Integrated care programme for acute episodes in patients with podoconiosis
Authors: Sarah C Hogan, L Claire Fuller
Journal: The Lancet Global Health (2018)

In their Article in The Lancet Global Health, Henok Negussie and colleagues1Negussie H Molla M Ngari M et al.Lymphoedema management to prevent acute dermatolymphangioadenitis in podoconiosis in northern Ethiopia (GoLBeT): a pragmatic randomised controlled trial.Lancet Glob Health. 2018; (published online May 14.)http://dx.doi.org/10.1016/S2214-109X(18)30124-4Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar describe their randomised control trial to investigate the effect of a lymphoedema management package on outcomes in patients with podoconiosis. Podoconiosis is a neglected tropical disease that causes disabling non-filarial lymphoedema in genetically predisposed people who have been chronically exposed to specific irritant soil minerals. This disease is endemic in 32 countries across Africa, Asia, and Latin America, with prevalence ranging from 0·1 to 8·0% in affected countries.2Deribe K Cano J Trueba ML Newport MJ Davey G Global epidemiology of podoconiosis: a systematic review.PLoS Negl Trop Dis. 2018; 12: e0006324Crossref PubMed Scopus (44) Google Scholar Patients with podoconiosis have reduced productivity3Tekola F Mariam DH Davey G Economic costs of endemic non-filarial elephantiasis in Wolaita Zone, Ethiopia.Trop Med Int Health. 2006; 11: 1136-1144Crossref PubMed Scopus (102) Google Scholar and quality of life4Henok L Davey G Validation of the Dermatology Life Quality Index among patients with podoconiosis in southern Ethiopia.Br J Dermatol. 2008; 159: 903-906Crossref PubMed Scopus (33) Google Scholar and suffer incapacitating episodes of acute dermatolymphangioadenitis. These patients often suffer from depression, and the severity of this depression has been found to correlate with number of recent episodes of acute dermatolymphangioadenitis.5Bartlett J Deribe K Tamiru A et al.Depression and disability in people with podoconiosis: a comparative cross-sectional study in rural northern Ethiopia.Int Health. 2016; 8: 124-131Crossref PubMed Scopus (36) Google Scholar Previous studies6Sikorski C Ashine M Zeleke Z Davey G Effectiveness of a simple lymphoedema treatment regimen in podoconiosis management in southern Ethiopia: one year follow-up.PLoS Negl Trop Dis. 2010; 4: e902Crossref PubMed Scopus (62) Google Scholar have suggested that the introduction of measures for foot hygiene can improve the quality of life and clinical stage of disease, but there have been no controlled studies to examine the effect of these measures on episodes of acute dermatolymphangioadenitis. There are few government-backed initiatives to eliminate or manage podoconiosis, despite this disease being a preventable and treatable condition; this absence of initiatives is partly because of the dearth of clear guidance on best practice. To address this need, Negussie and colleagues designed the Gojjam Lymphoedema Best practice Trial (GoLBeT), which was trialled in 696 patients in rural northern Ethiopia. They found that implementation of a simple package of measures including foot hygiene, skin care with moisturisers, bandages, exercises to improve lymph drainage, and encouragement to use shoes and socks can improve patient-reported outcomes in patients with podoconiosis. These outcomes were achieved due to a reduced number of episodes of acute dermatolymphangioadenitis, and an increased number of days without these episodes during 12 months of follow-up. This Article makes several contributions to the medical literature on podoconiosis. First, the authors have shown that a randomised control trial can be used effectively in such challenging, resource-poor settings by use of retention strategies and monthly group meetings to maintain follow-up rates and reinforce behavioural changes in geographically isolated communities. Through careful planning, the study team also successfully minimised the risk of performance bias within the control group. Additionally, the trial revealed that the overall baseline incidence of acute dermatolymphangioadenitis was higher than expected for the area,7Molla YB Tomczyk S Amberbir T Tamiru A Davey G Podoconiosis in East and West Gojam Zones, northern Ethiopia.PLoS Negl Trop Dis. 2012; 6: e1744Crossref PubMed Scopus (61) Google Scholar which underscores the need for continued monitoring. Finally, this