Environmental assessment of larvicide use in the onchocerciasis control programme

The objective of the Onchocerciasis Control Programme (OCP) is to eliminate onchocerciasis as a disease of public importance and as an obstacle to socio-economic development. The OCP was initially based solely on the control of the blackfly vector, Simulium damnosum sensu lato, by insecticide spraying of the breeding sites on river systems, where larval stages develop. Results of monitoring the environmental effects and the process of risk assessment for new insecticides are reviewed. The achievements of this strategy are outlined here by Davide Calamari, Laurent Yameogo, Jean-Marc Hougard and Christian Leveque.     

Elimination of the Djodji form of the blackfly Simulium sanctipauli sensu stricto as a result of larviciding by the WHO Onchocerciasis Control Programme in West Africa

Cytotaxonomic identifications of larvae of members of the Simulium damnosum Theobald (Diptera: Simuliidae) complex collected in forest zones of southeast Ghana and southwest Togo between 1977 and 1996 showed that the Djodji form of Simulium sanctipauli Vajime & Dunbar, a vector of onchocerciasis, was eliminated in 1988 by larvicide operations conducted by the World Health Organization (WHO) Onchocerciasis Control Programme (OCP) in West Africa. No members of the form were identified amongst 997 larvae collected up to 8 years after systematic control operations began in February 1988. The results are discussed in relation to estimates of the numbers of samples required to certify elimination and the possibility that other members of the S. damnosum complex were also eliminated by the OCP.     

Onchocerciasis in West Africa after 2002: a challenge to take up

Initially planned for a 20 year life time, the Onchocerciasis Control Programme in West Africa (OCP) will have finally continued its activities for nearly three decades (vector control alone from 1975 to 1989, then vector control and/or therapeutic treatment until 2002). Although onchocerciasis is no longer a problem of public health importance nor an obstacle to socio-economic development in the OCP area, the control of this filariasis is not over because OCP never aimed at eradication, neither of the parasite (Onchocerca volvulus), nor of its vector (Simulium damnosum s.l.). In 2003, the eleven Participating countries of OCP will take over the responsibility of carrying out the residual activities of monitoring and the control of this disease. This mission is of great importance because any recrudescence of the transmission could lead in the long run to the reappearance of the clinical signs of onchocerciasis, if not its most serious manifestations. For epidemiological and operational reasons, and given the disparity in national health policies and infrastructures, the capacities of the countries to take over the residual activities of monitoring and control of onchocerciasis are very unequal. Indeed, the interventions to be carried out are very different from one country to another and the process of integrating the residual activities into the national health systems is not taking place at the same pace. This inequality among the countries vis-a-vis the challenges to be met does not, however, prejudge the epidemiological situation after 2002 whose evolution will also depend on the effectiveness of the provisions made before that date by OCP, then after 2002, by the Regional Office for Africa of the World Health Organization which is currently setting up a sub-regional multidisease surveillance centre.     

Onchocerciasis control: Moving towards the millennium

The recognition of onchocerciasis as a major public health problem in the savanna belts of West Africa resulted in the establishment of the Onchocerciasis Control Programme (OCP) in 1974. Control was initially based on vector control by weekly larviciding. The OCP is now in transition towards its final phase in which repeated treatment with ivermectin, a safe and effective microfilaricide, is incorporated with vector control, or in certain circumstances is used alone. Ivermectin distribution hingeing on sustainable community systems is the basis of a new programme in endemic African countries outside the OCP and in the Americas. David Molyneux and John Davies describe the latest trends and developments related to onchocerciasis control.     

