Elimination of Onchocerciasis in Africa

Presentation by Manasvini Vimal Kumar

MADS 6642Global Health and Human Services Systems

Prof. Carlos Leon

Source: http://media-cache-ak0.pinimg.com/736x/f1/c6/1d/f1c61dd9f408646fd63c015bae93410c.jpg

IntroductionWorld’s II largest cause of Blindness (WHO,2014) Prevalence- 30/36 countries are African (83.34%) (WHO,2014) More than 99% of affected people are in Africa (WHO,2014) Population at risk = 120 m worldwide, 96% of these-in Africa (WHO,2014)

Figure showing prevalence of Onchocerciasis in AfricaSource: http://www.who.int/apoc/magazine_final_du_01_juillet_2011.pdf?ua=1 Page-21

Spread of disease

Transmission of Onchocerca volvulus (Source:WHO,2014)

Manifestation of Disease Papular rash Itching OnchodermatitisSkin lichenified called ‘Hanging Groin’Source: http://www.science.smith.edu/departments/Biology/SWILLIAM/fgn/gifs/oncohanginggroin.gif

Patchy depigmentation called ‘Leopard skin’ Source:http://media1.picsearch.com/is?b_9R78HMGgeyOMpvtQKI_o3-6tMy_2tDKyZjKDjpGJY&height=216

Chronic Onchocerciasis in eyes-Iridocyclitis, sclerosing keratitis River Blindness Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC100248/

Onchocerciasis Skin Disease Source: http://ts3.mm.bing.net/th?id=HN.608027757023529586&w=123&h=149&c=7&rs=1&pid=1.7

Burden of DiseaseDALYs Lost, by Disease and World Bank Region (thousands)

Source: Mathers forthcoming; WHO 2004b; authors' calculations

Disease(Date of info.)

East Asia & Pacific

Europe& Central Asia

Latin America & Carribean

M. East & North Africa

South Asia

Sub-Saharan Africa

High Income Countries

Total

Onchocerciasis (2003)

0 0 2 0.4 0 481 0 484

Onchocerciasis (Latest APOC data)

0 0 2 0.4 0 1487 0 1490

Social Determinants of Health Poverty-50% of the African & Asian population is inaccessible

to medicines (WHO, 2004). Lack of education- Unawareness about the vector and

transmission methods has led to increase in incidence and prevalence

Inequity of Wealth- 10/90 Gap: Research & development ineffective due to non cooperative government (WHO, 2004)

Poor water and sanitation facilities- temperature, river side-ideal for larval growth

River water used due to lack of clean water supply Clustered housing- 1 visit of Simulium fly can infect many

people Nomadic life- Leads to spread of disease faster Disaster and conflict among states- Prevention and elimination

programs are suspended (APOC, 2012)

Interventions

Onchocerciasis Control Program

• Time period- 1974-2002• Area covered =1,200,000 sq.km in

West Africa alone• Countries- 11-Benin, Burkina Faso,

Côte d'Ivoire, Ghana, Guinea Bissau, Guinea, Mali, Niger, Senegal, Sierra Leone and Togo

• Goal: Improve living conditions with upliftment of socio economic conditions

African Program for Onchocerciasis Control

• 1995- till date• Area covered= 19 countries in East

and Central Africa• Countries- Angola, Burundi,

Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Equatorial Guinea, Ethiopia, Gabon, Kenya, Liberia, Malawi, Mozambique, Nigeria, Rwanda, Sudan, Uganda, United Republic of Tanzania

• Goal: Eradication of the disease from Africa

• REMO-Rapid Epidemiological mapping done- 3 categories made

Definite CDTi No CDTi Possible CDTi

REMO used to identify CDTi areasThe figure shows Rapid Epidemiological Mapping of Onchocerciasis (REMO) in countries covered by

APOC, 2008, using 3 color scheme marking severitySource- Padmanabhan. A.(2010). Onchocerciasis control I Africa: Elimination is possible

Interventions Contd..OCP

• Procedure: Only prevention known, so, aerial larvicides sprayed over areas near rivers

• 1987-Ivermectin given to kill microfilariae, unknown to kill adult worms

• Accomplishments Transmission stopped everywhere except

Sierra Leone due to Civil War (Stanford, 2004)

Completely eradicated from Kenya (Stanford, 2004)

Saved 30 m people in 11 countries (Stanford, 2004)

Prevented blindness in 600,000 people (Stanford, 2004)

25 m hectares of land was made cultivable (Stanford, 2004)

