Reprint (rom the -' Bullet;n of lhe Pan American Health Organ;zation Vol. VII, No.4,1973.

ONCHOCERCIASIS IN BRAZILl

Mário A. P. Moraes,2 Habib Fraiha,3 and GeovaneM. Chaves4

An endemic focus of onchocerciasis, the so-called "river blindness" widespread' in parEs of Africa, has' been dis- covered in . Until recently the only confirmed foci in this Hemisphere were in Guatemala, Mexico, Colombia, and . The research confirming this new Brazilian focus indicares the disease has spread over a fairly large swath of backlands in the vicinity of the Brazil- Venezuela border.

Introduction 1967. Unfortunately, diagnosis of the case did not stimulate research aimed at finding The presence of the filaria worm Oncho- the focus of the disease. cerca volvulus in the New World has been In 1972 Moraes and Dias (10) reported known since 1915, when Robles (4, 12) finding two other cases in American woman discovered it in Guatemala. But until a missionaries living on the Toototobi River short time ago the known endemic areas of in the State of Amazonas among Indians of onchocerciasis in the Americas were lirnited the Waica Tribe, a subdivision of the Ya- to Guatemala, Mexico, and Venezuela (1, nornarna Indian group. Both women had 3). Isolated cases reported in Surinam (7) nodules in the sacral region that were sev- and Ecuador (8) could not be confirmed. eral years old. The diagnosis was made by Then in 1970 Little and D'Alessandro chance, in the course of a routine histo- (9) described the first focus in Colombia, pathologic exarnination. Some months later situated in a number of places along the Mi- a new case, originating in the same area, cay River. According to the authors, how- was discovered by Moraes and Chaves (11). ever, this focus was confined to a relatively The patient was yet another American smalI area. O. volvulus infections were de- woman rnissionary living among the Waicas, tected in 44 of 292 individuaIs exarnined, this time in the Surucucus Mountains of almost alI of whom were Negroes. the Territory. AlI three of these Only one indigenous case had previously patients were treated with diethylcarbama- been found in Brazil; it was discovered in zine (Hetrazan); the drug was also admin- the far-north Federal Territory of Roraima, istered to the husband of one of the and was described by Bearzoti, et ai. (2) in women after he complained of severe pru- figo of the thighs and buttocks. 1Also appearing in Portuguese in Boletín de Ia Oficina Sanitaria Panamericana (January 1964). The fact that the rnissionaries were living 2Associate Professor at the Federal University in contact with the Waicas, in the extreme of Pará, Belém, Brazil; and Pathologist, Evandro northern part of Brazil near the Venezuelan ChagasInstitute, Belém, Brazil. 3Parasitologist, Evandro Chagas Institute. Holder border, and the fact that the Venezuelan of grant from the National Research Council of Indians of the same Yanomama group cus- Brazil, TC n. 02712/72. tornarily crossed the border to visit villages 4Medical student at the University of Amazo- nas, Manaus, Brazil. on the Brazilian side, caused us to suggest

SO

~ Moraes, et ai. .ONCHOCERCIASIS IN BRAZIL SI

(11) that a focus of onchocerciasis might river, some insects of the vector genus extend throughout the parts of Brazil and Simulium were captured. These are known Venezuela inhabited by the Yanomamas.To throughout the Amazon region by the name verify this hypothesis, in July 1973 we of "pium," but the Waicas caU them travelled to the Toototobi River arfa, where "okuxib." However, this report covers only the first two rnissionary patients were still the finding of O. volvulus parasites among living. Apart from the parasitologic examina- those lndians that we were able to ex- tion of the lndians in villages along the amine.

MAP l-A hydrographic map of the northwestem Amazon indicating the location of the Toototobi River.

Materiais and Methods Mission of the New Tribes of Brazil) estab- lished their posto The Toototobi River is a small tributary To avoid isolation of this mission facility of the Demini (Map 1), which in turn is a for most of the year, a small airplane land. tributary of the . According to ing strip was built about one kilometer the classification system used for the rivers from the lndian village. The authors travel- of the Amazon Basin, it can be considered led there in a light airplane (belonging to a Tiver of "white water," that is, its water another religious group) that is commonly carries a large quantity of suspended clay used to transport missionaries and supplies particles. The area is very hard to reach by between Boa Vista (capital of the Roraima boat because rapids in the Demini are only Territory) and various mission posts that navigable during a short period each year dot the frontier region. The distance from when the Tiver is at flood stage. However, Boa Vista to the Toototobi post is about there are a number of Waica villages along 200 miles. its banks, and it was near one of these lndians from three villages on the Too. that the inissionaries (affiliated with the totobi were ex~iiled. The location of 52 P~Q~U~~-~~~~~~

MAP 2- The Toototobi River region, with the approximate location of the three villages surveyed: Chief Roberto's viUage (1), Chief Plinio's viUage (2), and Chief Fialho's viUage(3).

