1. Elimination of Onchocerciasis in
Africa
Presentation by
Manasvini Vimal Kumar
MADS 6642
Global Health and Human Services Systems
Prof. Carlos Leon
Source: http://media-cache-
ak0.pinimg.com/736x/f1/c6/1d/f1c61dd9f408646fd63c015bae93410c.jpg

2. Introduction
World’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 Africa
Source: http://www.who.int/apoc/magazine_final_du_01_juillet_2011.pdf?ua=1 Page-21

3. Spread of disease
Transmission of Onchocerca volvulus (Source:WHO,2014)

4. Manifestation of Disease
 Papular rash Itching Onchodermatitis
Skin 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_9R78HM
GgeyOMpvtQKI_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

5. Burden of Disease
DALYs 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
Onchoce
rciasis
(2003)
0 0 2 0.4 0 481 0 484
Onchoce
rciasis
(Latest
APOC
data)
0 0 2 0.4 0 1487 0 1490

6. 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)

7. 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

8. REMO used to identify CDTi areas
The figure shows Rapid Epidemiological Mapping of Onchocerciasis (REMO) in countries covered by
APOC, 2008, using 3 color scheme marking severity
Source- Padmanabhan. A.(2010). Onchocerciasis control I Africa: Elimination is possible

9. 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

10. ACCOMPLISHMENTS OF APOC
The 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

11. 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 blindness
Success 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%

12. Burden of Disease in 19 APOC countries (WHO,2014)
WEST AFRICA
Year 1975 2014
Affected 1,000,000 None
Blinded 35,000 300,000 prevented
Serious 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

13. 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 NTDs
140 projects under Product Development Partnership
Pledged-1.4 billion treatments b/w 2011-2020 to
eradicate 9 NTDs
Merck-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 NTDs
All R&D focused on Sub-Saharan Africa

14. 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)

15. 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

16. 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

17. References
African 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=1
African 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.pdf
Boutayeb, 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+D
ETERMINANTS+OF+ONCHOCERCIASIS&source=bl&ots=XzAUhdK0cT&sig=tw1O_MEqQatg-
hP_dOLuyKio3DA&hl=en&sa=X&ei=WjH5Uv7WJtSJqQHDjIDICw&ved=0CEYQ6AE
wAw#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

18. 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

19. 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.pdf
World Bank. (2013). The African Program for Onchocerciasis Control. Retrieved
from:
http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/AFRICAE
XT/E XTPARTNERSHIPS/0,,co
ntentMDK:21748460~pagePK:64168445~piPK:64168309~theSitePK:409
9373,0 0.html
(2004). Onchocerciasis (River blindness).Retrieved from :
http://www.stanford.edu/group/parasites/ParaSites2004/Onchocerciasis/
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