Merck promised free Ivermectin as much and for as long required (Stanford, 2004)

APOC• Procedure: Adopted CDTi approach-

Community Directed Treatment by Ivermectin- when discovered that ivermectin is effective against adult worms too

• From 1989-1994 –free distribution by Non -Governmental Organizations=Ivermectin Distribution Program

• Ground and aerial larvicides were sprayed

• Accomplishments After 5 years of treatment with

Ivermectin- 29,000 people & 500,000 black flies tested-no reoccurance (APOC,2012)

Success dtudied in Cameroon, Nigeria and Uganda to apply similar approach to other tropical diseases

ACCOMPLISHMENTS OF APOCThe graph shows estimated prevalence of Onchocerciasis infection and clinical manifestations in the

APOC population in 2005 and 2015, compared to the pre-APOC level

Source-African Program for Onchocerciasis Control. (2011). 15 Years of APOC 1995-2010

Impact of Interventions (APOC, 2012). APOC

Elimination- Kaduna, Zamfara and Ebonyi states of Nigeria Almost Eliminated- Taraba and Cross River 25 m hectares of arable regained 4 m children free from the risk of infection CDTi structure being used for Vitamin A deficiency and Lymphatic Filariasis T/t

OCP

7 West African countries 11 600, 000 people saved from blindnessSuccess of OPC formation of MDSC-Multi Disease Surveillance Centre NGDO group provided :- T/T during 1989-2009 460 million in APOC countries 116 million in ex-OCP countries Sudan –geographical coverage increased 10% 90% Sierra Leone -geographical coverage increased 64.3% 100%

Burden of Disease in 19 APOC countries (WHO,2014)

WEST AFRICAYear 1975 2014Affected 1,000,000 NoneBlinded 35,000 300,000 preventedSerious Eye Problems

100,000 -

Year/Disease 1995 2005 2015

Blindness 400,000 Decreased by 21% Further reduction by 45%

Low Vision 900,000 Decreased by 15% Further reduction by 55%

Troublesome Itch 15.3% affected Decreased by 55% Nil

DALYs Lost due to Onchocerciasis (Coffeng, L.E, Stalk W.A, Zoure, H.G, Veerman, J.L.,2013)

Attribute 1995-2010 2011-2015

DALYs Averted 8.5 million Additional 9.2 million

Cost at which Averted USD 257 million USD 221 million

International Federation of Pharmaceutical Manufacturers and Associations (Inception-1981;Active in field since 2012)

162 projects on NTDs140 projects under Product Development PartnershipPledged-1.4 billion treatments b/w 2011-2020 to eradicate 9 NTDsMerck-Mectizan Donation Program- pledged 'as many Ivermectin (Mectizan) as required for as long as required' Combination T/t proposed- Ivermectin+Albendazole for 2 goals

European and Developing Countries Clinical Trials Partnerships (Estb. 2003)

Funded U.S $ 3.05 billion for R&D on NTDsAll R&D focused on Sub-Saharan Africa

Graph showing APOC's success in minimizing cases of blindness in terms of DALYS Averted as against prevalence of different symptoms of Onchocerciasis in Africa, over last

20 years

Source: Coffeng, L.C., Stalk, W.A., Zouri, H.G.M. et al. (2013)

Effect on Social Determinants of Health APOC over 19 countries made sure Nomadic life is not a maintaining factor Special extension of program for Sierra Leone and Central African Republic contained spread Free Ivermectin by Merck, equal medical attention to poor &illiterate Aerial & ground sprays of insecticide solved transmission by overcrowding Ivermectin treatment in repeated doses also solved transmission by overcrowding Re-inspection of 29,000 people and 500,000 flies solved transmission CDTi training- overcame illiteracy barriers

Conclusion Onchocerciasis can be eliminated from Africa (WHO, 2014) Pruritic part will be (estimated) eliminated completely by 2015 (WHO, 2014) Estimated to be eradicated from Africa by 2020 (WHO, 2014) Without help from Merck for Mectizan (Ivermectin), success was difficult Most Importantly, without CDTi Approach, results would be slower

Source: http://www.globalpost.com/sites/default/files/imagecache/gp3_fullpage/river-blindness-6.jpg

