Impact of community-based lymphedema management on perceived disability among patients with lymphatic filariasis in Orissa State, India

Abstract

Background: Lymphatic filariasis (LF) infects approximately 120 million people worldwide. As many as 40 million have symptoms of LF disease, including lymphedema, elephantiasis, and hydrocele. India constitutes approximately 45% of the world's burden of LF. The Indian NGO Church's Auxiliary for Social Action (CASA) has been conducting a community-based lymphedema management program in Orissa State since 2007 that aims to reduce the morbidity associated with lymphedema and elephantiasis. The objective of this analysis is to evaluate the effects of this program on lymphedema patients' perceived disability.

Methodology/principal findings: For this prospective cohort study, 370 patients ≥14 years of age, who reported lymphedema lasting more than three months in one or both legs, were recruited from villages in the Bolagarh sub-district, Khurda District, Orissa, India. The World Health Organization Disability Assessment Schedule II was administered to participants at baseline (July, 2009), and then at regular intervals through 24 months (July, 2011), to assess patients' perceived disability. Disability scores decreased significantly (p<0.0001) from baseline to 24 months. Multivariable analysis using mixed effects modeling found that employment and time in the program were significantly associated with lower disability scores after two years of program involvement. Older age, female gender, the presence of other chronic health conditions, moderate (Stage 3) or advanced (Stage 4-7) lymphedema, reporting an adenolymphangitis (ADL) episode during the previous 30 days, and the presence of inter-digital lesions were associated with higher disability scores. Patients with moderate or advanced lymphedema experienced greater improvements in perceived disability over time. Patients participating in the program for at least 12 months also reported losing 2.5 fewer work days per month (p<0.001) due to their lymphedema, compared to baseline.

Significance: These results indicate that community-based lymphedema management programs can reduce disability and prevent days of work lost. These effects were sustained over a 24 month period.

Figure 1. Map of India.

The location of Orissa state (shaded gray) and Khurda District (shaded black) are indicated.

Figure 2. Mean WHO-DAS II disability scores by domain.

Scores for each domain are shown as labeled; total disability is shown in the lowest panel.

Figure 3. Total perceived disability scores.

Total WHO DAS II scores (composite of all 6 domains) are shown prior to enrollment and 24 months after enrollment in the lymphedema management program, by lymphedema stage category.

Figure 4. Reported days work lost.

Self-report of the mean number of days of work lost due to lymphedema-related disability in the past 30 days. Error bars represent 95% confidence intervals around the mean. All times were significantly different from baseline (time 0).