Mapping lymphatic filariasis morbidities in 24 endemic districts of Ethiopia

doi:10.21203/rs.3.rs-4949381/v1

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Research Article

Mapping lymphatic filariasis morbidities in 24 endemic districts of Ethiopia

https://doi.org/10.21203/rs.3.rs-4949381/v1

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published 13 Nov, 2024

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Background

The core strategy for achieving the second goal of the Global Program to Eliminate Lymphatic Filariasis (GPELF), which is to alleviate the suffering of affected populations, is Morbidity management and disability prevention (MMDP). Effectively registering and locating individuals suffering from LF remain critical gap in many LF-endemic settings for planning and ensuring access to MMDP services. This study aims to map the geographical distribution of LF morbidities across 24 endemic districts in Ethiopia.

Methods

A community-based cross-sectional study was conducted to identify individuals suffering from LF in 24 endemic districts. Using primary health care units (PHCUs), the study involved 946 trained Health Extension Workers (HEWs) who conducted house-to-house visits to identify and register individuals with lymphoedema and hydrocoele. Additionally, 77 trained supervisors and 87 team leaders coordinated the morbidity mapping in their respective districts and PHCUs. Surgeons performed confirmatory evaluations of individuals with lymphedema and hydrocele randomly sampled from selected districts. Statistical analysis of data, including severity of lymphoedema and acute attacks, was performed using STATA 17.

Results

A total of 15,527 cases of LF morbidities were identified. Among these, 14,946 (96.3%) were cases of limb lymphoedema, wile 581 (3.7%) were hydrocele. Of those with lymphedema, 8,396 (54.1%) were women. Additionally, 13,731 (88.4%) of cases resided in rural areas where access to preventive and curative services is limited. Of 14,591 cases with recorded information about acute attack, 10710 (73.4%) reported experiencing at least one acute attack in the last six months related to their lymphoedema, with a higher percentage of males reported (74.5%; n = 4981/6686). Out of 12,680 recorded cases of leg lymphedema, the percentage of reported acute attacks rose with severity: mild cases 64% (n = 5,618), moderate 68% (n = 5,169), and severe 70% (n = 1,893). Most patients, 64%, reported swollen legs for 1 to 10 years, indicating a high prevalence of recent cases. In contrast, only 25% of patients had swollen legs for 10 to 20 years, suggesting a decline in cases over this longer period. The HEW-surgeon confirmatory evaluation showed that 80% of hydrocele cases and 95% of lymphedema cases matched the HEWs' assessments, indicating strong agreement.

Conclusion

Using the existing Health Extension Program platform, this study identified a substantial number of lymphedema and hydrocele cases across 24 LF-endemic districts in Ethiopia, with strong agreement between HEWs and surgeons in their case assessments. Cases were predominantly recent lymphoedema, affecting mostly women and individuals in rural areas. PHCUs proved instrumental in identifying LF cases, as HEWs were well-positioned to engage with and support the communities they serve.

Lymphatic filariasis

Morbidity management and disability prevention

Morbidity Mapping

Lymphedema

Hydrocele

Ethiopia

Lymphatic filariasis (LF) is a debilitating and disfiguring neglected tropical disease (NTD) affecting 70 million people worldwide [1]. The condition is caused by parasitic nematodes such as Wuchereria bancrofti, Brugia malayi, or Brugia timori, and is transmitted by various mosquito species [2, 3]. The World Health Organization (WHO) has delineated 20 such NTDs for global control and eradication [4]. LF accounts for an estimated 2.78 million disability-adjusted life years (DALYs) [5], imposing a devastating impact on those affected and leading to acute dermatolymphangioadenitis (ADLA) or acute attacks, lymphoedema, elephantiasis, and hydrocele among other clinical symptoms [6-10].