Final report of the Conference on the eradicability of Onchocerciasis

Sixty-four experts from a variety of disciplines attended a Conference on the Eradicability of Onchocerciasis at The Carter Center, in Atlanta GA, held January 22-24, 2002. The Conference, which was organized by The Carter Center and the World Health Organization, with funding from the Bill & Melinda Gates Foundation, addressed the question: "Is onchocerciasis (River Blindness) eradicable with current knowledge and tools?" Former US President Jimmy Carter attended part of the final plenary proceedings on January 24.The Conference consisted of a series of presentations by invited expert speakers (Appendix C) and further deliberations in four workgroups (Appendix D) followed by plenary discussion of major conclusions. The presentations underlined epidemiological and entomological differences between onchocerciasis in Africa and the Americas. Whilst onchocerciasis in Africa covers extensive areas and is associated with striking human and fly population migrations and remarkably efficient black fly vectors, in the Americas onchocerciasis is found in limited foci. Human and fly population migration are not major problems in the Americas, where most black fly species are inefficient, though some efficient black flies are also found there. Vector control has been effectively applied in the Onchocerciasis Control Program in West Africa (OCP) with remarkable results, interrupting transmission in most parts of the original Program area. The use of ivermectin has given variable results: while ivermectin treatment has been effective in all endemic areas in controlling onchocerciasis as a public health problem, its potential for interrupting transmission is more promising in hypo- and mesoendemic areas. The African Program for Onchocerciasis Control (APOC), which supports onchocerciasis control in endemic African countries outside the OCP, applies ivermectin, its principal control tool, to communities in high-risk areas as determined by rapid epidemiological mapping of onchocerciasis (REMO) and Geographic Information Systems (GIS). In the Americas, through support of the Onchocerciasis Elimination Program in the Americas (OEPA), a strategy of bi-annual ivermectin treatment of at least 85% of the eligible populations in all endemic communities is showing very good results and promises to be effective in eliminating onchocerciasis in the region.The Conference concluded that onchocerciasis is not eradicable using current tools due to the major barriers to eradication in Africa. However, the Conference also concluded that in most if not all the Americas, and possibly Yemen and some sites in Africa, transmission of onchocerciasis can be eliminated using current tools. The Conference recommended that where interruption of transmission is feasible and cost effective, programs should aim for that goal using all appropriate and available interventions so that the Onchocerca volvulus can eventually be eliminated and interventions halted. Although interruption of transmission of onchocerciasis cannot currently be achieved in most of Africa, the Conference recommended that efforts be made to preserve areas in West Africa made free of onchocerciasis transmission through the Onchocerciasis Control Program over the past 25 years. In the remaining hyper and mesoendemic foci in Africa, continued annual distribution of ivermectin will keep onchocerciasis controlled to a point where it is no longer a public health problem or constraint to economic development.     

Molecular phytogeny and typing of blackflies (Diptera: Simuliidae) that serve as vectors of human or bovine onchocerciasis

Abstract. A subregion of the mitochondrial large subunit (16s) rRNA gene was amplified by polymerase chain reaction (PCR) from nine species of blackflies (Diptera: Simuliidae) which serve as natural or experimental vectors of human or bovine Onchocerca parasites. PCR products from each species of blackfly were tested by directed heteroduplex analysis (DHDA), and their genotypes established according to diagnostic banding patterns of the heteroduplex products. Three alleles of mitochondrial 16s rRNA were found to exist in members of the Simulium (Ewardsellum) damnosum sensu lato complex from West Africa, and two alleles were found in the Neotropical Simulium (Psilopelmia) ochraceum Walker complex and the Simulium (Simulium) metallicum Bellardi complex. Different single alleles were detected in Austrosimulium bancrofti , in English S.(S.)noelleri and in two North American laboratory vectors: Simulium (Psilozia) vittatum Zetterstedt and S.(S.)decorum Walker. Phylogenetic analysis of 16s sequences indicated that blackflies from West Africa and the Americas formed distinct clades. Neotropical onchocerciasis vectors were found to be more closely related to Nearctic and Palaearctic non-vector Simulium species than to the African vectors of onchocerciasis.     