~ these villages,whose chiefss were called Ro- Even if no microfilaria were found, the berto, Plinio, and Fialho by the mis- examination continued with an immediate sionaries,is shown in Map 2. According to search, prirnarily by palpation, for subcuta- a census taken by the rnissionaries,Rober- neous nodules. Missionaries' reports (11) to's village, Plinio's village, and Fialho's vil- had already informed us that the nodules lage had respective populations of 80, 52, were very hard to see, and this fact Was and 22 persons. confirmed during the examinations. One The first step in the examination con- characteristic of these nodules, known as sisted of taking a skin sample from each onchocercornas,is their high degree of mo- subject w'ith small scissors.This was obtain- bility in the subcutaneous tissue. They ed from the area of the shoulder blades if could quite readily be rolled around with no cutaneouslesions were observed;if there the index finger. were manifestations apparently attributable We were able to remove nodules from tó O. volvulus, however, the tissue was three Indians for histopathologic examina- taken from the affected area. The material tion. Another nodule was also removed obtained was placed in a drop of saline from one of the missionaries,whose case solution on a glassslide and covered with a was the first previously reported by Moraes coverslip. It was then warmed slightly and and Dias (10). exarnined at once for rnicrofilaria; if the first exarnination proved negative, the ma- terial was exarnined again ten minutes later. Results

5The Waicas do not use the terms, tuxaua, A total of 91 Indians (49 men and 42 cacique, or morobixaba. In their language the Chiei is the "one who talks," or in other words women) from the three villages were exam- the one. who gives orders. ined. Of this total, 41 persons (23 men MAP 2- The Toototobi River region, with the approximate location of the three villages surveyed: Chief Roberto's viUage (1), Chief Plinio's viUage (2), and Chief Fialho's viUage(3). Moraes, et aL .ONCHOCERCIASIS IN BRAZIL 53

and 18 women) were from Roberto's vil. in 10 of the 57 Indians with microfilaria, lage, the one closest to the rnission post; and also in one Indian wcman whose skin 36 persons (18 meu and 18 women) were test rernained negative even after a second from Plinio's village; and 14 (8 meu and 6 biopsy. In seven of these cases, including women) were from Fialho's village. that of this woman, the nodules were 10- Biopsy of the skin samplesshowed that calized principally in the scalp. In the three 57 Indians (30 meu and 27 women) were previously mentioned instances in which the infected with O. volvulus microfilaria. In detected nodules were actually removed other words, the results were 62 per cent from Indian subjects, histopathologic exam- positive, being slightly higher for the wom. ination revealed the presence of O. volvulus en (64 per cent positive) than for the meu in each case. In one nodule the filariae (61 per cent positive). The rate of positive were already in a state of degeneration. It findings for samples from each village was is probable that some onchocercomas es- 65 per cent for Roberto's village, 81 per caped notice during the examination, which cent for Plinio's village, and 57 per cent was somewhat hurried. If so, the small size for Fialho's village. and often very deep location of the nod- Ages of the positive cases ranged from ules were most certainly contributory fac- 13 to 58 years. af those in the 40-and- tors. over age group, ali of the individuaIs tested ane Indian ma~ and woman with micro- (a total of 13) were infected with micro- filaria in their skins (both from the village filaria (see Figure 1). Unfortunately, the of Chief Roberto) were blind in one eye. youngest Indians whom we could examine Another Indian woman, from the village of were already at least 10 or 11 years of Chief Fialho, complained of severe photo. age. According to the beliefs of the Yano- phobia when the biopsy was being taken. mamas, children's souls are not yet firmly We confirmed that she was suffering from lodged in their bodies and mar escape blepharoconjunctivitis, which had already through their mouths if they cry. Mothers caused a loss of eyelashes on her lower lido will make considerable effort to keep their This wornan had a massive case of the dis- children from crying for this reason. There. ease, nearly 30 microfilaria having been ob- Core, to avoid the major task of recovering tained from the small skin fragment exam. fugitive souls, we had to leave children ined. under 10 years of age out of the testo . Cutaneous manifestations, probably at- Subcutaneous nodules later were found tributable to O. volvulus microfilaria, were

FIGURE I-The results of a 1973 study of o. vo/vu/us microfiliaria infecting Indians of the Toototobi River, Brazil (subjects listed by village and agegroup).

