Acta Tropica 120S (2011) S55 S61. Contents lists available at ScienceDirect. Acta Tropica. journa l h o me pa g e:

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1 Acta Tropica 120S (2011) S55 S61 Contents lists available at ScienceDirect Acta Tropica journa l h o me pa g e: Efficacy of home-based lymphoedema management in reducing acute attacks in subjects with lymphatic filariasis in Burkina Faso Patrick Jullien a,, Jeanne d Arc Somé b, Pierre Brantus c, Roland W. Bougma d, Issouf Bamba d, Dominique Kyelem d a Handicap International, 14 Avenue Berthelot, Lyon, France b Handicap International, Quartier SOCOGIM, BP 541, CP 01 Ouagadougou, Burkina Faso c World Health Organization, Geneva, Switzerland d National Programme to Eliminate Lymphatic Filariasis, Ministry of Health, 03 B.P. 7009, Ouagadougou 03, Burkina Faso a r t i c l e i n f o Article history: Available online 4 April 2011 Keywords: Lymphatic filariasis Burkina Faso Lymphoedema management Acute attacks a b s t r a c t One of the two main goals of the Global Programme to Eliminate Lymphatic Filariasis (LF) is to provide care for those suffering from the devastating clinical manifestations of this filarial infection. Among the 120 million infected people worldwide, up to 16 million have lymphoedema. The WHO strategy for managing lymphoedema is based on rigorous skin hygiene, exercise, antibiotics and antifungals when indicated. The aim is to reduce acute attacks of adenolymphangitis and cellulitis responsible for lymphoedema progression and disability. The objective of our study was to assess the effectiveness of home-based lymphoedema management implemented by the national health system of Burkina Faso. Any patient was eligible to participate in the study if suffering from LF-related lymphoedema of a lower limb at any stage, and receiving care as part of the health education and washing project between April 2005 and December The primary readout was the occurrence of an acute attack in the month preceding the consultation reported by the patient or observed by the care-giver. In all, 1089 patients were enrolled in the study. Before lymphoedema management intervention, 78.1% (95%CI: ) of the patients had an acute attack in the month preceding the consultation; after four and half months of lymphoedema management, this was reduced to 39.1% (95%CI: ). A reduction of acute attacks related to the number of consultations or related to the patients age and gender was not observed. Our results suggest that the home-based lymphoedema management programme in the primary health care system of Burkina Faso is effective in reducing morbidity due to LF in the short-term (4.5 months). The lymphoedema management requires no additional human resources, but whether its effect can be sustained remains to be seen Published by Elsevier B.V. 1. Introduction In lymphatic filariasis (LF), adult-stage parasites infiltrate the lymphatic system which plays a key role maintaining the fluid balance between tissue and blood (Figueredo-Silva and Dreyer, 2005). Severe chronic clinical symptoms often develop in adults, including hydrocele and lymphoedema (swelling of the lower limbs, arms, scrotum, and breasts). LF places a significant social and economic burden on affected individuals, their communities and the health system (Gyapong et al., 1996a; Perera et al., 2007; Ramaiah et al., 2000; Sabesan et al., 1992; Wijesinghe et al., 2007). Disabilityadjusted life years (DALYs) due to LF are estimated to be 5.7 million, Corresponding author. Tel.: addresses: docteur.jullien@gmail.com, patrick.jullien@free.fr (P. Jullien). second only to malaria among tropical diseases (Mathers et al., 2007). Lymphoedema of the entire leg or arm may occur in up to 10% of women or men in endemic communities (Njenga et al., 2007). Lymphoedema of the leg affects an estimated 16 million persons worldwide (Addiss and Brady, 2007). The strategy of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) is based on interrupting transmission using mass drug administration, and, in parallel, alleviating and preventing suffering and disability caused by the disease (Ottesen et al., 1997). This programme has been implemented in a large number of countries since 2000 and has led to significant health benefits, including reduced and averted morbidity (Ottesen et al., 2008; WHO, 2008). Acute attacks (localised inflammation of the skin, nodes and lymphatic vessels accompanied by fever) may occur several times per year and cause pain, oedema aggravation and the exacerbation of physical disabilities (Chandrasena et al., 2007; Pani and X/$ see front matter 2011 Published by Elsevier B.V. doi: /j.actatropica

