Podoconiosis in East and West Gojam Zones, Northern Ethiopia

Background: Podoconiosis is a neglected tropical disease (NTD) that is prevalent in red clay soil-covered highlands of tropical Africa, Central and South America, and northern India. It is estimated that up to one million cases exist in Ethiopia. This study aimed to estimate the prevalence of podoconiosis in East and West Gojam Zones of Amhara Region in northern Ethiopia. Methodology/Principal Findings: A cross-sectional household survey was conducted in Debre Eliyas and Dembecha woredas (districts) in East and West Gojam Zones, respectively. The survey covered all 17,553 households in 20 kebeles (administrative subunits) randomly selected from the two woredas. A detailed structured interview was conducted on 1,704 cases of podoconiosis identified in the survey. Results: The prevalence of podoconiosis in the population aged 15 years and above was found to be 3.3% (95% CI, 3.2% to 3.6%). 87% of cases were in the economically active age group (15–64 years). On average, patients sought treatment five years after the start of the leg swelling. Most subjects had second (42.7%) or third (36.1%) clinical stage disease, 97.9% had mossy lesions, and 53% had open wounds. On average, patients had five episodes of acute adenolymphangitis (ALA) per year and spent a total of 90 days per year with ALA. The median age of first use of shoes and socks were 22 and 23 years, respectively. More men than women owned more than one pair of shoes (61.1% vs. 50.5%; x2 = 11.6 p = 0.001). At the time of interview, 23.6% of the respondents were barefoot, of whom about two-thirds were women. Conclusions: This study showed high prevalence of podoconiosis and associated morbidities such as ALA, mossy lesions and open wounds in northern Ethiopia. Predominance of cases at early clinical stage of podoconiosis indicates the potential for reversing the swelling and calls for disease prevention interventions

Effectiveness of a simple lymphoedema treatment regimen in podoconiosis management in southern Ethiopia: one year follow-up

Background: Podoconiosis is a non-filarial elephantiasis caused by long-term barefoot exposure to volcanic soils in endemic areas. Irritant silicate particles penetrate the skin, causing a progressive, debilitating lymphoedema of the lower leg, often starting in the second decade of life. A simple patient-led treatment approach appropriate for resource poor settings has been developed, comprising (1) education on aetiology and prevention of podoconiosis, (2) foot hygiene (daily washing with soap, water and an antiseptic), (3) the regular use of emollient, (4) elevation of the limb at night, and (5) emphasis on the consistent use of shoes and socks. Methodology/Principal Findings: We did a 12-month, non-comparative, longitudinal evaluation of 33 patients newly presenting to one clinic site of a non-government organization (the Mossy Foot Treatment & Prevention Association, MFTPA) in southern Ethiopia. Outcome measures used for the monitoring of disease progress were (1) the clinical staging system for podoconiosis, and (2) the Amharic Dermatology Life Quality Index (DLQI), both of which have been recently validated for use in this setting. Digital photographs were also taken at each visit. Twenty-seven patients completed follow up. Characteristics of patients completing follow-up were not significantly different to those not. Mean clinical stage and lower leg circumference decreased significantly (mean difference -0.67 (95% CI -0.38 to -0.96) and -2.00 (95% CI -1.26 to -2.74), respectively, p<0.001 for both changes). Mean DLQI diminished from 21 (out of a maximum of 30) to 6 (p<0.001). There was a non-significant change in proportion of patients with mossy lesions (p = 0.375). Conclusions/Significance: This simple, resource-appropriate regimen has a considerable impact both on clinical progression and self-reported quality of life of affected individuals. The regimen appears ideal for scaling up to other endemic regions in Ethiopia and internationally. We recommend that further research in the area include analysis of cost-effectiveness of the regimen

Byssinosis and other respiratory symptoms among factory workers in Akaki textile factory, Ethiopia