~e of Roberto's village Plinio's viII age Fialho's village Total subjects No. of No. No. of No. No. of No. No. of No. persons positive % persons positive % persons positive % persons positive % examined examined examined examined

10 -14 5 1 20.0 8 1 12.5 2 O 0.0 15 2 13.3 15 -1-9 7 1 14.2 6 3 50.0 5 2 40.0 18 6 33.3 20 -29 15 12 80.0 10 7 70.0 2 1 50.0 27 20 74.0 30-39 7 685.7 9 8 88.8 2 2100.0 18 16 88.8 40 and 7 7 100.0 3 3 100.0 3 3 100.0 13 13 100.0 over Total 41 27 65.8 36 22 61.1 14 8 57.1 91 57 62.6 54 PAHO BULLETIN .Vai. VII, No. 4. 1973

observed in a number of cases.These most coincides with the geographic distribution of frequently took the form of slightly ery- the Yanomama lndian group and probably thematous and high1y pruritic papules local- that of the Makiritare lndians as well. One ized in the regions of the buttocks and of these factors is the nature of the region shoulder blades, and of dry, shiny, and inhabited by these lndians among the Cu- wrinkIed patches of skin in the same re- rupira, Tapirapecó, Urucuzeiro, Surucucus, gions. Whenever these lesions were found, and Parima mountains. This area is rather the biopsy was invariably positive. (Second high and thus favors propagation of the only to malaria, the principal complaint of Simulium flies that transmit O. volvulus. the Waicas is severe prurigo in the upper Another equalIy important factor are the and lower extremities.) frequent visits between the various vilIages, Besides the Indians, tive people from the almost always motivated by the periodic two rnissionary families living in the area ceremonial gatherings of the Yanomamas. were exarnined. None of them were found The visitors generalIy remain in the host to have microfilaria in the skin. However, vilIages for several days, which is a suf- as previously noted, we removed an oncho- ficient period for transmission. Furthermore, cercotic nodule from one of the women. there is no doubt that the diseasehas been Histopathologic examination of this nodule, carried from the previously reported focus taken from the left iliac crest, showed fila- in eastern Venezuela to the headwaters of riae in the process of degeneration.This mis- the and to its tributaries, such as sionary had been given the diethylcarbama- the Mavaca River, from whence it has zine treatment only a short while before, passedto Brazil via either the visits of the after examination of another nodule re- Waicas or their migrations. moved earlier. Moreover, she had admin- The Yanomama people are characterized istered the same drug to her husband when by a high degree of mobility. Of the 91 he complained of intense prurigo in the lndians we examined, at least 11 had once area of the pelvic girdle. Despite this come from the region of the Orinoco or symptom, no microftlaria were found in bis from the mountains along the border, ac- skin during the course of several subsequent cording to information given us by the mis- biopsies. sionaries.And of these 11, every one tested positively for microfIlaria. One among them named Tito, who had come from the Ori- Discussion flOCOregion, was only 14 years of age. According to Chagnon (5) and Chagnon As we have previously suggested,this et ai. (6), the Yanomamas'total population firm evidence that O. vo/vulus'exists among is estimated at or above 10,000 persons.living Indians living along the Toototobi River in some 125 scattered vilIages con- means that Brazil should be included on taining anywhere from 40 to 250 inhabit- the world's list of areas with endemic on- ants. The Makiritares, whose territory over- chocerciasis. It also makes Brazil the third laps part of the Yanomamas' are estimated country of in which the to have around 2,000 members. They are presence of these filariae has been con- also distributed in a number of vilIages, firmed. most of which have from 50 to 150 in- Even though the Toototobi River focus habitants and almost alI of which are 10- by itself is small, certain factors relating to cated within Venezuelanterritory. While the the Waicas lead us to suppose that there is Yanomamasare accustomed to travelIing on an extensive endemic zone, including por- foot through the forests, the Makiritares tions. of both Brazil and Venezuela, that prefer river traveI, building canoes and Moraes. et ai. .ONCHOCERCIASIS IN BRAZIL 55 making long trips upon the tributaries on living in the village of Chief Roberto, but the right side of the Orinoco descending had actualIy come from the area of the from the mountains; they thus come in Mapulau River, a tributary of the Demini contact with distant settlements of civilized downriver from the Toototobi. people. Although any conclusions about the dis- Prior to the arrival of missionaries in Ya- ease in this general region would be pre- nomama territory, the latter got alI their mature, given the small size of the area metal implements from the Makiritares, who studied, it is noteworthy that nodules were thus served as intermediaries between the found in only 17 per cent of the positive Yanomamas and the whites. It is almost cases, about the same percentage found certain that through their contacts with the among those suffering from onchocerciasis two groups the Makiritares alSO served as a in Venezuela. In Mexico and in Guatemala connecting link in the spread of oncho- the nodules are much more numerous. cerciasis. However, the preferred location for the Besides these background considerations, nodules studied, i.e. the head, is a more a number of findings confirm that the en- common site in Mexico and Guatemala than dernic area is quite extensive, and that the in Venezuela. More studies at various local- Toototobi River focus is only a small part ities within the endemic area will be of i t. These findings are as folIows: needed in order to definitively determine (I) Moraes and Chaves (11) found a mis- the characteristics of this new focus of the sionary from the Surucucus mountains in disease. Roraima to have onchocercotic nodules. (2) Toototobi rnissionaries have reported that one of their company living on the ACKNOWLEDGMENTS Venezuelan side of the borde r had an O. volvu/us nodule removed in the United The authors wish to express their ap- States. (3) Blind Indians are known to be preciation to Keith Wardlaw and Tony present among Waicas living along the Ma- Poulson, missionaries at the Toototobi River rari River (a tributary of the Padauiri) in station, for their untiring and valuable co- the State of Amazonas. (4) FinalIy, one in- operation in the work that went into this fected person included in this study was study.