2 S56 P. Jullien et al. / Acta Tropica 120S (2011) S55 S61 Srividya, 1995; Ramaiah et al., 1997). It is now recognised that cutaneous infection plays an important role in the onset of acute episodes and in the pathogenesis of lymphoedema (Dreyer et al., 2006; McPherson et al., 2006; Suma et al., 2002). Good daily hygiene, including washing, reduces the risk of bacterial infection, and simple exercises stimulate lymph flow. Both practices can significantly improve lymphoedema in the early stages, reduce the risk of the onset of bacterial infection or acute symptoms and sometimes improve the lymphoedema itself. Hence, monitoring the occurrence of acute attacks appears to be a potential tool of assessing the effectiveness of a washing programme. This paper reports on a study conducted within the primary health care system in two health regions, including eight districts in Burkina Faso The washing programme in Burkina Faso In 2002, prior to the enrolment of patients in this study, the National Programme to Eliminate Lymphatic Filariasis (NPELF) and Handicap International began implementing a disability alleviation programme. Its lymphoedema management component was designated as the washing project. The project included training of health workers and health education professionals in lymphoedema management. Communities, patients and their families received constant education; health personal were provided with skills and resources (supplies, medication) for lymphoedema management. The trained staff then taught LF patients and their family members how to manage the condition. Once taught, patients were provided with a plastic basin, a cup and a piece of soap to enable them to start lymphoedema management at home. The homebased care strategy aimed at promoting, maintaining, monitoring and restoring health in the patient s home by the patient or by a family member. Patients were advised when they should seek care at a nearby health facility. Hence, responsibility was given to patients (and their families) to care for themselves in the hope that this strategy would be more sustainable than relying entirely on the health staff to carry out home visits. In some instances, community volunteers were closely involved throughout the process. Registers were made available at the health centre and district levels for recording patients information. The practice of washing, a key component of lymphoedema management, was defined as careful washing, wiping and drying of the area affected by lymphoedema up to four times a day with soap and water, including the deep skin folds and the areas between the toes, followed by careful drying (Dreyer et al., 2000a). The project is embedded within the existing national health system, in which each health centre covers several villages or wards. Individuals from a catchment area typically visit their assigned health centre for preventive and curative care. In 2005, the average catchment area radius for health centres was 8.19 km and the average population covered was 10,079 inhabitants. There was at least one qualified nurse per health centre (Direction des Etudes et de la Planification, 2007). The care provided by health workers for patients with LF and other diseases included preventive and outreach services. For lymphoedema management, each health worker was responsible for following up to fifteen patients. The findings of the evaluation reported in this paper are of particular importance because: (1) the national scope of the project being implemented in an existing health and primary healthcare system not specifically dedicated to LF morbidity management, and (2) the large number of LF patients identified, more than ten thousand in the two regions (PNEFL, 2008). The objective of monitoring was to assess the effectiveness of the washing programme in improving the clinical condition of lymphoedema patients as part of the regular healthcare system outlined above. Fig. 1. Flowchart of the number of patients enrolled in the washing program and the eligible study population. 2. Methods In April 2005, an EpiInfo-based monitoring tool for project evaluation was set up in the two regions included in our study, Gaoua and Tenkodogo. These regions were participating in mass drug administration campaigns using a single dose of albendazole and ivermectin, with treatment coverage for ranging from 55% to 86% of the total population (PNEFL, 2008). The two regions had the highest pre-intervention filarial antigenemia prevalence by ICT in the country, with rates ranging from 34% to 74% (Gyapong et al., 2002). To avoid adding to the health workers workload, the monitoring tool was designed to record the fewest possible variables. The system provided a quick and easy local analysis of results, at district and regional levels. Study population: The washing programme initially enrolled a total of 4514 patients suffering from LF-related lymphoedema, before inclusion