Background: Textile cotton workers are at risk for occupational lung disease, including Byssinosis and chronic Bronchitis. Byssinosis is primarily associated with exposure to cotton dust.Objectives: To determine the prevalence of and factors associated with byssinosis and respiratory symptoms among workers in cotton mills of Akaki textile factory.Methods: A cross-sectional study was conducted among 417 randomly selected factory workers. Information was collected through interview using the modified American Thoracic Society standard respiratory symptoms questionnaires. Forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC) and FEV1/FVC ratio were measured using portable medical spirometers. Area sampling for cotton dust concentration in the work environment was measured using Data RAM 4 real time measurement for 8 hours during a day shift.Results: The highest prevalence of respiratory symptoms was found in the carding section - cough 77%, phlegm 62%, chest tightness 46% and dyspnea 62%. The Overall prevalence of chronic bronchitis was 32%. Those working in the carding section appeared 13 times more likely to have chronic bronchitis compared to other sections (Adjusted OR=13.4, 95% CI 3.43-52.6). The prevalence of byssinosis was 38%; the highest being recorded in the carding section at 84.6%. High exposure to cotton dust was noted among those in the blowing and carding section at mean dust levels of 32.2 mg/m3 and 8 mg/m3, respectively. About 11% of byssinotics developed severe chronic FEV1 changes. Conclusion: This study provides evidence of a strong relationship between exposure to cotton dust and byssinosis and other respiratory impairments, which is mediated through chronic ventilator impairments. Preventive measures are warranted in order to reduce the high prevalence of byssinosis and other respiratory disorders in textile manufacturing. [Ethiop. J .Health Dev. 2010;24(2):133-139

Multi-line Adaptive Perimetry (MAP): A New Procedure for Quantifying Visual Field Integrity for Rapid Assessment of Macular Diseases.

PurposeIn order to monitor visual defects associated with macular degeneration (MD), we present a new psychophysical assessment called multiline adaptive perimetry (MAP) that measures visual field integrity by simultaneously estimating regions associated with perceptual distortions (metamorphopsia) and visual sensitivity loss (scotoma).MethodsWe first ran simulations of MAP with a computerized model of a human observer to determine optimal test design characteristics. In experiment 1, predictions of the model were assessed by simulating metamorphopsia with an eye-tracking device with 20 healthy vision participants. In experiment 2, eight patients (16 eyes) with macular disease completed two MAP assessments separated by about 12 weeks, while a subset (10 eyes) also completed repeated Macular Integrity Assessment (MAIA) microperimetry and Amsler grid exams.ResultsResults revealed strong repeatability of MAP and high accuracy, sensitivity, and specificity (0.89, 0.81, and 0.90, respectively) in classifying patient eyes with severe visual impairment. We also found a significant relationship in terms of the spatial patterns of performance across visual field loci derived from MAP and MAIA microperimetry. However, there was a lack of correspondence between MAP and subjective Amsler grid reports in isolating perceptually distorted regions.ConclusionsThese results highlight the validity and efficacy of MAP in producing quantitative maps of visual field disturbances, including simultaneous mapping of metamorphopsia and sensitivity impairment.Translational relevanceFuture work will be needed to assess applicability of this examination for potential early detection of MD symptoms and/or portable assessment on a home device or computer

