Podoconiosis in East and West Gojam Zones, Northern Ethiopia Article (Published Version) Molla, Yordanos B, Tomczyk, Sara, Amberbir, Tsige, Tamiru, Abreham and Davey, Gail (2012) Podoconiosis in East and West Gojam Zones, Northern Ethiopia. PLoS Neglected Tropical Diseases, 6 (7). e1744. ISSN 1935-2727 This version is available from Sussex Research Online: http://sro.sussex.ac.uk/id/eprint/41005/ This document is made available in accordance with publisher policies and may differ from the published version or from the version of record. If you wish to cite this item you are advised to consult the publisher’s version. Please see the URL above for details on accessing the published version. Copyright and reuse: Sussex Research Online is a digital repository of the research output of the University. Copyright and all moral rights to the version of the paper presented here belong to the individual author(s) and/or other copyright owners. 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Molla1*, Sara Tomczyk2, Tsige Amberbir2, Abreham Tamiru3, Gail Davey1 1 Brighton and Sussex Medical School, Falmer, Brighton, United Kingdom, 2 International Orthodox Christian Charities, Addis Ababa, Ethiopia, 3 International Orthodox Christian Charities, Debre Markos, Ethiopia Abstract 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. Citation: Molla YB, Tomczyk S, Amberbir T, Tamiru A, Davey G (2012) Podoconiosis in East and West Gojam Zones, Northern Ethiopia. PLoS Negl Trop Dis 6(7): e1744. doi:10.1371/journal.pntd.0001744 Editor: John Owusu Gyapong, Ghana Health Service, Ghana Received February 29, 2012; Accepted June 11, 2012; Published July 17, 2012 Copyright: ß 2012 Molla et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This study was supported by the Ethiopian Country Office of the International Orthodox Christian Charities (IOCC) through funding from TOMS. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: [email protected] Introduction identified clinically in endemic areas (above 1200 m) without the need to do laboratory tests because it usually presents with Podoconiosis is a non- infectious elephantiasis distinct from bilateral and asymmetric swelling on the lower limbs with rare lymphatic filariasis that affects barefoot individuals exposed to red groin involvement unlike the lymphatic form of elephantiasis [4]. clay soil of volcanic origin. In particular, podoconiosis is prevalent Similarly, the nervous system is intact in podoconiosis and there is among barefoot subsistence farmers that live and work in these neither loss of sensation nor thickened nerves or trophic ulcers areas [1]. Even though the pathogenesis of the diseases has not yet unlike leprosy [5,6]. Podoconiosis can be prevented, early forms of been investigated in depth, it is believed to be caused by fine the disease can be treated, disease progression can be curbed and particles in the soil that penetrate the skin and induce an the disease can potentially be eliminated as a public health burden inflammatory reaction in the lymphatic system [2]. The disease with low technology but effective measures such as washing feet results in bilateral progressive swelling of the lower legs, usually with soap and water on a regular basis and wearing protective limited below the level of the knees. Based on the disease shoes consistently [7,8,9]. progression, podoconiosis is classified into five stages where the High prevalence of podoconiosis has been reported in many first and second stages have swelling limited below ankle which is parts of highland Africa: Ethiopia [10], Cameroon [11], Rwanda either reversible over night (stage one) or not (stage two). The third [12], Burundi, Sudan [13], Uganda [14], Tanzania [15], Kenya stage of the disease has water bag like or nodular swelling above [16], the islands of Bioko, Sao Tome and Principe [17], and the level of the ankle. The fourth stage entails above knee swelling Equatorial Guinea [18]. Up to one million cases are estimated to whereas the fifth stage involves joint fixation as a result of exist in Ethiopia, of whom one-third belong in the economically surrounding soft tissue overgrowth [3]. Podoconiosis can be productive age group [10]. Recent studies in southern and western www.plosntds.org 1 July 2012 | Volume 6 | Issue 7 | e1744 Podoconiosis in Northern Ethiopia Author Summary giving consent for research in Ethiopia) were encountered, consent was obtained from their parents or guardians. The use of verbal Podoconiosis is non-infectious elephantiasis that affects consent was approved by the ethical review committee because the barefoot people that have prolonged exposure to red clay majority of the study participants cannot read and write. soil. It is common in tropical Africa, central America and northern India. Podoconiosis presents as bilateral below Study design and study area knee swelling. Podoconiosis can be both prevented and This study was a cross-sectional community-based house-to- controlled by consistently washing feet, wearing shoes, house survey. The study was conducted in East and West Gojam and using antiseptics and emollients. This survey is the biggest conducted to date in Ethiopia: 17,553 households Zones of Amhara Regional State. All villages (Ketena) in known in East and West Gojam Zones of northern Ethiopia were podoconiosis-endemic kebeles (the lowest level government admin- included, and 1,704 patients were identified. We inter- istrative structure in Ethiopia) were included in the house to house viewed patients in detail about manifestations of acute case enumeration. Identification of the study area was based on a attacks (painful inflammation of the foot and leg with report by IOCC’s podoconiosis treatment center, written in 2010 swollen lymph nodes and fever), clinical disease stage, summarizing information from key local informants. The study treatment seeking, foot washing and shoe wearing participants were residents of the selected kebeles and podoconiosis practices. We found the prevalence of podoconiosis to cases in all households with podoconiosis. be 3.3%. Most patients were farmers, uneducated and within the economically active age group. There was no Sampling procedure and sample size determination gender difference in occurrence of podoconiosis and in The Ethiopian administrative structure is organized hierarchi- foot washing practices. The onset of leg swelling and the cally, with multiple Zones in each Region. Each Zone contains age of first shoe wearing were similar. We also found delayed treatment seeking and many days confined to bed multiple Woredas (equivalent to districts). Each Woreda contains during acute inflammatory episodes. We conclude that Kebeles and there are villages with multiple