and exclusion criteria, in the eight districts of Batie, Gaoua, Diebougou, Dano, Koupela, Ouargaye, Tenkodogo and Zabre between April 2005 and December Lymphoedema was defined as the swelling of subcutaneous tissues due to the presence of excessive lymph fluid. Any person with lymphoedema living in an LF-endemic area was considered to have an LF complication unless other causes were suspected or found. Enrolled patients did not have any other known etiology of lymphoedema after being seen by a health professional. Primary endpoint: Incidence (occurrence) of an acute attack of adenolymphangitis and cellulitis in the month preceding the consultation reported by the patient or observed by the care-giver. A one month time frame was used to minimize potential memory recall bias. This endpoint was selected in reference to previous studies in which a favourable evolution was observed in the three months following the beginning of treatment. Secondary endpoint: Frequency of consultations, the target being one consultation per month for each patient at the health facility. Inclusion criteria: Any patient suffering from LF-related lymphoedema of a lower limb, whatever the severity, and who had received care under the health education and washing project between April 1, 2005 and December 31, Care included hygiene, washing, teaching good practices, treatment of wounds, acute attacks and other ailments. Exclusion criteria: Any patient not monitored within 4.5 months of their admission into the project was excluded. Fig. 1 shows the total number of enrolled patients before and after applying inclusion/exclusion criteria. Most of the patients

3 P. Jullien et al. / Acta Tropica 120S (2011) S55 S61 S57 enrolled in the washing programme were not included in the present analysis (n = 2936): either they were enrolled in the project before the setting up of the Epi-info monitoring tool (n = 2645) and were probably already experiencing a reduction in the number of acute attacks, or they were not suffering from lymphoedema of the lower limb (n = 291) Data collection All patients were enrolled by the above-mentioned trained health professionals and their admission date was recorded. Data recorded in the monitoring system included patient contact details, age, gender, the anatomical location of the lymphoedema, occurrence of acute attacks and consultation date. Acute attacks were observed by the care-giver (health worker or nurse) during the consultation, or noted when taking down the patient s history (acute attack episode during the month preceding the consultation). A leaflet describing signs of acute attacks that had been given to each patient during their training was used to identify acute attacks when taking down each patient s history. The main symptoms of an acute attack are painful, warm, red and swollen skin, peeling of the skin, painful lymph node in the inguinal area, fever, headaches, chills and sometimes nausea and vomiting. Patients records were entered into the computer at the health district level using Epi Info 3.3 package (Centers for Disease Control and Prevention, Atlanta, GA). Data were later anonymously transferred and then compiled at the national level for analysis. Although patient training covered all aspects of lymphoedema management, the resource-limited national health setting in which the assessment was being conducted meant that the stage of lymphoedema, the frequency of the daily washing and the adherence to foot hygiene (wearing shoes, slippers, clean shoes, clean nails, soil between toes) were not systematically assessed. The goal was to keep everything as simple and easy as possible for the staff at the peripheral level of the health system Data quality control First-level data quality control was carried out using a data entry form with logical checks. A secondary level data quality check was carried out on a sample of 4514 patients. For this purpose, two quality control assessments were conducted (in March and October 2007) in each of the districts on a sample of 3% of patients, randomly selected from the data sets. This analysis indicated various error rates according to the variable. The majority of errors were related to identification (15%: first name, identification number) and age (13%) which did not affect ability to contact patients for follow-up. No error on the main variable (acute attacks in the preceding month) was recorded. The datasets were considered to be satisfactory in 85% of the cases (95%CI: 74 92) Data analysis Data were processed and analysed using the Stata version 10 software package for statistical analyses. Analysis was carried out based on a risk of 5%. Chi-square tests were used to compare dichotomous variables and a P-value < 0.05 was considered statistically significant Ethical issues The