with bilateral asymmetrical swelling of lower limbs lasting ≥ 1month, plus ≥ 1 of the following: skin itching; burning sensation; plantar oedema; lymph-ooze; prominent skin markings; rigid toes; mossy papillomata. A probable case was a suspect case with negative microfilaria antigen immunological-card test results. We conducted active case-finding in affected communities. In a case-control study we compared shoe-use and feet-washing practices before disease onset among 40 probable case-persons and 75 asymptomatic village control-persons, matched by age (± 5y) and sex. We collected soil samples to characterize soil-irritant composition. Results: our active case-finding identified 52 suspect cases in two affected sub-counties during 1980-2015 (incidence = 2.9/100,000/year), including 40 probable cases (mean age = 47y; range: 13-80y). The annual case counts did not increase significantly over time. All case-persons had negative immunological-card test. In the case-control study, 93% (37/40) of probable case-persons and 31% (23/75) of controls-persons never wore shoes at work (ORM-H = 6.7; 95%CI = 1.7-26); 80% (32/40) of probable case-persons and 55% (39/75) of control-persons never wore shoes at home (ORM-H = 4.4, 95%CI = 1.5-13); 70% (27/39) of probable case-persons and 47% (34/72) of control-persons washed feet at day-end rather than immediately after work (OR = 11, 95%CI = 2.1-57). Soils samples were characterized as being rich black-red volcanic clay. Conclusion: the reported elephantiasis was podoconiosis, which was associated with prolonged foot exposure to volcanic soil. We recommended health education on foot protection and washing, and universal use of protective shoes

Socioeconomic Factors Associated with Compliance with Mass Drug Administration for Lymphatic Filariasis Elimination in Kenya: Descriptive Study Results

Background: Annual Mass Drug Administration (MDA) to at least 65 - 80of the population at risk is necessary for Lymphatic Filariasis (LF) elimination. In Kenya; MDA based on diethylcarbamazine and albendazole; using the community-directed treatment (ComDT) approach has been implemented thrice in the Kwale and Malindi districts. To identify the socioeconomic factors influencing compliance with MDA; a retrospective cross-sectional study was conducted in the two districts after the 2008 MDA. Materials and Methods: In Kwale; the Tsimba location was selected for high and Gadini for low coverage; while in Malindi; the Goshi location represented high and Gongoni; low coverage. Using systematic sampling; nine villages were selected from the four locations. Quantitative data was collected from 965 systematically selected household heads and analyzed using SPSS v. 15. For qualitative data; which was analyzed manually according to core themes of the study; 80 opinion leaders and 80 LF patients with clinical signs were purposively selected and interviewed; and 16 focus group discussions (FGDs) conducted with adult and youth male and female groups. Results: Christians were slightly more (49.1) in the high compliance areas compared to Muslims (34.3); while Muslims prevailed (40.6) in the low compliance areas compared to Christians (29). On the income level; 27from the low compared to 12.2from the high compliance areas had a main occupation; indicative of a higher income; and 95from the low compared to 78from high compliance areas owned land; also an indicator of higher economic status. Accurate knowledge of the cause of swollen limbs was higher (37) in the high compared to 25.8in the low compliance areas; and so was accurate knowledge about the cause of swollen genitals (26.8in high compared to 14in low). Risk perception was higher in the high compliance areas (52compared to 45) and access to MDA information seemed to have been better in the high compared to low compliance areas. Patients from the high compliance areas had a higher mean number of years with chronic disease (15.2 compared to 9.7). Conclusions: There is a need for more investment in reaching out to groups that are often missed during MDAs. Different strategies have to be devised to reach those in specific religious groupings and those in casual employment. This could include prolonging the duration of MDA to capture those who are out during the week seeking for casual and other forms of employment

Factors Associated With the Motivation of Community Drug Distributors in the Lymphatic Filariasis Elimination Programme in Kenya

Annual mass drug administration (MDA) is the main strategy for elimination of lymphatic filariasis (LF); globally. In Kenya; community drug distributors (CDDs) are used to deliver drugs to household members. To determine factors influencing CDDs' motivation; a retrospective cross-sectional study based on qualitative data was conducted in Kwale and Malindi districts after the 2008 MDA. In Kwale; Tsimba location represented high and Gadini low compliance while in Malindi; Goshi and Gongoni locations represented high and low compliance areas; respectively. Fifteen CDDs; 80 opinion leaders; 80 LF patients; five health personnel; four LF coordinators and the National Programme Manager were purposively selected and interviewed. Sixteen focus group discussions (FGDs) were conducted with single-sex adult and youth male and female groups. The factors that possibly had a positive influence on CDDs' motivation were: higher education level; trust and familiarity with community members. All CDDs reported that getting recognised; being trained on LF and an innate desire to help their communities raised their motivation. Factors that possibly had negative influence included: inadequate training; drug supplies and community sensitisation and lack of supervision. The majority of the CDDs reported a lack of or outdated record-keeping books; a limited drug distribution period; inadequate moral support and incentives as negative factors on their motivation. Factors that motivate CDDs are those that enhance their capacities to perform their duties and endear respect in the communities where they serve

Community-directed Treatment of Lymphatic Filariasis in Kenya and its Role in the National Programmes for Elimination of Lymphatic Filariasis

