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THE EPIDEMIOLOGY and CONTROL of ONCHOCERCIASIS in WEST AFRICA Copyright 1989, J.H.F.Remme, Ouagadougou

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THE EPIDEMIOLOGY and CONTROL of ONCHOCERCIASIS in WEST AFRICA Copyright 1989, J.H.F.Remme, Ouagadougou THE EPIDEMIOLOGY AND CONTROL OF ONCHOCERCIASIS IN WEST AFRICA Copyright 1989, J.H.F.Remme, Ouagadougou Printed by Reprocentrum De Heij, Reeuwijk, The Netherlands ISBN 90-72245-46-6 THE EPIDEMIOLOGY AND CONTROL OF ONCHOCERCIASIS IN WEST-AFRICA De epidemio1ogie en bestrijding van onchocerciasis in West Afrika PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van Rector Magnificus prof.dr. C.J. Rijnvos en vo1gens bes1uit van bet College van Dekanen. De openbare verdediging za1 p1aatsvinden op woensdag 29 november 1989 om 15.45 uur door JAN HENDRIK FRED ERIK REMME geboren te Gouda 3 PROMOTIE COMMISSIE: PROMOTORES: PROF. DR. IR. J.D.F. HABBEMA PROF. DR. A.S. MULLER OVERIGE LEDEN: PROF. DR. J. HUISMAN PROF. DR. H.J. VANDER KAA Y 4 Aan mijn ouders Aan: Marge Wande Michelle Jane 5 TABLE OF CONTENTS Page List of abbreviations and specific terms used in onchocerciasis epidemiology 9 Map of West Africa and the Onchocerciasis Control Programme 10 I. INTRODUCTION AND STUDY OBJECTIVES 11 II. ONCHOCERCIASIS IN WEST AFRICA: A REVIEW 15 Introduction 16 2.1 Demographic aspects of the epidemiology and control of onchocerciasis in West Africa 17 Introduction 18 Disease and transmission 18 Intensity of transmission and man-vector contact 21 Population density and population movement in the Volta River Basin area before the start of control 24 The Onchocerciasis Control Programme (OCP) 29 Changes in migration and settlement patterns after 12 years of control 31 Cessation of larviciding and some related demographic questions 33 References 35 III. EPIDEMIOLOGICAL PATTERNS OF OCULAR ONCHOCERCIASIS IN WEST AFRICA 37 Introduction 38 3.1 Ocular onchocerciasis and intensity of infection in the community. 39 I. West African savanna Introduction 40 Materials and Methods 40 Results 43 Discussion 49 References 51 3.2 Ocular onchocerciasis and intensity of infection in the community. II. West African rainforest foci of Simulium yabense 53 Introduction 54 Materials and Methods 54 Results 56 Discussion 61 References 63 Addendum: other applications of the methodology 63 6 IV. EPIDEMIOLOGICAL EVALUATION OF THE IMPACT OF VECTOR CON­ TROL AND PREDICTION OF EPIDEMIOLOGICAL TRENDS DURING THE CONTROL PERIOD 65 Introduction 66 4.1 A force-of-infection model for onchocerciasis and its applications in the epidemiological evaluation of the Onchocerciasis Control Programme in the Volta River Basin area 67 Introduction 68 Force-of-Onchocerciasis-Infection Model 70 Epidemiological trends predicted by the model 72 Observed epidemiological trends in the OCP and their comparison with the predictions of the model 74 Discussion 79 References 82 4.2 The effect of 7-8 years of vector control on the evolution of ocular onchocerciasis in West African savanna 83 Introduction 84 Materials and Methods 84 Results 86 Discussion 88 References 91 4.3 The population dynamics of Onchocerca volvulus after 8 years of vector control in West Africa 93 Introduction 94 Materials and Methods 95 Results 97 Discussion I 0 I References 106 4.4 The effects of 11 years of Simulium control in the OCP on ABRs, ATPs, prevalence and intensity of O.volvulus infection and on the incidence and prevalence of eye lesions I 07 Introduction I 08 Results of the entomological evaluation 108 Results of the epidemiological evaluation Ill Conclusioru; 115 4.5 The predicted and observed decline in onchocerciasis infection during 14 years of successful vector control with reference to the reproductive lifespan of Onchocerca volvulus 117 Introduction 118 Materials and Methods 119 R~~ts Ill Discussion 124 References 127 Appendix I: Simulation of onchocerciasis infection in cohorts of adults using the Host-Parasite Model 128 7 V. COMMUNITY TRIALS OF IVERMECTIN IN ONCHOCERCIASIS 131 Introduction 132 5.1 A community trial of ivermectin in the onchocerciasis focus of Asubende, Ghana. I. Effect on the microfilarial reservoir and the transmission of Onchocerca volvulus 133 Introduction 134 Materials and Methods 134 Results 138 Discussion 143 References 145 5.2 Adverse reactions after mass treatment of onchocerciasis with ivermectin: Combined results from eight community trials 147 Introduction 148 Materials and Methods 148 Results 151 Discussion 159 References 161 5.3 Changes in ocular onchocerciasis four and twelve months after community- based treatment with ivermectin in an bolo-endemic onchocerciasis focus 163 Introduction 164 Patients and Methods 164 Results 167 Discussion 171 References 172 VI. GENERAL CONCLUSIONS 175 VII. SUMMARY 181 Summary 182 Samenvatting 187 Acknowledgements 193 Curriculum Vitae 195 8 List of abbreviations and specific terms used in onchocerciasis epidemiology ABR Annual Biting Rate: estimated number of Simulium bites a person at a catching point would receive per year ATP Annual Transmission Potential: estimated number of L3 which would have been transmitted to a person at a catching point per year choroido-retinitis inflammation of the choroid and