Countries seeking to achieve recognition for eradicating lymphatic LF must demonstrate two key requirements: first, they must show that disease transmission is halted through mass drug administration (MDA); second, they must provide a minimum package of care for individuals suffering from lymphoedema and hydrocele in LF-endemic areas [11]. This care package includes hydrocoele surgery [12, 13], ADLA episode assistance [14, 15], and management of LE to prevent its progression. To complete the WHO dossier for certification process for LF elimination as a public health problem, a country must first estimate the number of patients in endemic areas at the implementation unit (IU) level and report on the number of facilities equipped to provide the necessary care. Additionally, evaluations of the preparedness and quality of care offered at these facilities are required [16, 17] [18].

Ethiopia's Ministry of Health (MoH) aims to eliminate LF from the country by 2027. Initial efforts focus on identifying LF-endemic districts and mapping patients with lymphoedema and hydrocele patients to guide intervention strategies [18]. To address LF-related morbidities effectively, a detailed enumeration of cases is required, categorized by factors such as pertinent age, gender, and the nature of lymphoedema or hydrocele. Recognizing the urgency to extend expand Morbidity Management and Disability Prevention (MMDP) services, the MoH has initiated morbidity mapping in 24 LF-endemic districts across Ethiopia. The END FUND, an organization dedicated to tackling NTDs, leads fundraising efforts to provide treatments for affected populations, and collaborates with various stakeholders to maximize impact [19]. Through the END FUND-LFMMDP project under the Ethiopian MOH National Program for the Elimination of NTDs, efforts are underway to identify and support individuals with lymphoedema and hydrocele in these districts, thereby improving the reach and effectiveness of MMDP interventions and ensuring comprehensive care. However, effectively registering and locating individuals suffering from LF remain critical gap in many LF-endemic settings for planning and ensuring access to MMDP services. Therefore, this study aims to map the geographical distribution of LF morbidities across 24 endemic districts in Ethiopia.

Study Design

A community-based cross-sectional study was conducted using the Health Extension Worker (HEW) network to identify cases. Trained HEWs conducted house-to-house visits in each targeted woreda. Since its inception in 2006, the Ethiopian Health Extension Program has maintained a network of over 70,000 community-based HEWs, supported by a supervisory framework. These healthcare personnel were strategically positioned to conduct comprehensive screenings and register cases of lymphedema and hydrocele during their house-to-house visits within their designated areas.

Study Area

The study was carried out across 24 districts in Ethiopia, with every household in these 24 endemic areas being visited to compile a comprehensive list of all cases. These woredas were selected in collaboration with the MOH and Regional Health Bureaus due to their LF endemic status and being among the few remaining districts the regions where morbidity mapping had not been completed.

Participants

The study population was households living in the 24 LF-endemic districts, while the study participants were individuals identified as LF cases. Eligibility criteria required participants to be adult males or females, residents of one of the 24 endemic districts, and willing to provide informed consent.

Study Procedure

In each district, individuals who completed the Training of Trainers program went on to train NTD focal persons in each woreda, PHCU directors at each health center, and at least two HEWs from each health post. The training aimed to enhance the skills of HEWs and PHCUs in screening, identifying, and registering lymphedema patients. It was designed to help HEWs distinguish LF-related lymphedema from other lower limb swellings caused by different conditions. A total of 946 HEWs, 77 supervisors. and 87 team leaders from 24 districts were trained to collect and report case data. HEWs screened and registered individuals with lymphedema and hydrocele through house-to-house visits. The mapping work at the woreda level was supervised by each Woreda Health Office NTD focal person, while burden assessment in their catchment areas was overseen by the PHCU directors.

For data collection, survey materials including household registration sheets and patient questionnaires were utilized. Despite the expertise of HEWs, a random quality check was conducted to verify the accuracy of the identified cases. This verification was performed by certified surgeons who confirmed the classification of registered cases as either lymphedema, hydrocele, or other disease condition. Following the morbidity mapping, a random sample of ten individuals with lymphedema and two with hydrocele were evaluated to confirm their conditions and stages. Additionally, assessors determined whether the scrotal swelling in hydrocele cases was due to LF or other conditions such as hernias, and they communicated their findings to the study team.