work reported here is based on the monitoring and evaluation of a nationwide public health programme namely the NPELF in Burkina Faso. Administrative clearance was obtained for this washing programme and for the implementation of its monitoring tool. In addition, the purpose of the data collection was explained and Table 1 Distribution of acute attacks in patients with lower limb lymphoedema following the washing implementation. Acute attacks Consultation months later Difference Yes % % % No % % Total % % 2 with matching (discordant pairs b = 489; c = 65): 2 Mantel Haenszel weighted 0 (not corrected) = ; p < informed oral consent was obtained from all enrolled patients. Data obtained from patients remained confidential. Care was provided to all patients with acute attacks, including advice, antibiotics, antifungal drugs, and pain killers as appropriate. 3. Results 3.1. Study population The eligible population selected for the analysis included 1089 patients (24% of the 4514 lymphoedema patients enrolled in the washing project). There were more women (74.5%; n = 811) than men (25.0%; n = 272); the gender of 6 patients was not recorded. The mean age of the study population was 46.6 years (range years), with no age difference between men and women (p > 0.6) Primary endpoint: incidence of acute attacks The 1089 patients were monitored for 4.5 months (Table 1). Before their admission, the acute attack incidence was 78.1% (95%CI: ). They attended 1 5 consultations after their admission and their clinical evaluation was recorded at each consultation. After admission, the acute attack incidence decreased from 78.1% to 39.1% (95%CI: ); this is a decrease of 38.9% (95%CI: ); however, 65 patients (6.0%, 95%CI: ) with no acute attack during the month prior to enrolment did suffer from attacks after beginning the programme Patients lost to follow up The large number of patients (n = 489) excluded from the above analysis was equal to a drop-out rate (31%). This prompted us to assess the extent to which excluding the lost-to-follow up population might have affected the results. We found that in this secondary analysis there was no statistical difference between group 2 (n = 489) and group 1 (n = 1089) with regard to gender (p > 0.3); however, there was a slight difference with regard to age (p = 0.03) with group 2 being younger (mean age = 44.9 years, 95%CI: ) than group 1 (mean age = 46.6 years, 95%CI: ). Before the admission of patients from combined groups (n = 1578), the acute attacks incidence was 80.0% (95%CI: ). Because of the lack of follow-up records for group 2 (n = 489), we chose the worse-case scenario which was that all group 2 patients were still suffering from acute attacks which means no improvement was observed. In this scenario (merged groups; n = 1578), a 22.05% (95%CI: ) decrease in acute attacks incidence was observed with incidence falling from 80.0% to 58.0% (95%CI: ) (Table 2) Secondary endpoint: frequency of consultations Results for the secondary endpoint are shown in Table 3. The 1089 patients had a total of 2 6 consultations (including the admis-

4 S58 P. Jullien et al. / Acta Tropica 120S (2011) S55 S61 Table 2 Distribution of acute attacks in patients with and without follow up visit. Acute attacks Before (consultation 1) After Difference Group 1 Group 2 Total Yes % % % No % % Total % % 2 with matching (discordant pairs b = 489; c = 141): 2 Mantel Haenszel weighted (not corrected) = ; p < Table 3 Average interval between consultations by number of consultations per patient. Number of consultations a Total Number of patients patients Percentage of patients 27.6% 22.0% 25.9% 22.7% 1.8% 100% Average interval (days) Confidence interval ±4.3 ±1.6 ±0.5 ±0.3 ±0.4 ±1.5 a Including admission consultation. sion consultation). For all patients, the average interval between two consultations was 47.4 days (95%CI: ). The target of 1 consultation per month per patient (the maximum accepted duration between two consultations was 31 days) was met in less than a quarter of patients (n = 258 patients); for 23.7% (95%CI: ) of the patients, the average interval between 2 consultations was equal to or less than 31 days (Fig. 2). This interval was longer for the remaining patients (76.3%) who attended between 2 and 5 consultations in 4.5 months Incidence of acute attacks according to the frequency of consultations The proportion of patients with and without acute attacks in the month prior to each consultation is shown in Table 4. The percentage of patients suffering from episodes of acute attacks decreased from 78.1% to 31.2% (Table 4) after 3 visits following admission. The number of acute attacks decreased when the frequency of consultations increased by up to 1 per month (Fig. 3). There was no significant benefit noted when comparing 5 or 6 consultations to 4 consultations (p = 0.59). Before starting the washing programme, patients who later attended 5 or 6 consultations did not suffer more or less frequent acute attacks than those who only attended four (p = 0.65) Other endpoints: gender and age For the 1089 patients (both inclusion and exclusion criteria), multivariate analysis by logistic regression showed no difference in acute attacks incidence according to gender (p > 0.6) or age (p > 0.7), before treatment and after treatment. 