Revision of the Ketaketa subcomplex of blackflies of the Simulium damnosum complex

A revision of the taxonomy of the Ketaketa subcomplex of the Simulium damnosum Theobald complex (Diptera: Simuliidae) is presented including new material from Tanzania, Malawi and South Africa. The cytotaxonomy, morphology and molecular identity of known and new taxa are described. The Ketaketa subcomplex is cytotaxonomically defined by the paracentric inversion 1L-7. We recognize three sibling species, namely Simulium latipollex (Enderlein), Simulium plumbeum Krueger, sp.n. and Simulium kipengere Krueger, sp.n., the latter comprising three cytoforms: 'Typical', 'Linthipe' and 'Mombo'. The cytoforms 'Mwamphanzi', 'Ketaketa' and 'Hammerkopi' are synonymized with S. plumbeum. Identification keys are provided on the basis of chromosomal and morphological characters. In view of their potential role as vectors of human onchocerciasis (river blindness) we also discuss the possible medical importance of the different cytoforms and their geographical distribution.     

Impact of ivermectin on onchocerciasis transmission: assessing the empirical evidence that repeated ivermectin mass treatments may lead to elimination/eradication in West-Africa

BACKGROUND: The Onchocerciasis Control Program (OCP) in West Africa has been closed down at the end of 2002. All subsequent control will be transferred to the participating countries and will almost entirely be based on periodic mass treatment with ivermectin. This makes the question whether elimination of infection or eradication of onchocerciasis can be achieved using this strategy of critical importance. This study was undertaken to explore this issue. METHODS: An empirical approach was adopted in which a comprehensive analysis was undertaken of available data on the impact of more than a decade of ivermectin treatment on onchocerciasis infection and transmission. Relevant entomological and epidemiological data from 14 river basins in the OCP and one basin in Cameroon were reviewed. Areas were distinguished by frequency of treatment (6-monthly or annually), endemicity level and additional control measures such as vector control. Assessment of results were in terms of epidemiological and entomological parameters, and as a measure of inputs, therapeutic and geographical coverage rates were used. RESULTS: In all of the river basins studied, ivermectin treatment sharply reduced prevalence and intensity of infection. Significant transmission, however, is still ongoing in some basins after 10-12 years of ivermectin treatment. In other basins, transmission may have been interrupted, but this needs to be confirmed by in-depth evaluations. In one mesoendemic basin, where 20 rounds of four-monthly treatment reduced prevalence of infection to levels as low as 2-3%, there was significant recrudescence of infection within a few years after interruption of treatment. CONCLUSIONS: Ivermectin treatment has been very successful in eliminating onchocerciasis as a public health problem. However, the results presented in this paper make it almost certain that repeated ivermectin mass treatment will not lead to the elimination of transmission of onchocerciasis from West Africa. Data on 6-monthly treatments are not sufficient to draw definitive conclusions.     

The Mectizan® Donation Program – highlights from 2005

Through the Mectizan^® Donation Program, Merck & Co., Inc. has donated Mectizan (ivermectin, MSD) for the treatment of onchocerciasis worldwide since 1987. Mectizan has also been donated for the elimination of lymphatic filariasis (LF) since 1998 in African countries and in Yemen where onchocerciasis and LF are co-endemic; for LF elimination programs, Mectizan is co-administered with albendazole, which is donated by GlaxoSmithKline. The Mectizan Donation Program works in collaboration with the Mectizan Expert Committee/Albendazole Coordination, its scientific advisory committee. In 2005, a total of 62,201,310 treatments of Mectizan for onchocerciasis were approved for delivery via mass treatment programs in Africa, Latin America, and Yemen. Seventy-seven percent and 20% of these treatments for onchocerciasis were for countries included in the African Programme for Onchocerciasis Control (APOC) and the former-Onchocerciasis Control Programme in West Africa (OCP), respectively. The remaining 3% of treatments approved were for the six onchocerciasis endemic countries in Latin America, where mass treatment is carried out twice-yearly with the goal of completely eliminating morbidity and eventually transmission of infection, and for Yemen. All 33 onchocerciasis endemic countries where mass treatment with Mectizan is indicated have ongoing mass treatment programs. In 2005, 42,052,583 treatments of co-administered albendazole and Mectizan were approved for national Programs to Eliminate LF (PELFs) in Africa and Yemen. There are ongoing PELFs using albendazole and Mectizan in nine African countries and Yemen; these represent 35% of the total number of countries expected to require the co-administration of these two chemotherapeutic agents for LF elimination. In Africa, the expansion of existing PELFs and the initiation of new ones have been hampered by lack of resources, technical difficulties with the mapping of LF endemicity, and the co-endemicity of LF and loiasis. Included in this review are recommendations recently put forward for the co-administration of albendazole and Mectizan in areas endemic for LF, loiasis, and onchocerciasis.     

