Patterns of epidemiology and control of onchocerciasis in West Africa

This paper summarizes the work of the Onchocerciasis Control Programme (OCP) in West Africa, a programme which over a 22 year history has reduced the public health problems of blinding onchocerciasis in eleven countries of West Africa through vector control and, more recently, ivermectin distribution. The paper emphasizes the different approaches to control the programme has developed in the different parts of the programme area which have been determined by the epidemiology of the disease (savanna/forest form), the migratory characteristics of the vectors, intensity of the disease before commencement of treatment, the combined impact of vector control and ivermectin and the likelihood of infiltration of infective blackflies from outside the programme area. The programme has constantly monitored the impact of operations on the trends in prevalence, incidence, annual transmission potential, ocular morbidity and species of fly populations, and as a result, has identified areas where special interventions are required until the programme comes to an end in 2002. The paper illustrates the changes in intensity of infection as measured by community microfilarial load and annual transmission potential over the duration of the programme control activities. The paper also defines and justifies the control strategies in different areas and identifies areas for special intervention

Ivermectin, ‘Wonder drug’ from Japan: the human use perspective

Discovered in the late-1970s, the pioneering drug ivermectin, a dihydro derivative of avermectin—originating solely from a single microorganism isolated at the Kitasato Intitute, Tokyo, Japan from Japanese soil—has had an immeasurably beneficial impact in improving the lives and welfare of billions of people throughout the world. Originally introduced as a veterinary drug, it kills a wide range of internal and external parasites in commercial livestock and companion animals. It was quickly discovered to be ideal in combating two of the world’s most devastating and disfiguring diseases which have plagued the world’s poor throughout the tropics for centuries. It is now being used free-of-charge as the sole tool in campaigns to eliminate both diseases globally. It has also been used to successfully overcome several other human diseases and new uses for it are continually being found. This paper looks in depth at the events surrounding ivermectin’s passage from being a huge success in Animal Health into its widespread use in humans, a development which has led many to describe it as a “wonder” drug

Études entomologiques de post-traitement dans le programme de lutte contre l'onchocercose en Afrique de l'Ouest

En 1989, le programme de lutte contre l'onchocercose en Afrique de l'Ouest a procédé dans sa zone initiale aux premiers arrêts de traitements larvicides dans les bassins où les résultats entomologiques et épidémiologiques étaient jugés satisfaisants. C'est dans ce contexte qu'ont été instituées des études entomologiques de post-traitement qui avaient pour but de s'assurer qu'il n'y avait pas de reprise de la transmission de la maladie malgré l'arrêt des traitements et, par conséquent, le retour des simulies à leur niveau initial. Les 18 points étudiés ont donné dans l'ensemble des résultats satisfaisants : les taux d'infectivité, qui variaient avant le début des traitements entre 60 et 90 larves infectantes pour 1 000 femelles pares, sont descendus à moins de I larve infectante pour 1 000 pares, seuil au-dessous duquel le risque de recrudescence de l'infection onchocerquienne est jugé très improbable. Un seul point fait exception où le taux d'infectivité des simulies, relativement élevé (8,9 larves infectantes pour 1 000 pares), a entraîné une reprise des traitements larvicides. Les valeurs obtenues en deux autres points, bien qu'acceptables (1,08 et 1,16), ont permis de déceler la présence de migrants humains infectés qui, pour éviter toute reprise de la transmission de l'onchocercose, ont été traités avec un microfilaricide, l'ivermectine. Dans l'ensemble, les excellents résultats mis en évidence par ces études entomologiques de post-traitement ont conduit à la cessation définitive des épandages larvicides dans plus de 90 % des bassins de l'aire initiale du Programme

Can ivermectin mass treatments eliminate onchocerciasis in Africa?

OBJECTIVE: To elucidate the conditions in which mass treatment with ivermectin reduces the transmission of Onchocerca volvulus sufficiently to eliminate infection from an African community. METHODS: ONCHOSIM, a microsimulation model for onchocerciasis transmission, was used to explore the implications of different treatment intervals, coverage levels and precontrol endemicities for the likelihood of elimination. FINDINGS: Simulations suggested that control strategies based exclusively on ivermectin mass treatments could eliminate onchocerciasis. The duration of treatment required to eliminate infection depended heavily on the treatment programme and precontrol endemicity. In areas with medium to high levels of infection, annual mass treatments with 65% coverage for at least 25 years were necessary. Model predictions suggested that durations exceeding 35 years would be required if there were much heterogeneity in exposure to vector bites and, consequently, wide individual variation in microfilaria counts. If the treatment interval were reduced from 12 to 6 months the time for completion of the programme could be more than halved and elimination could be accomplished in areas of hyperendemicity, provided that the effects of each treatment would be the same as with annual treatments. However, it was doubtful whether high coverage levels could be sustained long enough to achieve worldwide eradication. CONCLUSION: Elimination of onchocerciasis from most endemic foci in Africa appears to be possible. However, the requirements in terms of duration, coverage, and frequency of treatment may be prohibitive in highly endemic areas