Ethics statement

Ethical approval for this study was obtained from Ethical Review Committees of each respective region. Informed consent was obtained from all household heads and patients involved in the study. All adult participants provided informed consent, with those who could read and write signing a written informed consent. For those unable to read and write, the consent information was read to them aloud, and their verbal consent was consented.

Statistical Analysis

All data were entered into Microsoft Excel Version 12.3.6 (Microsoft Corp., Redmond, VA, USA) and data analysis was conducted using STATA 17 (StataCorp) software. Each participant was assigned a unique ID, and all data sets were merged using this ID before analysis. Prevalence estimates (per total 10,000 population) were calculated using the 2015 population estimates derived from the 2007 census [20] and adjusted for annual growth rates [21]. Statistical analyses were conduct to compare regions and variables, including disease condition, severity of lymphoedema, acute attacks, sex and age. Confirmatory assessments were conducted in each zone to validate results.

Background Characteristics

In this study, a total of 15,527 cases were collected, including 14,946 (96.3%) lymphedema and 581 (3.7%) hydrocele cases, through door-to-door interviews conducted from August 28, 2023 to October 26, 2023. Of these, 8,396 (54.1%) were, 51% were less than 40 years and the rest 49% were above 40 years, 10,137 (65.3%) do not read and write, and 11,001 (70.8%) were married and 61% of the participants are farmers, 20% of the participants are house wife, 4% merchant and day laborer the rest 11% of the participants are others

In this study, a total of 15,527 cases were collected, comprising 581 (3.7%) hydrocele cases and 14,946 (96.3%) lymphedema cases, through door-to-door interviews conducted from August 28, 2023, to October 26, 2023. Among the participants, 7,131 (45.9%) were male, 7,919 (51%) were under 40 years old, 10,137 (65.3%) were illiterate, and 11,001 (70.8%) were married (Table 1).

Table 1

Background Characteristics of study participants (n = 15,527)
Variable	Number	%
Sex
Male	7,131	45.9%
Female	8,396	54.1%
Residence
Rural	13,731	88.4%
Urban	1,796	11.6%
Marital status
Single	2,253	14.5%
Married	11,001	70.8%
Separated	543	3.5%
Divorced	430	2.8
Widowed	1300	8.4%
Educational status
Do not Read and Write	10,137	65.3%
Not attended formal education but can read and write	889	5.7%
Grade 1–4	2,089	13.5%
Grade 5–8	1,251	8%.1
Other	1,161	7.4%

Table 2 presents the number of cases reported per clinical condition for each region, zone and district. For the total of 15,527 cases reported, the cases are distributed as follows: Ari zone 41 case (41.5%male; mean age 46.9 years), South Omo zone 285 case (69.2% male; mean age 41.0 years), Bench Seko zone 2,564 case (40.5% male; mean age 40.6years), Dawro zone 436 case (51.6% male; mean age 47.1 years), Gofa zone 1,384 case (57.3% male; mean age 43.4 years), Konta zone 1,130 case (56.8% male; mean age 46.4 years), ), Yem zone 984 case (52.6% male; mean age 45.8 years) and Illu Aba Bora zone 8703 cases (43.6% male; mean age 45.9 years), which had the highest number of reported patients. In terms of clinical conditions, the total number of cases reported comprised of 15,527 (96.3%) leg lymphoedema and 581 (3.7%) hydrocele. No individual was reported to have both leg lymphedema and hydrocele.