SUMMARY

A chance identification of onchocercal nod- found in II of the lndians one of whom ules in American woman missionaries living showed no cutaneous microfila~ia. among the Waica lndians in northern Brazil has The fact that two of the lndians examined resulted in discovery of a focus of the disease were blind in one eye and another had along the Toototobi River in the State of blepharoconjunctivitis suggests that ocular Amazonas. This is the first focus of oncho- involvement may be relatively common among cerciasis to be recorded in Brazil. those infected with the parasite. However, Of 91 lndians examined, 57 had Onchocerca examinations for microfilaria in the anterior volvulus rnicrofilaria present in their skins. AlI chamber of the eye were not performed. these lndians were living in three malocas or The authors believe that the focus discovered villages along the course of that river, only a may be quite extensive, corresponding to the short distance fIam the post occupied by two geographic distribution of the Yanomama of the missionaries. Subcutaneous nodules were lndian group to which the Waica Tribe belongs. 56 PAROBULLETIN .Vai. VI/. No. 4. 1973

REFERENCES

(1) Barranco, D.G., and M.S. Mallén. "Geografía (7) Hartz, P.H. "Does Onchocerciasis Occur in médica de Ia oncocercosis, genero ancho- Surinam? " Docum Neer et Indones Morbis cerca Diesing, 1841." Rev Inst Med Trop 1>"op2: 355-356, 1950. 860 Paulo 10: 316-325, 1968. (8) Leon, L.A., and P. Wigodzinsky. "Los Si- (2) Bearzoti, P., E. Lane, and J. Menezes, Jr. múlidos dei Ecuador y su importancia en "Relato de um caso de oncocercose ad- medicina tropical (Diptera. Simulidae)." quirida no Brasil." Rev Paul Med 70: 102, Rev Ecuator Ent Parasitol 1: 23-39, 1953. 1967. (3) Burch, T .A. "The Ecology of Onchocer- (9) Little, M.D., and A. D' Alessandro. "Oncho- ciasis." ln Studies in Disease Ecology. cerciasis in Colombia; Parasitologic Findings Hafner Pub., New York, 1961. in the First Observed Focus." Am J Trop (4) Calderón, V.M. "Enfermedad nueva en Guate- Med Hyg 19: 831-836, 1970. mala (resumen de una conferencia)." La (10) Moraes, M., and L. B. Dias. "Oncocercose no Juventud Medica 17: 97-115, 1917. Estado do Amazonas." Rev Inst Med 1>"op (5) Chagnon, N.A. Yanomam6 The Fterce Peo- S~o Paulo 14: 330-333, 1972. pie. Case Studies in Cultural Anthropology. Holt, Rinehart, and Winston; New York, (11) Moraes, M., and G.M. Chaves. "Um caso de 1968. oncocercose no Território de Roraima, Bra- (6) Chagnon, N.A., J.V. Neel, L. Weitkamp, H. sil." Rev Inst Med Trop S~o Paulo. (In Gershowitz, and M. Ayres. "The lnfluence press.) of Cultural Factors on the Demography (12) Robles R. "Oncocercose humaine au Gua- and Pattem of Gene Flow flOro the témala produisant Ia cecité et 'l'erysipele Makiritare to the Yanomama lndians." Am du littoral' (erisipela de Ia costa)." Buli J Phys Anthropol 32: 339-349, 1970. Soc Pathol Exot 12: 442-463, 1919.