The Effect of Hygiene-Based Lymphedema Management in Lymphatic Filariasis-Endemic Areas: A Systematic Review and Meta-analysis

Abstract

BackgroundLymphedema of the leg and its advanced form, known as elephantiasis, are significant causes of disability and morbidity in areas endemic for lymphatic filariasis (LF), with an estimated 14 million persons affected worldwide. The twin goals of the World Health Organization’s Global Program to Eliminate Lymphatic Filariasis include interrupting transmission of the parasitic worms that cause LF and providing care to persons who suffer from its clinical manifestations, including lymphedema—so-called morbidity management and disability prevention (MMDP). Scaling up of MMDP has been slow, in part because of a lack of consensus about the effectiveness of recommended hygiene-based interventions for clinical lymphedema.Methods and FindingsWe conducted a systemic review and meta-analyses to estimate the effectiveness of hygiene-based interventions on LF-related lymphedema. We systematically searched PubMed, Embase, ISI Web of Knowledge, MedCarib, Lilacs, REPIDISCA, DESASTRES, and African Index Medicus databases through March 23, 2015 with no restriction on year of publication. Studies were eligible for inclusion if they (1) were conducted in an area endemic for LF, (2) involved hygiene-based interventions to manage lymphedema, and (3) assessed lymphedema-related morbidity. For clinical outcomes for which three or more studies assessed comparable interventions for lymphedema, we conducted random-effects meta-analyses. Twenty-two studies met the inclusion criteria and two meta-analyses were possible. To evaluate study quality, we developed a set of criteria derived from the GRADE methodology. Publication bias was assessed using funnel plots. Participation in hygiene-based lymphedema management was associated with a lower incidence of acute dermatolymphagioadenitis (ADLA), (Odds Ratio 0.32, 95% CI 0.25–0.40), as well as with a decreased percentage of patients reporting at least one episode of ADLA during follow-up (OR 0.29, 95% CI 0.12–0.47). Limitations included high heterogeneity across studies and variation in components of lymphedema management.ConclusionsAvailable evidence strongly supports the effectiveness of hygiene-based lymphedema management in LF-endemic areas. Despite the aforementioned limitations, these findings highlight the potential to significantly reduce LF-associated morbidity and disability as well as the need to develop standardized approaches to MMDP in LF-endemic areas.

Quantifying the socio-economic impact of leg lymphoedema on patient caregivers in a lymphatic filariasis and podoconiosis co-endemic district of Ethiopia

“…However, differential diagnosis may be important in certain circumstances, and previous studies have utilised tests such as filarial antigen testing, filarial antibody testing and parasitological examination to exclude an LF diagnosis in LF and podoconiosis co-endemic areas [15]. All patients experienced frequent ADLAs, with a higher frequency of ADLAs in patients with severe stage lymphoedema [6,7,42], which contribute to the progression of disease and are key predictors of disability [8][9][10]. Whilst recall bias may have influenced the number of ADLAs reported, patients with mild/moderate and severe lymphoedema experienced an average of 6 and 10 respectively, which may be broadly extrapolated to 12 to 20 ADLAs per year.…”

“…Alongside the disfigurements, patients experience re-current acute dermatolymphangioadenitis (ADLA) known as 'acute attacks', which are episodes of febrile illness, malaise and extensive swelling caused by secondary bacterial infection [6,7]. ADLAs have been identified as a critical factor contributing to the progression of diseases and predictor of disability [8][9][10]. Productive hours are lost, and the impairments render a socially excluded reality for many, thereby, contributing to the global loss of 2.78 million Disability Adjusted Life Years (DALYS) [11].…”

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

“…As such, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) recognises that in order to eliminate LF as a public health problem, these conditions need to be effectively managed [8, 9]. Lymphoedema management primarily consists of simple hygiene measures such as frequent washing and exercise, with there being strong evidence that these measures lower the number of acute attacks, improve self-assessed quality of life, and decrease swelling [10]. …”

Portable infrared imaging for longitudinal limb volume monitoring in patients with lymphatic filariasis

“…Outcomes used to assess the success of hygiene based lymphedema management include frequency of adenolymphangitis episodes, changes in stage, surveys to assess perceived disability/quality of life/depression, and measurements of leg size (i.e. volume or circumference) [14]. Infrared imaging with 3DIS has many advantages over volume displacement and tape measurements of limb circumference as a method for determining limb size.…”