Table 2

Reported number and prevalence (per 10,000 of the total population) of clinical cases
Region Ari	Zone	#	District	Total population	Lymphedema		Hydrocoele		Both conditions
	Zone	#	District	Total population	N	%	N	%	N	%
	Ari	1	Jinka	34,723	38	10.9	3	0.9	41	11.8
Ari overall total				34,723	38	10.9	3	0.9	41	11.8
South Ethiopia Region	South Omo	2	Selamago	40,338	114	28.3	25	6.2	139	34.5
	South Omo	3	Benatsemay	76,647	52	6.8	23	3.0	75	9.8
	South Omo	4	Hammer	86,394	37	4.3	34	3.9	71	8.2
	Gofa	5	Uba Debretsehay	87,761	501	57.1	25	2.8	526	59.9
	Gofa	6	Melekoza	120,907	822	68.0	36	3.0	858	71.0
South Ethiopia Region overall total				446,770	1526	35	143	3.2	1669	37.4
South West Ethiopia Region	Dawro	7	Esera	94,329	425	45.1	11	3.2	436	46.2
	Konta	8	Ameya Town	20,408	232	113.7	17	1.2	249	122.0
	Konta	9	Ameya Zuria	40,430	274	67.8	20	8.3	294	72.7
	Konta	10	Elahanchano	27,516	150	54.5	6	4.9	156	56.7
	Konta	11	Chida	14,920	158	105.9	0	2.2	158	105.9
	Konta	12	Konta Koisha	30,896	258	83.5	15	0.0	273	88.4
	Bench Sheko	13	Mizan Aman Town	85,680	336	39.2	5	4.9	341	39.8
	Bench Sheko	14	South Bench	13,4536	990	73.6	18	0.6	1008	74.9
	Bench Sheko	15	Shey Bench	149,068	1195	80.2	20	1.3	1215	81.5
South West Ethiopia Region overall total				597,783	4018	67.2	112	1.9	4130	69.1
Central Ethiopia Region	Yem	16	Saja town	13,502	203	150.3	3	2.2	206	152.6
	Yem	17	Saja Zuria	28,549	263	92.1	9	3.2	272	95.3
	Yem	18	Fofa	57,015	340	59.6	16	2.8	356	62.4
	Yem	19	Toba	27,122	147	54.2	3	1.1	150	55.3
Central Ethiopia Region overall total				126,188	953	75.5	31	2.5	984	78.0
Oromia	Illu Aba Bora	20	Alge Sach	119,457	1537	128.7	53	4.4	1,590	133.1
	Illu Aba Bora	21	Bilo Nopa	44,610	784	175.7	17	3.8	801	179.6
	Illu Aba Bora	22	Bure	79,522	1975	248.4	55	6.9	2030	255.3
	Illu Aba Bora	23	Darimu	222,189	2620	117.9	134	6.0	2754	123.9
	Illu Aba Bora	24	Yayo	83,439	1495	179.2	33	4.0	1528	183.1
Oromia overall total				549,217	8411	153.1	292	5.3	8703	158.5
Overall total				1,719,958	14946	86.9	581	3.4	15,527	90.3

Acute attacks

Of all the 15,527 cases identified, 936 lacked reliable information on acute attacks in the last six months and were therefore excluded from this analysis (Table 3). Of the remining 14,591 cases with recorded information, 10710 (73.4%) reported experiencing at least one acute attack in the last six months related to their swelling/lymphoedema. Overall, a higher percentage of males reported having an acute attack in the last six months (74.5%; n = 4981/6686) than females (72.5%; n = 5729/7905).

Table 3

Reported acute attacks for all conditions by different age groups and by sex
Overall			Differences by sex
Age group	Total cases	No. Positive (%)	Sex	Subtotal (n)	Total positive	Positive %
< 20	763	544(71.3)	M	299	212	70.9
< 20	763	544(71.3)	F	464	332	71.6
20–29	1,763	1,318(74.8)	M	706	548	77.6
20–29	1,763	1,318(74.8)	F	1057	770	72.8
30–39	3,557	2,658(74.7)	M	1435	1,112	77.5
30–39	3,557	2,658(74.7)	F	2122	1,546	72.9
40–49	3,457	2,558(74.0)	M	1674	1,264	75.5
40–49	3,457	2,558(74.0)	F	1783	1,294	72.6
50–59	2,432	1,758(72.3)	M	1143	826	72.3
50–59	2,432	1,758(72.3)	F	1289	932	72.3
60–69	1,736	1,251(72.1)	M	887	639	72.0
60–69	1,736	1,251(72.1)	F	849	612	72.1
> 70	883	623(70.6)	M	542	380	70.1
> 70	883	623(70.6)	F	341	243	71.3
Total	14,591	10710(73.4)	M	6686	4,981	74.5
Total	14,591	10710(73.4)	F	7905	5,729	72.5