We conducted a prospective; cross-sectional study to examine and compare treatment coverage of lymphatic filariasis by the health system (HST) and a health system implemented; community-directed treatment for the control of lymphatic filariasis (ComDT/HS) in 44 randomly selected villages in coastal Kenya. Demographic information on the villages and peripheral health facilities to guide design and implementation was obtained from a situation analysis phase of this study. A series of interactive training sessions on basic biology of lymphatic filariasis; concept and philosophy of ComDT/HS were given to members of the District Health Management Team (DHMT); peripheral health staff; community leaders and community drug distributors (CDDs) prior to ivermectin distribution. An intensive sensitization process of the community by the trained peripheral health staff and community leaders followed before selection of the CDDs. Quantitative and qualitative data for evaluation of the study were collected by coverage surveys of randomly selected households; focus group discussions and interviews; immediately after the drug distribution. Treatment coverage of all eligible persons was 46.5 and 88in HST and ComDT/HS villages; respectively; P 0.001. In comparing treatment coverage by the two study arms in relationship to the distance from a health facility; coverage among HST and not ComDT/HS villages was influenced by distance. In Kenya; ComDT/HS can effectively be implemented by the regular health system and can attain coverage levels compatible with the global filariasis elimination goal

Supreme Worth of Clinical Epidemiology in Africa : Bancroftian Filariasis as a Just One Case in Point

"Clinical epidemiology is going to be the Discipline par excellence of the next century; if not the millennium. Coming as it does from one who has spent decades in clinical medicine and therapeutics; this is a bold statement. Clinical epidemiology answers the questions what? Where? How? When? Who? Why? And Which? In matters of health and disease. It is because these questions have come to be answered effectively with respect to bancroftian Filariasis that it has been included in the world's six ""potentially eradicable"" diseases. In his impressive Review Article on page (); Dr. Gyapong takes us through answers to these epidemiology questions [1]. Filariasis occurs in 38 African countries where the mere presence of a hydrocele affords ""a rapid diagnostic index"" for infection [2]; while the so-called ""filarial dance sign"" is known to be present in intrascrotal lymphatics of microfilaraemic patients [3]. That the social and economic consequences of filarial morbidity are enormous on community preventive measures. People must be told that the mosquito; not juju or other ""supernatural factors: [1] is the culprit. I am old enough to remember the ""Town council Man"" in colonial Gold Coast. He would visit every house assigned to him; enforcing environmental sanitation and destroying pools of water and mosquito breeding places. If but one cocoanut shell was found in the compound with water in it;whether or not it contained a mosquito larva; the head of the household was given summons to go to court and pay a fine. Came independence and the community also became independent of the ""Town Council Man"" with the result that there are infinitely more mosquitoes now in independent Ghana than there were in the colonial Gold Coast. ""The WHO""; it is widely held; ""will do it for us"". Today; a vaccine is awaited for most things while the insects flourish. Deal with mosquito; and both malaria and Filariasis will be dealt a death blow. Fortunately; ivermectin will reduce the parasitic reservoir from which transmission occurs; and diagnosis of subclinical cases no longer has to rely on blood sampling at night or on Diethyl Carbamazine provocation tests [4]; but is reliably achieved using finger prick to detect Og4C3 circulating antigens day or night [5;6]. Mosquito nets reduce nocturnal bites and hence incidence of both malaria and Filariasis. Doctors should keep long-term records and ascertain whether insecticide impregnanted nets lead to pesticide resistance or not. Spraying should never be abandoned as it had often been on the rumour that ""it does no good; and produces insecticide resistance"". These preventive measures are best supervised through decentralised programmes [1;7] and are most effectively conducted in the mother tongue of the community at the grassroots [8]. Local businessmen and market women should be encouraged to assist chiefs and community leaders in giving monthly prizes in environmental sanitation while public health experts chart the effect of such sanitation on morbidity of Filariasis and mortality from malaria. We should go back to the ""Sanitary Branch"" institutions of the colonial days[9] when clinical epidemiology did much to protect the health of the community. Central government should fund trips to Japan; Taiwan; Solomon Islands; South Korea and some parts of China [1] for African health workers to learn first hand how those communities managed to eradicate lymphatic Filariasis. Even with the current AIDS problem; I remain convinced that clinical epidemiology is the answer [10]. Vaccines have achieved much this century; but to ""wait for WHO to give us vaccines"" while we neglect ourselves and our environment is wholly irresponsible."

The Clinical Epidemiology and Prospects for Control of Lympatic Filariasis in Africa

This paper reviews some of the current opinions in the epidemiology and control of lymphatic filariasis in general and in Africa in particular in view of the current global initiative to eliminate the disease as a public health problem. Despite some gaps in the knowledge of the natural history of the disease; there are sufficient tools available for initiating control activities. The focus of filariasis research should therefore shift towards operational research in the application of these tools

Guidelines for rapid assessment of LOA LOA

RAPLOA is a rapid assessment procedure for Loa loa that uses a simple questionnaire on the history of eye worm to predict whether or not loiasis is present in a community at a high level of endemicity. In highly endemic communities; there is a risk of severe adverse reactions to the drug ivermectin following its use as treatment for ether onchocerciasis or lymphatic filariasis. RAPLOA will facilitate the planning of ivermectin distribution programmes by predicting in which communities ivermectin treatment for onchocerciasis can be safely implemented.This document describes the APLOA method; and provides guidelines on how to implement RAPLOA and how to interpret the results. The guidelines are intended for planners and implementers of ivermectin distribution programmes in Africa