Significant improvement in quality of life following surgery for hydrocoele caused by lymphatic filariasis in Malawi: A prospective cohort study.

BACKGROUND: Lymphatic filariasis (LF) is a mosquito-borne parasitic infection that causes significant disabling and disfiguring clinical manifestations. Hydrocoele (scrotal swelling) is the most common clinical condition, which affects an estimated 25 million men globally. The recommended strategy is surgical intervention, yet little is known about the impact of hydrocoele on men's lives, and how it may change if they have access to surgery. METHODOLOGY/PRINCIPAL FINDINGS: We prospectively recruited and followed-up men who underwent surgery for hydrocoele at six hospitals in an LF endemic area of Malawi in December 2015. Men were interviewed at hospitals pre-surgery and followed-up at 3-months and 6-months post-surgery. Data on demographic characteristics, clinical condition, barriers to surgery, post-surgery symptoms/complications and quality of life indicators were collected and analysed pre- and post-surgery, by age group and stage of disease (mild/moderate vs. severe), using chi-square tests and student's t test (paired). 201 men were interviewed pre-surgery, 152 at 3-months and 137 at 6-months post-surgery. Most men had unilateral hydrocoeles (65.2%), mild/moderate stages (57.7%) with an average duration of 11.4 years. The most reported cause of hydrocoele was it being sexually transmitted (22.4%), and the main barrier to surgery was the cost (36.3%). Pre-surgery, a significant difference in the scrotum side affected was found by age group (X2 = 5.978, p = 0.05), and men with severe stage hydrocoele reported more problems with their quality of life than those with mild/moderate stage (t = 2.793; p = 0.0006). Post-surgery, around half of the men reported some pain/discomfort (55.9%), swelling (8.6%), bleeding (3.3%) and infection (5.9%), most of which had resolved at 3-months when the most significant improvements in their quality of life were found (t = 21.3902; p = 0.000). Post-surgery at 6 months all men reported no physical, social, psychological problems and took no time off work. CONCLUSION/SIGNIFICANCE: Surgery had a significant positive impact on many aspects of a patient's life, and the expansion of this treatment to all those affected in LF endemic areas would greatly improve the quality of men's and their families' lives, and greatly contribute to the global goal of providing universal health care.

Economic benefits and costs of surgery for filarial hydrocele in Malawi.

BACKGROUND: Lymphatic filariasis (LF) is endemic in 72 countries of Africa, Asia, Oceania, and the Americas. An estimated 25 million men live with the disabling effects of filarial hydrocele. Hydrocele can be corrected with surgery with few complications. For most men, hydrocelectomy reduces or corrects filarial hydrocele and permits them to resume regular activities of daily living and gainful employment. METHODOLOGY AND PRINCIPAL FINDINGS: This study measures the economic loss due to filarial hydrocele and the benefits of hydrocelectomy and is based on pre- and post-operative surveys of patients in southern Malawi. We find the average number of days of work lost due to filarial hydrocele and daily earnings for men in rural Malawi. We calculate average annual lost earnings and find the present discounted value for all years from the time of surgery to the end of working life. We estimate the total costs of surgery. We compare the benefit of the work capacity restored to the costs of surgery to determine the benefit-cost ratio. For men younger than 65 years old, the average annual earnings loss attributed to hydrocele is US$126. The average discounted present value of lifetime earnings loss for those men is US$1684. The average budgetary cost of the hydrocelectomy is US$68. The ratio of the benefit of surgery to its costs is US$1684/US$68 or 24.8. Sensitivity analysis demonstrates that the results are robust to variations in cost of surgery and length of working life. CONCLUSION: The lifetime benefits of hydrocelectomy-to the man, his family, and his community-far exceed the costs of repairing the hydrocele. Scaling up subsidies to hydrocelectomy campaigns should be a priority for governments and international aid organizations to prevent and alleviate disability and lost earnings that aggravate poverty among the many millions of men with filarial hydrocele.

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.

Developing a community-led SMS reporting tool for the rapid assessment of lymphatic filariasis morbidity burden: case studies from Malawi and Ghana.

BACKGROUND: Lymphoedema and hydrocoele are the two most common clinical manifestations of lymphatic filariasis (LF). In order to effectively target morbidity management strategies, more information is rapidly needed on morbidity burden across all endemic countries. The purpose of this study was to develop and test an SMS tool (MeasureSMS) which enables trained community-based health workers to report basic information on all cases they identified. METHODS: The tool was trialled in Chikwawa district, Malawi and Ahanta West district, Ghana in 2014. Salaried health surveillance assistants (HSAs) identified and reported cases in Malawi whereas volunteer community health workers (CHWs) were used in Ghana. Health workers were trained in recognising lymphoedema and hydrocoeles and submitting individual case data using MeasureSMS, after which they undertook a LF morbidity survey. After the reporting period, a random sample of reported cases was visited by a physician to verify the health workers' diagnoses. The proportion of correctly diagnosed cases i.e. the positive predictive value (PPV) was then calculated. RESULTS: HSAs in Malawi successfully reported 256 unique cases by SMS from 107 communities (166 hydrocoele, 88 lymphoedema, 2 with both), resulting in an estimated adult prevalence of 17.7 per 10,000 and 33.0 per 10,000 for lymphoedema and hydrocoele respectively. In Ghana, despite being less experienced in using SMS, CHWs successfully reported 360 unique cases by SMS from 33 communities (169 hydrocoele, 185 lymphoedema, 6 with both), resulting in an estimated adult prevalence of 76.9 per 10,000 and 70.5 per 10,000 adults for lymphoedema and hydrocoele respectively. The verification exercise resulted in a PPV for lymphoedema and hydrocoele diagnosis of 90 % (n = 42, 95 % CI 76.5 - 96.9) and 92 % (n = 49, 95 % CI 79.5 - 97.4) in Malawi and 94 % (n = 34, 95 % CI 78.9 %-99.0 %) and 47 % (n = 59, 35.1 %-61.7 %) in Ghana, indicating that non-invasive methods for diagnosing hydrocoeles needed to be further emphasised. CONCLUSIONS: The study concludes that given the appropriate education and tools, community-based health workers are exceptionally well-placed to participate in quantifying LF morbidity burden, and other NTDs with observable symptoms. This concept has the potential to enable national programmes to more effectively monitor their community impact in an efficient, timely and cost-effective way.

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.

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.

Lymphatic filariasis morbidity mapping: a comprehensive examination of lymphoedema burden in Chikwawa district, Malawi.

BACKGROUND: Managing lymphatic filariasis (LF) morbidity and reducing disability is one of the two primary goals of the Global Programme to Eliminate Lymphatic Filariasis. However, in order to achieve this, the geographical distribution of LF morbidity needs to be better estimated. METHODS: All cases of lymphoedema within a single health centre catchment area (pop. 42 000) in the southern region of Malawi were examined. Maps of lymphoedema burden were produced and trends in patient demographics, severity of lymphoedema (Dreyer staging) and health-seeking behaviour were explored. The number of lymphoedema cases was compared with records maintained by the Ministry of Health, Malawi. RESULTS: A total of 69 lymphoedema cases were identified (32 per 10 000 population), of which 48 (70%) were female and 21 (30%) male. The majority of cases (51/69) had Dreyer stage 2-3, and almost all (65/69) had experienced acute attacks as a result of their lymphoedema. This burden was much greater than that estimated by Ministry of Health (33 cases). CONCLUSIONS: Current case detection methods underestimate the burden of lymphoedema in Malawi. There is a continued need to develop new LF morbidity identification and surveillance approaches to ensure that future morbidity management strategies are effectively targeted.