Leg lymphoedema

In terms of severity of leg lymphoedema, 12,680 cases had recorded information (Table 4). Overall, the percentage of reported acute attacks increased with the severity of the condition; mild cases had 64% (n = 5,618), moderate cases 68% (n = 5,169) and severe cases 70% (n = 1,893) When we examining sex distribution, the percentage of acute attacks was the same for both moderate, sever, and acute cases among males.

Table 4

Reported leg lymphoedema severity and acute attacks of reported cases.
Severity	Overall		Difference by sex
Severity	Total case	No. positive	sex	Subtotal	Total positive	Positive
Mild	5,618	3,596(64%)	M	2,502	1,524	60.9
	5,618	3,596(64%)	F	3,116	2,072	66.5
Moderate	5,169	3,514(68%)	M	2,287	1,459	63.8
	5,169	3,514(68%)	F	2,882	1,955	67.8
Sever	1,893	1,325(70%)	M	866	627	72.4
	1,893	1,325(70%)	F	1,027	698	68.0
Total	12,680		M	5,655	3,610	63.8
			F	7,025	4,725	67.3

A significant majority of patients, 64%, reported having swollen legs for 1 to 10 years, indicating a high prevalence of relatively recent cases. In contrast, among patients who have experienced swollen legs for 10 to 20 years, the prevalence drops notably to 25%, suggesting a decline in the proportion of cases over this longer timeframe (Table 5).

Table 5

Years of leg swelling experience
S. No	Number of years patient live with swollen leg	Proportion of people with lymphedema
1	1–10	64%
2	10–20	25%
3	> 20	11%

Confirmatory Test

After the initial assessment, a confirmatory evaluation was conducted in each zone to confirm the results. The findings showed that 80% pf hydrocele cases aligned with the assessments made by HEWs, indicating a high level of agreement. Similarly, 95%, of lymphedema cases were consistent with HEW assessments.

This study represents a comprehensive community-wide clinical case survey of LF in 24 endemic areas in Ethiopia. Previous research done in 2018 focused on the integrated morbidity mapping of LF and podoconiosis in 20 co-endemic districts in Ethiopia [22]. This earlier study reported cases of leg lymphoedema, hydrocoele, both leg lymphoedema and hydrocoele, and breast lymphoedema [22]. Additionally, earlier geographical mapping in 2007 of LF in 112 districts in Western Ethiopia only recorded advanced cases of LF-related lymphedema and hydrocele [23]. In 2013, integrated endemicity mapping in 658 woredas reported clinical cases of LF and podoconiosis from only two kebeles per district using a two-stage cluster purposive sampling strategy [24, 25]. Other studies evaluating the clinical burden of podoconiosis or LF separately have focused on areas known to be endemic for the respective disease and have been conducted on a smaller geographic scale [26–31]. In addition to these, the national program now has included additional information on the geographical distribution of disease, with the Zone of Ari, South Omo, Gofa, Dawro, Konta, Bench Sheko, Yem and Illu Aba Bora are being the most affected in South Ethiopia Region, South West Ethiopia Region, Central Ethiopia Region and Oromia region of which more than 50% of the cased has been identified in Oromia region.

