Chronic Wounds and Lymphoedema: Neglected areas of public health
The management of diseases and conditions such as diabetes mellitus, venous ulceration, pressure ulcers, traumatic wounds and AIDS related wounds, have benefited from improved medical knowledge and technology leading to better care and reduction in both the morbidity and economic burden. Additionally, it is anticipated that utilizing modern wound care methods for wounds related to leprosy, Buruli ulcer, trauma and common tropical ulcers, will also lead to significant benefits.
Epidemiology
The precise global burden of chronic wounds and lymphoedema is not known. International statistics giving the full picture of the prevalence, disability, and impairment of wounds, burns and lymphoedema are difficult to acquire. The aetiologies of these conditions are numerous with regional, national and local specificities.
However, the epidemiology and economic burden of the chronic wound is well documented in the developed world. Each year, in North America, between five and seven million chronic and/or complex wounds occur. A recent study in the UK showed a prevalence of patients with a wound was 3.55 per 1000 population. The majority of wounds were surgical/trauma (48%), leg/foot (28%) and pressure ulcers (21%). Prevalence of wounds among hospital inpatients was 30.7%. Wounds in Australia are highly significant health issue: some estimates suggest that over 200,000 Australians have problem wounds at any one time.
With the growing epidemic of non-communicable diseases and longer life expectancy, the prevalence and impact of chronic wounds and lymphoedema are likely to increase. Furthermore, studies show worrisome data about the extent of chronic wounds and lymphoedema in resource poor nations. In India, a recent study estimated a prevalence rate of chronic wounds at 4.5 per 1000 population. The incidence of acute wounds was more than double at 10.5 per 1000 population.
The etiology of these wounds included systemic conditions such as diabetes, atherosclerosis, tuberculosis, leprosy, venous ulcers, pressure ulcers, vasculitis and trauma. In India, filariasis may account for 23 million cases of lymphoedema. According to data from epidemiological studies, the incidence of chronic ulcers in surgical hospitalized patients in China is 1.5% to 20.3%.
Diabetes is the third leading cause of general mortality in Mexico. Between 8% and 12% of the general population in Mexico, 4 to 6 million people, currently have diabetes. Buruli ulcer has been reported from 30 countries in Africa, the Americas, Asia and the Western Pacific, mainly in tropical and subtropical regions. In Ghana more than 14,000 cases have been recorded since 1993--986 cases in 2008.
Economic impact & Social impact
In the UK, the attributable cost of wound care in 2006-2007 was 9.89 million Pounds: 2.03 million Pounds per 100,000 population and 1.44% of the local health-care budget. Costs included 1.69 million Pounds spent on dressings, 45.4 full-time nurses (valued at 3.076 million Pounds) and 60-61 acute hospital beds (valued at 5.13 million Pounds). The cost of wound care is significant. The most important components are the costs of wound-related hospitalization and the opportunity cost of nurse time. The 32% of patients treated in hospital accounted for 63% of total costs.
While the costs related to hospitalization, nursing time and dressings and drugs are considerable. The economic and social impact resulting from mis-management of chronic wounds and lymphoedema disabilities on families, communities, and nations, is huge. In addition to the preventable human suffering and disabilities, this burden encompasses the cost of caring for disabled men, women and children; lost earnings by the patients and sometimes family caregivers; and an ongoing cycle of poverty and deprivation for poor families and societies.
Chronic leg wounds in the USA account for the estimated loss of two million workdays per year. The impact of loss of self-esteem, continued pain, and possible depression is difficult to quantify but is certainly real.
Chronic and complex wounds can lead to complications such as infection, pain, and limb amputation. The psychological problems that such patients and their families acquire are better managed today because of a greater understanding of their needs, as a result of Quality of Life Studies. Patients affected by these types of wounds often require assistance in performing common daily tasks. Neglect can lead to malnutrition, further morbidity, and, as with the diabetic foot, higher mortality rates.
In addition to any loss of earnings, people may have to choose between a commitment to work and a commitment to medical management of their wound. This choice has increased significance in resource-poor nations. In many cases, a disabling wound results in the loss of two or more people from the work force—the patient and the family member caring for the patient. A wound can control a life. People may have to cope with specialized devices or beds, lack of mobility, dressing changes, drainage, odour, clothing limitations, and sleep deprivation. Healing may take months or years, and unsuccessful wound treatment can lead to limb loss or even death. Sixty percent of non-traumatic lower limb amputations are associated with diabetes.
Limited access to modern technology for managing chronic wounds and lymphoedema in developing countries
Advances in modern wound and lymphoedema management have occurred mainly in the developed world. In the developing countries however, outdated techniques, practices and materials are used managing these conditions thus leading to prolonged morbidity, suffering and high costs. For example observations throughout the world have shown common mis-management deficiencies.
Standard wound care most often is reduced to tissue toxic cleansing solutions, misuse of topical antibiotics, wet to dry gauze dressings and the absence of compression bandaging. Management of lymphoedema, filiriasis in particular, often demonstrates a lack of basic hygiene and absence of compression bandaging. This scenario too often results in severe disability, isolation, and in far too many cases, amputation. In these countries, recycling of dressings and bandages are common and frequent changes of dressings are not done as often as needed because of limited availability of materials or costs.
Acting together to end neglect and unacceptable suffering
The mission of WAWLC is to provide guidance for safe and effective wound and lymphoedema care through public health recommendations, education and training at all levels, and country support for implementation of such activities. These levels are to include tertiary, secondary, primary and community involvement for lymphoedema and both the acute and the chronic wound. The education philosophy of WAWLC strives to "teach the teachers" optimizing local clinicians and integration into the existing healthcare structure.
It is intended that such care be provided in a cost effective manner utilizing, where possible, locally available products and currently available essential drugs and dressing supplies. The teaching and training programs will include the use of therapies common to multiple disciplines. It is believed that significant benefit will be achieved by decreasing now prevalent, ineffective, costly remedies. Experience has shown that misdiagnoses and lack of understanding of the principles of modern wound and lymphoedema care can be devastating to the overall health and economic welfare of all communities.
The globalization of modern wound and lymphoedema management is about to take a giant step. The chronic suffering, disability, isolation and limb loss resulting from inadequate or improper care for millions of men, women and children will be alleviated by effective care not by unaffordable medications, and dressings, not by difficult to learn techniques, and not by transient experts. This gift to millions will come from continuing knowledge of the basic principles of wound and lymphoedema management, techniques for application of these principles and the teamwork of both national and international clinicians. WAWLC will be the catalyst for this paradigm shift in essential medical care.
Over the past two decades, the world has seen tremendous medical advances in modern wound care and lymphoedema management, principally, due to new scientific knowledge, techniques and materials. These advances have occurred mainly in the developed countries. The diagnosis and treatment of chronic wounds and lymphoedema, both primary and secondary in etiology, involves all medical specialties and all ages.