4. Discussion Entering data for all 4514 monitored lymphoedema patients created an extra workload for health centre staff, as their responsibilities already extends far beyond lymphoedema management, with several life-threatening pathologies logically taking precedence (malaria, meningitis, yellow fever, measles and other common diseases). This can explain, in part, the 15% error rate detected in the quality control assessments. Nonetheless, the motivation of the healthcare professionals involved and the large number of patients enrolled in the programme (4514) and correctly monitored (n = 1089) has generated results showing significant clinical improvement. Collecting more detailed data from each enrolled patient would have been very informative; this was a limitation created by the project being embedded within the national health system. It appears that documenting the reasons for the high drop-out rate of 12.4% for this study and the status of these 23.7% of patients 76.3% of patients Consultation n 1 (admission) 0 1 month 2 months 3 months 4 months 136 days 5 months Number of consultations per patient Fig. 2. Distribution of intervals between two consultations for patients with lymphoedema of the lower limb, according to the number of consultations per patients.

5 P. Jullien et al. / Acta Tropica 120S (2011) S55 S61 S59 Table 4 Distribution of acute attack episodes by number of consultations. Consultations With acute attack Without acute attack Total Admission % % % After % % % % % % % % % % % % % % % 2 without matching ( After values only): 2 0 Mantel Haenszel = 27.33; p < patients is essential for strengthening the washing programme, as studies found that washing was the measure practised by most lymphoedema patients after attending a lymphoedema management clinic (Bontha et al., 2007; Suma et al., 2002). The primary endpoint was the presence or absence of acute attacks in the month preceding the visit to the health centre, as reported by the patient or observed by a health professional. The baseline incidence of acute attacks (78.1% of patients) fell considerably to 39.1% after 4.5 months of washing (Table 1). Clinical improvement was still statistically significant when comparing discordant pairs (p < ). Despite the hypothesis of no improvement for the entire lost-to-follow up group (n = 489), acute attacks were less frequent than before the programme (22% gain). However, we cannot explain the high drop-out rate (31%), and we have not been able to investigate this specific issue. With regard to the frequency of consultations, it is possible that patients may not only have reported acute attacks from the preceding month, but also earlier attacks. Therefore, patients who were visiting clinics less than once per month (they had a total of 2 or 3 visits over the 4.5-month period) may have reported more episodes. In Sri Lanka, however, Chandrasena et al. have shown that patients are able to recall acute attacks for a considerable length of time because they are so painful and/or incapacitating (Chandrasena et al., 2004). Our results also show no significant benefit for patients who visited the health centre more than once a month (5 or 6 visits) compared to those who visited it once a month (Fig. 3). When starting the washing programme (on admission), these patients did not report more frequent acute attacks than the others did. During the washing programme, they were not able to report more frequent episodes than if they had visited the clinics only 4 times. These results suggest there is no justification for recommending more than one consultation per month, as it was not possible to ascertain whether it is better to consult once a month or otherwise. Previous studies have shown similar clinical improvements in lymphoedema patients that followed pilot washing programmes in Sri Lanka, Madagascar and Zanzibar (WHO, 2004). The occurrence of acute attacks after 4 months was reduced further than in our study (38.9%) in Madagascar (85.4%), in Sri Lanka (89.2%) and in Zanzibar (60.1%). However, the limitation of these three reports was the smaller sample size of monitored subjects (24, 37 and 62, respectively, in Zanzibar, Sri Lanka and Madagascar). Another difference between our study and the three above-mentioned experiences was the