trial complements what is known already about management of lymphoedema in lymphatic filariasis, another cause of tropical lymphoedema in many of the areas affected by podoconiosis. Previous research has revealed that foot hygiene also has a beneficial effect on the number of episodes of acute dermatolymphangioadenitis in people with lymphatic filariasis, both with and without the addition of antibiotic or antiseptic treatment.8Jullien P Somé Jd Brantus P Bougma RW Bamba I Kyelem D Efficacy of home-based lymphoedema management in reducing acute attacks in subjects with lymphatic filariasis in Burkina Faso.Acta Trop. 2011; 120: S55-S61Crossref PubMed Scopus (24) Google Scholar, 9Kerketta AS Babu BV Rath K Jangid PK Nayak AN Kar SK A randomized clinical trial to compare the efficacy of three treatment regimens along with footcare in the morbidity management of filarial lymphoedema.Trop Med Int Health. 2005; 10: 698-705Crossref PubMed Scopus (35) Google Scholar In 2000, WHO launched the Global Programme to Eliminate Lymphatic Filariasis,10WHOMorbidity management and disability prevention.http://www.who.int/lymphatic_filariasis/managing-morbidity/en/Date accessed: April 2, 2018Google Scholar which recommends a Morbidity Management and Disability Prevention minimum package of care for all patients with lymphatic filariasis. Integrated management strategies of foot care in patients with lymphatic filariasis and podoconiosis have been shown to be cost-effective in Ethiopia, where these diseases co-exist.11Deribe K Kebede B Tamiru M et al.Integrated morbidity management for lymphatic filariasis and podoconiosis, Ethiopia.Bull World Health Organ. 2017; 95: 652-656Crossref PubMed Scopus (19) Google Scholar Furthermore, the 2013 World Health Assembly resolution12WHOSixty-Sixth World Health Assembly. Agenda item 16.2: neglected tropical diseases.http://www.who.int/neglected_diseases/mediacentre/WHA_66.12_Eng.pdfDate: May 27, 2013Date accessed: April 2, 2018Google Scholar recommends integration of care for neglected tropical diseases to reduce costs and enhance health-care coverage. The results of the GoLBeT trial support the need for further integrated care programmes aimed at improving foot protection and foot care in all patients with lymphoedema. This initiative would have the added benefit of protecting the target population from other neglected health risks, such as soil-transmitted helminths and envenomation from snake bites. The GoLBeT trial raises important questions that still need to be addressed. Despite similar treatment adherence rates between the sexes, Negussie and colleagues found that men had a better response to the intervention than women. This result has not been seen in lymphatic filariasis,8Jullien P Somé Jd Brantus P Bougma RW Bamba I Kyelem D Efficacy of home-based lymphoedema management in reducing acute attacks in subjects with lymphatic filariasis in Burkina Faso.Acta Trop. 2011; 120: S55-S61Crossref PubMed Scopus (24) Google Scholar and further work might help to elucidate reasons for this different response. Future projects might combine foot care with antibiotics or antiseptics, address the preventative role of footwear, or focus on the outcomes of combined programmes for intervention into neglected tropical diseases. This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on May 22, 2018 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on May 22, 2018 LCF is a member of the steering group, Footwork, the International Podoconiosis Initiative. SCH declares no competing interests. Lymphoedema management to prevent acute dermatolymphangioadenitis in podoconiosis in northern Ethiopia (GoLBeT): a pragmatic randomised controlled trialA simple, inexpensive package of lymphoedema self-care is effective in reducing the frequency and duration of acute dermatolymphangioadenitis. We recommend its implementation by the governments of endemic countries. Full-Text PDF Open AccessCorrection to Lancet Glob Health 2018; published online May 14. https://doi.org/10.1016/S2214-109X(18)30226-2Hogan SC, Fuller LC. Integrated care programme for acute episodes in patients with podoconiosis. Lancet Glob Health 2018; published online May 14. https://doi.org/10.1016/S2214-109X(18)30226-2—In this Comment, the name of the first author of the linked Article, Henok Negussie, was incorrect. This correction has been made as of May 22, 2018. Full-Text PDF Open Access