Prediction of core body temperature from multiple variables

This paper aims to improve the prediction of rectal temperature (Tre) from insulated skin temperature (Tis) and micro-climate temperature (Tmc) previously reported (Richmond et al., Insulated skin temperature as a measure of core body temperature for individuals wearing CBRN protective clothing. Physiol Meas 2013; 34:1531–43.) using additional physiological and/or environmental variables, under several clothing and climatic conditions. Twelve male (25.8±5.1 years; 73.6±11.5kg; 178±6cm) and nine female (24.2±5.1 years; 62.4±11.5kg; 169±3cm) volunteers completed six trials, each consisting of two 40-min periods of treadmill walking separated by a 20-min rest, wearing permeable or impermeable clothing, under neutral (25°C, 50%), moderate (35°C, 35%), and hot (40°C, 25%) conditions, with and without solar radiation (600W m−2). Participants were measured for heart rate (HR) (Polar, Finland), skin temperature (Ts) at 11 sites, Tis (Grant, Cambridge, UK), and breathing rate (f) (Hidalgo, Cambridge, UK). Tmc and relative humidity were measured within the clothing. Tre was monitored as the 'gold standard' measure of Tc for industrial or military applications using a 10cm flexible probe (Grant, Cambridge, UK). A stepwise multiple regression analysis was run to determine which of 30 variables (Tis, Ts at 11 sites, HR, f, Tmc, temperature, and humidity inside the clothing front and back, body mass, age, body fat, sex, clothing, Thermal comfort, sensation and perception, and sweat rate) were the strongest on which to base the model. Using a bootstrap methodology to develop the equation, the best model in terms of practicality and validity included Tis, Tmc, HR, and 'work' (0 = rest; 1 = exercise), predicting Tre with a standard error of the estimate of 0.27°C and adjusted r2 of 0.86. The sensitivity and specificity for predicting individuals who reached 39°C was 97 and 85%, respectively. Insulated skin temperature was the most important individual parameter for the prediction of Tre. This paper provides novel information about the viability of predicting Tc under a wide range of conditions, using predictors which can practically be measured in a field environment

Community-based control of a neglected tropical disease: the mossy foot treatment and prevention association

Podoconiosis (endemic non-filarial elephantiasis, also known as mossy foot) is a non-communicable disease now found exclusively in the tropics, caused by the conjunction of environmental, genetic, and economic factors. Silicate particles formed by the disintegration of lava in areas of high altitude (over 1,000 m) and seasonal rainfall (over 1,000 mm per annum) penetrate the skin of barefoot subsistence farmers, and in susceptible individuals cause lymphatic blockage and subsequent elephantiasis [1]. Although an estimated one million Ethiopians (of a total population of 77 million) are afflicted with podoconiosis [2], which creates a huge economic burden in endemic areas [3], no national policy has yet been developed to control or prevent the condition, and most affected communities remain unaware of treatment options

Oestradiol and sex hormone-binding globulin in premenopausal and post-menopausal meat-eaters, vegetarians and vegans

Endogenous oestradiol is strongly associated with breast cancer risk but its determinants are poorly understood. To test the hypothesis that vegetarians have lower plasma oestradiol and higher sex hormone-binding globulin (SHBG) than meat-eaters we assayed samples from 640 premenopausal women (153 meat-eaters, 382 vegetarians, 105 vegans) and 457 post-menopausal women (223 meat-eaters, 196 vegetarians, 38 vegans). Vegetarians and vegans had lower mean body mass indices (BMI) and lower plasma cholesterol concentrations than meat-eaters, but there were no statistically significant differences between meat-eaters, vegetarians and vegans in pre- or post-menopausal plasma concentrations of oestradiol or SHBG. Before adjusting for BMI there were small differences in the direction expected, with the vegetarians and vegans having higher SHBG and lower oestradiol (more noticeable amongst post-menopausal women) than the meat-eaters. These small differences were essentially eliminated by adjusting for BMI. Thus this study implies that the relatively low BMI of vegetarians and vegans does cause small changes in SHBG and in post-menopausal oestradiol, but that the composition of vegetarian diets may not have any additional effects on these hormones

Individual correlates of podoconiosis in areas of varying endemicity: a case-control study