different approaches used in implementing the washing programme: a community and family approach was adopted in Zanzibar and Madagascar and patients received monthly home visits; in Sri Lanka, patients were monitored by means of a monthly doctor s appointment at the clinic because of easy access to health facilities. Finally, insufficient washing or drying can also explain these differences. A plateau of acute attack occurrence was observed on all 3 of the WHO pilot project sites for months 3 5. This levelling-off of the reduction in acute attacks was observed in our study 4 5 months after starting the washing (Fig. 3). It is interesting to note that none of the 24 patients reported a single acute attack after 7 months in Zanzibar, confirming that good daily hygiene practice plays an important role in lymphoedema management. The effectiveness of lymphoedema management in decreasing acute attacks in LF patients was also reported in Haiti (Addiss et al., 1999), Guyana (McPherson, 2003; McPherson et al., 2006), India (Joseph et al., 2004; Kerketta et al., 2005; Shenoy et al., 1995; Shenoy et al., 1999) and Sri Lanka (Chandrasena et al., 2004). Studies in Haiti found continuing effectiveness of homebased hygiene and skin care on acute attack occurrence after 12 months (Addiss et al., 1999), and after 18 months (Dahl, 2001) following completion of clinic-based coaching. In India, Suma and colleagues reported a sustained reduction in attacks following two years of self-care at home (Suma et al., 2002). Furthermore, a study in India found that substantial numbers of patients were only practicing the washing of the affected limb regularly at home since they were being specifically taught at a lymphoedema clinic (Bontha et al., 2007). There are no data suggesting that the effectiveness of washing could be related to the species of filarial parasite; however, several studies reported a difference in the incidence of acute attacks Fig. 3. Incidence of acute attacks in 4.5 months, according to the number of consultations.

6 S60 P. Jullien et al. / Acta Tropica 120S (2011) S55 S61 related to parasite species. Our study was carried out in a bancroftian filariasis area, where the number of acute attacks could be higher than in areas with brugian filariasis; indeed, Shenoy recently reported a two-fold higher frequency of acute attacks in Wuchereria bancrofti areas (Shenoy, 2008). Addiss and Brady (2007) have previously reported an average of episodes of acute attacks per lymphoedema, with brugian filariasis patients experiencing episodes (Pani et al., 1989; Rao et al., 1982; Sabesan et al., 1992; Suma et al., 2002) in Kerala, India. In the same review, the authors reported a lower incidence of acute attacks from bancroftian filariasis patients ranging from 1.5 to 6 episodes (Addiss et al., 1999; McPherson et al., 2006; Pani et al., 1995; Sabesan et al., 1992). Another confounding factor in our results could be the potential impact of the on-going mass drug administration (MDA) on the occurrence of acute attacks. Although there is no published literature to our knowledge on the impact of the current MDA regimen (ivermectin + albendazole once a year) on the occurrence of acute attacks, there have been several reports of a reduction in lymphoedema following MDA as recommended by the Global Programme to Eliminate Lymphatic Filariasis (Bockarie et al., 2002; Yuvaraj et al., 2008). However, in Ghana, Dunyo and colleagues found no effect of MDA on lymphoedema (Dunyo et al., 2000). In addition to possible MDA impact, models and observations suggest that disease including acute attacks may be reduced in low microfilarial prevalence and transmission situations given the prevalence relationship between disease and microfilaraemia (Bockarie et al., 2002; Gyapong et al., 1996a; Michael et al., 2008; Shi et al., 2000). Our study was conducted in districts where MDA began in 2001 (Gaoua region) and 2002 (Tenkodogo region), and therefore any impact of MDA on acute attack incidence would affect the pre- and post-intervention incidences. Our study did not provide insight into the effect of the washing strategy on the occurrence of acute attacks according to the stage and severity of lymphoedema as shown elsewhere because these details were not systematically collected (Dreyer, 2000b; Gasarasi et al., 2000; Gyapong et al., 1996b; Pani and Srividya, 1995; Suma et al., 2002). Nevertheless, all studies agree that the washing method should be encouraged in all endemic communities to halt the progression of lymphoedema or acute attacks (Dreyer et al., 2009; Shenoy, 2008; WHO, 2004). This is supported by the absence of reports on the ineffectiveness of washing on acute attacks. Several observations reported that lymphoedema of the leg is more common in women than in men in