An additional study verified that the previously described data is essential for figuring out the resources required to manage the illnesses affecting these patients, and it will help choose where in the urban region care services may be most efficiently offered. Similar to many other endemic nations, Ethiopia has established strategic alliances between its national LF program and foreign funders in order to address the significant clinical illness burden of LF in the nation, with the goal of eradicating LF nationwide by 2027. Other countries like Tanzania plans to engage CHVs to provide home-based LE training and care for patients and their caregivers have already been developed with the region's NTD and home-based care teams. These services are intended to be supplementary to the specialist filariasis clinic which has been operated by the national programme in Dar es Salaam since 2000 [32, 33]. Along with directing morbidity management efforts, the information gathered from this study will offer insight into how manage morbidity and prevent disability among those already infected with LF[34, 35].

Urban environments can be challenging to conduct MDA in due to variables like increased population movement, and low compliance can lead to MDA coverage levels that are insufficient to permanently cease transmission. Furthermore, it is unclear how much the patient distribution in this transitory urban population reflects the patterns of transmission. However, patient mapping's additional information on disease transmission might be helpful in expanding MDA distribution points to improve coverage, focusing more intense community sensitization campaigns on possible high-risk areas, and/or increasing awareness throughout the city as a whole [36–37]. Since it has been demonstrated that LE management programs can be crucial for enhancing and expanding MDA coverage, it is expected that future MDAs will profit from strong and efficient morbidity management initiatives [38].

In this study, a total of 15,527 morbidities were identified, of which 14,946 (96.3%) were found to have limb lymphoedema and 581 (3.7%) to have hydrocele. Among these, 8,396 (54.1%) were women with lymphedema and 13,731 (88.4%) cases were found in rural areas where a access to preventive and curative services is limited. Using the existing Health Extension Program platform, the study identified a substantial number of lymphedema and hydrocele cases across 24 LF-endemic districts in Ethiopia, with strong agreement between HEWs and surgeons in their case assessments. Cases were predominantly recent lymphoedema, affecting mostly women and individuals in rural areas. PHCUs proved instrumental in identifying LF cases, as HEWs were well-positioned to engage with and support the communities they serve.

ADLA

Acute dermatolymphangioadenitis

DALYs

disability-adjusted-life years

FMoH

Federal Ministry of Health

GPELF

Global Programme to Eliminate LF

HEW

Health Extension Worker

implementation unit

lymphoedema/elephantiasis

Lymphatic filariasis

MMDP

morbidity management and disability prevention

NaPAN

National podoconiosis action network

NTD

neglected tropical disease

MDA

mass drug administration

PHCU

primary health care unit

TOT

Training of Trainers

WHO

World Health Organization

Acknowledgements

The authors acknowledge the Ethiopian Ministry of Health, Regional Health Bureaus, and Zonal and District Health Departments and Health Offices and their NTD for persons and HEWs their paramount support. The authors are also thankful to the National Podoconiosis Action Network, for its outstanding project coordination and management.

Funding

This work was supported by The END FUND. Through the END FUND-LFMMDP project under the National Program for the Elimination of NTDs, to identify and serve individuals with lymphoedema and hydrocele in 24 districts

Ethics declarations

Ethics approval and consent to participate

The study was approved by the Institutional Review Board (IRB) in each region, with permission letters secured from the appropriate facilities. Participants were given ample time to ask questions before interviews and procedures were carried out. All procedures followed the Helsinki Declaration and national ethical guidelines. Informed consent was obtained from all eligible adults in each household, and the process was conducted in a private setting. Consent forms were translated from English to Amharic and back-translated to English for accuracy.

Authors contributions

HB conceived the idea, analyzed the data, and write the first draft; FH, MM, AM, MM, FS, BO, HT, TB and TM revised the draft; and all authors approved the final version for publication. All authors have read and approved the final manuscript.

Availability of data and materials

The dataset supporting the conclusions of this article is included within the article and its additional files. Any additional material can be obtained upon reasonable request.

Consent for publication

Not applicable.

Competing of interests

The authors declare that they have no conflict of interest.

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Mapping lymphatic filariasis morbidities in 24 endemic districts of Ethiopia

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Background

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Introduction

Methods

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Background Characteristics

Acute attacks

Leg lymphoedema

Confirmatory Test

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