ReferencesAfrican Program for Onchocerciasis Control. (2010). Conceptual and operational framework of Onchocerciasis elimination with Ivermectin treatment. Retrieved from: http://www.who.int/mediacentre/factsheets/fs095/en/African Program for Onchocerciasis Control. (2011). 15 Years of APOC 1995-2010. Retrieved from: http://www.who.int/apoc/magazine_final_du_01_juillet_2011.pdf?ua=1African Union. (2013). Neglected tropical diseases in the Africa region. Retrieved from http://www.carmma.org/sites/default/files/PDF- uploads/Background%20Report%20on%20Neglected%20Tropical%20Diseases- English.pdfBoutayeb, Boutayeb.(2009).Social determinants, health equity and human development. Bentham Science

Publishers Ltd. Retrieved from: http://books.google.ca/books?id=kzRLW7dk_k8C&pg=PA8&lpg=PA8&dq=SOCIAL+DETERMINANTS+OF+ONCHOCERCIASIS&source=bl&ots=XzAUhdK0cT&sig=tw1O_MEqQatg- hP_dOLuyKio3DA&hl=en&sa=X&ei=WjH5Uv7WJtSJqQHDjIDICw&ved=0CEYQ6AEwAw#v=onepage&q&f=true

Coffeng, L.C., Stalk, W.A., Zouri, H.G.M. et al. (2013). African program for onchocerciasis control 1995-2015: Model estimated health impact and cost. PLOS Neglected tropical diseases. 7(1).2032. doi 10.1371/journal.pntd.0002032. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/?term=23383355[PMID]&report=imagesdocsum  EDCTP. (2012). Neglected Infectious Diseases stakeholder meeting. Retrieved from: http://www.edctp.org/Neglected_Infectious_Diseases_St.868.0.html

References contd..• Hall, L.R. & Pearlman, E. (1999).Pathogenesis of onchocercal keratitis (River Blindness).PMC.

Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC100248/• IFPMA.(2012). Ending neglected tropical disease. Retrieved from:

http://www.ifpma.org/fileadmin/content/Publication/2012/IFPMA-NTD- NewLogoJUNE2.pdf• The International Bank for Reconstruction and Development. (2006). Disease control priorities

– in developing countries. Jamison, D.T., Breman, J.G., & Measham, A.R. (2nd Ed). Washington. The World Bank. Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK11745/

• Jamison, D.T., Feachem, R.G., Makgoba, M.W.(2006). Disease and mortality in Sub-Saharan Africa (2nd Ed.). Washington, D.C. World Bank. Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK2279/

• Manafa, O.U., Awolola, T.S.& Isamah A.N. (2003).Onchocerciasis in Ossi, Ondi state, Nigeria: Effectiveness of motivational strategies in sustaining compliance with community Ivermectin treatment. Popline.21(2).177-189.Retrieved from: http://www.popline.org/node/259317

• Padmanabhan. A.(2010). Onchocerciasis control I Africa: Elimination is possible. Global Network neglected tropical diseases. Retrieved from: http://endtheneglect.org/2010/11/onchocerciasis- control-in-africa-elimination-is-possible/

• Pan American Health Organization.(2013, July 29). Columbia is first country in the world to eliminate river blindness. PAHO/WHO verifies elimination of the disease, congratulates Columbia for its achievement. Retrieved from: http://www.paho.org/hq/index.php?option=com_content&view=article&id=8912&Itemid =1926

• Policycures.(2012). Global funding of innovation for neglected diseases: G-Finder. Retrieved from: http://policycures.org/downloads/GF2012%20Summary.pdf

References contd..WHO.(2014). Onchocerciasis-river blindness. Retrieved from: http://www.who.int/mediacentre/factsheets/fs095/en/ WHO.(2014). Onchocerciasis-Status of Onchocerciasis in APOC countries.. Retrieved from: http://www.who.int/apoc/onchocerciasis/status/en/WHO. (2009). Experts strategize on elimination of river blindness transmission in

Africa. Retrieved from: http://www.who.int/apoc/media/pr_oncho_elimination_africa.pdfWorld Bank. (2013). The African Program for Onchocerciasis Control. Retrieved

from: http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/AFRICAEXT/E XTPARTNERSHIPS/0,,contentMDK:21748460~pagePK:64168445~piPK:64168309~theSitePK:4099373,0 0.html(2004). Onchocerciasis (River blindness).Retrieved from : http://www.stanford.edu/group/parasites/ParaSites2004/Onchocerciasis/

http://www.bing.com/images/search?q=pictures+of+onchocerciasis&qpvt= pictur es+of+onchocerciasis&FORM=IQFRML#view=detail&id=2E1E2B1879C01E5ED1F3B29CC7B 956A24 DA7D4E0&selectedIndex=29