bancroftian filariasis areas (Barry et al., 1971; Gyapong et al., 1994; Lammie et al., 1993), although this finding did not correlate with those of Pani and colleagues in India (Pani et al., 1991). Our study population consisted of more females than males, but our results could not show any difference in the benefits of washing with regard to gender. This seems to contradict studies showing that females tend to experience higher acute attack rates than males (Addiss and Brady, 2007), but exceptions to this finding were reported (Ramaiah et al., 1996). The majority of our patients were adults and there was no agerelated difference in clinical improvements due to washing. Our youngest subject with acute attacks (10 years of age) was older than the case (2 years of age) reported in a South Indian study (Ramaiah et al., 1996). Our findings were not in agreement with other studies suggesting that increasing age is a risk factor in the occurrence of acute attacks (Gasarasi et al., 2000; Ramaiah et al., 1996). To summarise, the aim of this study was to assess the effectiveness of the home-based washing programme in managing complications due to LF in the primary healthcare system of Burkina Faso. Healthcare professionals, who were neither specialised in, nor working exclusively on LF, enrolled a large number of patients (4514). Our highly significant results confirmed the effectiveness of this programme, with clinical improvements in half of the patients within 4.5 months. The number of consultations did not affect the outcome of washing practice, nor did gender or age factors. Our assessment confirmed an acceptable and user-friendly way of monitoring programmes for morbidity management at the district level that does not require any additional human resources. This is an important argument for encouraging districts to add a morbidity alleviation component to their local action plans, as questions had been raised about how best to monitor and evaluate long-term lymphoedema management. The occurrence of acute attacks in the previous month appears to be an easy-to-use indicator for lymphoedema management programmes in national programmes to eliminate LF at the local level. To improve the already encouraging results seen in the Burkina Faso washing programme, a community home-based approach, as recommended by WHO, could be introduced to improve access to care for more patients. An alternative or even additional long-term solution, although less affordable, would be to strengthen the existing health system, which has already had a positive impact on a large number of LF patients. This would provide a platform for integrating LF care with that of other chronic conditions (diabetes, leprosy, buruli ulcer, leishmaniasis, etc.). Indeed, the entire country is LF-endemic and more than 13,000 LF-related lymphoedema patients were recorded during the 2005 mass drug administration campaign (PNEFL, 2008). These patients require life-long care. It is clear that extending this programme to other regions of Burkina Faso and to other resourcelimited lymphatic filariasis endemic countries to improve access to care for lymphoedema patients would yield positive results. Conflict of interest The authors declare that they have no competing interests. Acknowledgments The authors wish to thank all health system workers and Handicap International staff involved in the morbidity alleviation project in Burkina Faso for their valuable assistance. References Addiss, D.G., Louis-Charles, J., Wendt, J.M., Epidemiology of acute attacks among patients in a treatment program for filariasis-associated lymphoedema of the leg, Leogane, Haiti. Am. J. Trop. Med. Hyg. 61 (Suppl. 3), 320 (Abstract 415). 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Chandrasena, T.G.A.N., Premaratna, R., Muthugala, M.A., Pathmeswaran, A., De Silva, N.R., Modified Dermatology Life Quality Index as a measure of quality of life in patients with filarial lymphoedema. Trans. R. Soc. Trop. Med. Hyg. 101, Dahl, B.A., Lymphoedema treatment in Leogane, Haiti: an effective, sustainable and replicable model program for lymphatic filariasis morbidity control. MPH thesis, Emory University, Atlanta, GA, 42 pp. Direction des Etudes et de la Planification, Annuaire statistique/sante 2006 Ministère de la Santé; Ouagadougou, Burkina Faso. SiteSante/statistiques/annuaire-2006.pdf. Dreyer, G., Addis, D., Bettinger, J., Dreyer, P., Noroes, J., Rio, F., 2000a. Lymphoedema Staff Manual. Treatment and Prevention of Problems Associated with Lymphatic Filariasis. World Health Organization. Dreyer, G., 2000b. New insights into the natural history and pathology of bancroftian filariasis: implications for clinical management and filariasis control programmes. Trans. R. Soc. 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