retina of the eye CMFL Community Microfilarial Load, i.e. the geometric mean mf/s among persons aged 20 years or more. CMFL/AC the geometric mean MFAC among persons aged 20 years or more. CMFL/C the geometric mean DMFC among persons aged 20 years or more. DMFC dead mf in the cornea force-of-infection the probability of (super)infection per unit of time bolo-endemic community with a CMFL > 40 mfjs hyper-endemic community with a prevalence of skin snip positives > 60% host-parasite model an epidemiological model which describes the dynamics of the parasite and its reproduction in a human host population infective flies flies harbouring infective (L3) O.volvulus larvae iridocyclitis inflammation of the iris and the ciliary body of the eye ivermectin new microfilaricide registered in 1987 under the proprietary name Mectiza.n™ for the treatment of human onchocerciasis Ll larval stage of 0. volvulus in the vector before the first moult L2 larval stage of 0. volvulus between first and second moult L3 larval stage of 0. volvulus following second moult in the vector. This is the infective stage which may be transmitted to man larvicide an agent for killing the aquatic larval stages of the vector LMFC living mf in the cornea longevity of an period between inoculation of L3 and death of the last mf due to infection this onchocerciasis infection mf microfilariae, i.e. the offspring of the adult O.volvulus mfjs mf per skin snip MFAC mf in the anterior chamber of the eye microlllaricide chemotherapeutic agent which kills microfilariae nodulectomy surgical removal of subcutaneous nodules containing adult O.volvulus OCP OnchocerciaSis Control Programme in West Africa Onchocerca volvulus the filarial nematode which causes onchocerciasis (an) onchocerciasis inoculation of L3 larva and the subsequent development of one adult infection fertilized female worm which produces mf optic atrophy degeneration of the optic nerve pre-patent period period between inoculation of L3 and first appearance of mf in the skin due to this onchocerciasis infection reinvasion long distance migration of vectors, which are often highly infective, into a controlled area sclerosing keratitis opacification of the cornea following corneal inflammation Simulium damnosum sl. the vector of onchocerciasis in West Africa (the blackfly) consisting of several sibling species. The most important are the savanna vectors S.damnosum s.s. and S.sirbanum, and the forest vectors S.soubrense, S.sanctipauli, S.yahense and S.squamosum. skin snip skin biopsy for microscopic examination for presence of mf SSPH Severe Symptomatic Postural Hypotension superinfection a new onchocerciasis infection in a person who already is harbouring at least one onchocerciasis infection 9 0- ... ..I. ,,. I WEST AFRICA AND THE ONCHOCERCIASIS CONTROL PROGRAMME I I ______ J I ,,J -------- ,j MALl _,,,---- ---- -J-- _, !!.'. .. LEGEND Iii PtotrGMIIlt luodqwotlttl D Optrollonol ouo hutlqulttlll t Atrohu e Stclot htodquarlt1'1 • S~o~buctor htodquorltre 0 tOO 100 !00 400WII • Ollltr-clhu OCP-VCU: IALDRY/f()(: 1 1-l-11 Chapter 1 Introduction and Study Objectives II INTRODUCI'ION Onchocerciasis is a major parasitic disease which is endemic in large parts of Africa and in isolated foci in Central and South America and in Yemen. It has been estimated that as many as 18 million people are infected with the parasite, the filarial nematode Onchocerca volvulus, and more than 99% of all infected people live in Africa. The adult worm produces millions of microfilariae which migrate into the skin of the human host. The parasite is transmitted by blackflies (Diptera, Simuliidae), which ingest microfilariae during a bloodmeal on man. In the flies, some of these microfilariae develop into infective larvae which can be transmitted to another person during a subsequent bloodmeal to develop into new adult worms. The microfilariae are the main cause of the clinical manifestations of the disease which include dermal, lymphatic and systemic complications. However, the most severe complications are onchocercal lesions of the eye which may ultimately lead to total blindness. The World Health Organization estimates that some 340,000 people are blind as a result of onchocerciasis. The majority of the onchocercal blind are found in the West and Central African savanna belt where the disease is most severe. There, onchocerciasis is not only a major public health problem, but often also an obstacle to socio-economic development. Fear of the disease has led to the depopulation of relatively fertile river valleys where the vector of the disease, Simulium damnosum s.l., has its breeding sites and where transmission is most intense. The possibilities for onchocerciasis control are limited. Until recently chemotherapy was not an option because the existing drugs for the treatment of onchocerciasis produced very serious adverse reactions which prevented their utilization on a mass scale. The only alternative was vector control through the application of larvicides to the rivers where the breeding sites of the vector are found. During the 1950s vector control was applied successfully in certain isolated foci in East Africa where the vector Simulium neavei s.s.
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