Mectizan and onchocerciasis : a decade of accomplishment and prospects for the future : the evolution of a drug into a development concept

For many years there was no suitable drug available for the control of onchocerciasis. The advent of Mectizan (ivermectin, MSD ; an effective microfilaricide), its registration in October 1987 for the treatment of human onchocerciasis, and its suitability for large-scale application were major break-throughs in the control of human onchocerciasis via chemotherapy. Several studies, both fly-feeding experiments and community trials, have established that Mectizan treatment causes a significant reduction in the transmission of infection. Although long-term treatment in some isolated foci (such as occur in the New World and in some hypo- and meso-endemic areas elsewhere) appears to interrupt transmission, more prolonged treatement is required to prove if transmission can be stopped. Advantage could be taken of the significant impact of Mectizan on transmission by giving treatement while or just before transmission by blackflies is most intense. (Résumé d'auteur

Can ivermectin mass treatments eliminate onchocerciasis in Africa?

OBJECTIVE: To elucidate the conditions in which mass treatment with ivermectin reduces the transmission of Onchocerca volvulus sufficiently to eliminate infection from an African community. METHODS: ONCHOSIM, a microsimulation model for onchocerciasis transmission, was used to explore the implications of different treatment intervals, coverage levels and precontrol endemicities for the likelihood of elimination. FINDINGS: Simulations suggested that control strategies based exclusively on ivermectin mass treatments could eliminate onchocerciasis. The duration of treatment required to eliminate infection depended heavily on the treatment programme and precontrol endemicity. In areas with medium to high levels of infection, annual mass treatments with 65% coverage for at least 25 years were necessary. Model predictions suggested that durations exceeding 35 years would be required if there were much heterogeneity in exposure to vector bites and, consequently, wide individual variation in microfilaria counts. If the treatment interval were reduced from 12 to 6 months the time for completion of the programme could be more than halved and elimination could be accomplished in areas of hyperendemicity, provided that the effects of each treatment would be the same as with annual treatments. However, it was doubtful whether high coverage levels could be sustained long enough to achieve worldwide eradication. CONCLUSION: Elimination of onchocerciasis from most endemic foci in Africa appears to be possible. However, the requirements in terms of duration, coverage, and frequency of treatment may be prohibitive in highly endemic areas

Impact of combined large-scale ivermectin distribution and vector control on transmission of Onchocerca volvulus in the Niger basin, Guinea

As part of the WHO Onchocerciasis Control Programme in West Africa (OCP), the attack phase of operations in the Niger basin in Guinea began in 1989 with the simultaneous use of ivermectin and vector control. Larvicide applications coupled with annual large-scale ivermectin distribution have greatly reduced blackfly infectivity (by 78.8% for the number of infective larvae per 1000 parous flies). The combination of vector control and ivermectin has permitted excellent control of transmission. In the original OCP area, it took 6-8 years of vector control atone to obtain an equivalent decrease in blackfly infectivity. For the same number of flies caught, transmission was much higher in areas where ivermectin had not been distributed. The combined use of ivermectin and vector control has opened up new prospects for carrying out OCP operations with, notably, the possibility of reducing larviciding operations.Dans le cadre du Programme OMS de lutte contre l’onchocercose en Afrique de l’Ouest, la phase d’attaque des opérations dans le bassin du Niger en Guinée a démarré en 1989 avec l’utilisation simultanée de l’ivermectine et de la lutte antivectorielle. Parmi les seize points retenus pour cette étude, tous situés dans des foyers holoendémiques de savane, la moitié sont répartis dans le bassin du Haut Niger en Guinée et les autres dans l’aire initiale du Programme.Après trois à quatre années d’opérations avec une distribution annuelle d’ivermectine à grande échelle, on note en Guinée une forte réduction de l’infestation des simulies (78,8 % pour la proportion de mouches infestantes et 82,9 % pour le nombre de larves infestantes pour 1 000 femelles pares). La prévalence des microfilaires a peu diminué; en revanche, les charges microfilariennes des communautés qui mesurent l’intensité de l’infestation ont chuté de 60 à 80 % par rapport aux données de prétraitement. La combinaison de la lutte antivectorielle et de la distribution de masse de l’ivermectine a permis un excellent contrôle de la transmission. Par contre, dans l’aire initiale du programme, il a fallu 6 à 8 ans de lutte antivectorielle seule pour obtenir une réduction équivalente de l’infestation des simulies. A nombre égal de mouches capturées, la transmission est beaucoup plus forte dans les zones où l’ivermectine n’est pas distribuée, même après plusieurs armées de lutte antivectorielle efficace et ininterrompue.L’utilisation combinée de l’ivermectine et de la lutte antivectorielle ouvre des perspectives nouvelles dans la conduite des opérations avec notamment une possibilité d’allégement de la lutte antivectorielle