BACKGROUND Podoconiosis is a non-filarial form of elephantiasis resulting in lymphedema of the lower legs. Previous studies have suggested that podoconiosis arises from the interplay of individual and environmental factors. Here, our aim was to understand the individual-level correlates of podoconiosis by comparing 460 podoconiosis-affected individuals and 707 unaffected controls. METHODS/PRINCIPAL FINDINGS This was a case-control study carried out in six kebeles (the lowest governmental administrative unit) in northern Ethiopia. Each kebele was classified into one of three endemicity levels: 'low' (prevalence 5%). A total of 142 (30.7%) households had two or more cases of podoconiosis. Compared to controls, the majority of the cases, especially women, were less educated (OR = 1.7, 95% CI = 1.3 to 2.2), were unmarried (OR = 3.4, 95% CI = 2.6-4.6) and had lower income (t = -4.4, p<0.0001). On average, cases started wearing shoes ten years later than controls. Among cases, age of first wearing shoes was positively correlated with age of onset of podoconiosis (r = 0.6, t = 12.5, p<0.0001). Among all study participants average duration of shoe wearing was less than 30 years. Between both cases and controls, people in 'high' and 'medium' endemicity kebeles were less likely than people in 'low' endemicity areas to 'ever' have owned shoes (OR = 0.5, 95% CI = 0.4-0.7). CONCLUSIONS Late use of shoes, usually after the onset of podoconiosis, and inequalities in education, income and marriage were found among cases, particularly among females. There were clustering of cases within households, thus interventions against podoconiosis will benefit from household-targeted case tracing. Most importantly, we identified a secular increase in shoe-wearing over recent years, which may give opportunities to promote shoe-wearing without increasing stigma among those at high risk of podoconiosis

Factors related to discontinued clinic attendance by patients with podoconiosis in southern Ethiopia: a qualitative study

Background Podoconiosis is a lymphoedema of non-infectious cause which results in long-term ill health in affected individuals. Simple, effective treatment is available in certain parts of Ethiopia, but evidence indicates that not all patients continue collecting treatment supplies from clinic sites once started. We used qualitative techniques to explore factors related to discontinued attendance at outreach clinics of a non-government organization in southern Ethiopia. Methods A cross-sectional qualitative study was conducted in four clinic sites through unstructured in-depth interviews, key informant interviews and focus group discussions with the involvement of 88 study subjects. Results Discontinuation of clinic visits is common among podoconiosis patients. The reasons were: remoteness from the clinic sites, unrealistic expectation of ‘special’ aid, worry about increasing stigma, illness and misconceptions about treatment. Conclusions Several of these factors are remediable through community and individual information and education. Appropriate routes to deliver this information must be identified. Certain factors (such as distance to clinic sites and stigma) require substantial expansion of services or liaison with village-level government health services

Spatial distribution of podoconiosis in relation to environmental factors in Ethiopia: a historical review

BACKGROUND An up-to-date and reliable map of podoconiosis is needed to design geographically targeted and cost-effective intervention in Ethiopia. Identifying the ecological correlates of the distribution of podoconiosis is the first step for distribution and risk maps. The objective of this study was to investigate the spatial distribution and ecological correlates of podoconiosis using historical and contemporary survey data. METHODS Data on the observed prevalence of podoconiosis were abstracted from published and unpublished literature into a standardized database, according to strict inclusion and exclusion criteria. In total, 10 studies conducted between 1969 and 2012 were included, and data were available for 401,674 individuals older than 15 years of age from 229 locations. A range of high resolution environmental factors were investigated to determine their association with podoconiosis prevalence, using logistic regression. RESULTS The prevalence of podoconiosis in Ethiopia was estimated at 3.4% (95% CI 3.3%-3.4%) with marked regional variation. We identified significant associations between mean annual Land Surface Temperature (LST), mean annual precipitation, topography of the land and fine soil texture and high prevalence of podoconiosis. The derived maps indicate both widespread occurrence of podoconiosis and a marked variability in prevalence of podoconiosis, with prevalence typically highest at altitudes >1500 m above sea level (masl), with >1500 mm annual rainfall and mean annual LST of 19-21°C. No (or very little) podoconiosis occurred at altitudes 24°C. CONCLUSION Podoconiosis remains a public health problem in Ethiopia over considerable areas of the country, but exhibits marked geographical variation associated in part with key environmental factors. This is work in progress and the results presented here will be refined in future work