Control of River Blindness in West Africa: Case History of Biodiversity in a Disease Control Program

The elimination of river blindness (onchocerciasis) in West Africa has been one of the most successful public health and economic development programs yet conducted. Control was based on aerial application of insecticides to control the aquatic, larval stages of black flies in the Simulium damnosum complex and distribution of ivermectin-based drugs to reduce incidence of the filarial worm, Onchocerca volvulus, that may ultimately result in blindness. Control efforts were long-term (1974–2003), extensive (with as many as 50,000 km of river miles being treated weekly for 12 years or longer), and far-reaching (distribution of drugs to almost 7 million people in 11 West African countries). The challenges and success of the program were strongly related to biodiversity: the vector S. damnosum is actually a complex of several species and subspecies, which vary in their competence in disease transmission; the filarial worm O. volvulus has different forms that vary in their virulence and incidence of producing blindness in humans; maintenance of the biodiversity of the non-target riverine fauna was a prime concern of both the control program and the donor countries that supported it; the main insecticide used to control the black fly vector was derived from a bacterium Bacillus thuringensis israelensis; and the drug used in controlling the filarial worm was derived from a soil-dwelling Streptomyces fungus. Long-term biomonitoring studies indicate that environmental damage (e.g., loss of sensitive taxa) incurred was reversed when insecticide applications ceased.     

Cytotaxonomic confirmation of two forms of Simulium sirbanum in the eastern part of the Onchocerciasis Control Programme in West Africa

An earlier report (Cheke et al., 1987) of morphological differences between populations of Simulium sirbanum Vajime & Dunbar in West Africa was confirmed cytotaxonomically. Populations with adult males having Type III scutal patterns were associated with male larvae heterozygous for the inversion IS-3, whereas adult males with Type IV scutal patterns were associated with larvae homozygous for IS-3. The taxonomic implications are briefly discussed but the evidence is considered to be inappropriate for resurrecting S. sudanense Vajime & Dunbar. Aspects of the biology of the two forms and their importance in onchocerciasis transmission are discussed.     

Freshwater ecology and biodiversity in the tropics: what did we learn from 30 years of onchocerciasis control and the associated biomonitoring of West African rivers?

To release humans from river blindness, the Onchocerciasis Control Programme in West Africa (OCP) was implemented in 1974 and ended in 2002. It has emphasized preservation of biodiversity and inclusion of long-term freshwater biomonitoring since its inception, a position that is unique among the other international development programmes. The biodiversity of the disease system of river blindness includes the black fly vector complex and the worm parasite. Several species of black fly vectors differ in their behaviour, which causes differences in the disease transmission processes. Likewise, different strains of the worm parasite have different pathogenic potentials and are differently transmitted by the same vector species. This complexity of the onchocerciasis disease system was not expected at the beginning of the control programme. It has been progressively discovered, partly as a result of the improvement of molecular biology techniques during the period of OCP. The biological basis for the control of the disease includes the diversity of invertebrate predators of aquatic stages of the vector as well as the sensitivity of these non-target predators to the diversity of insecticides used during OCP. Both the interspecific and intraspecific (i.e. instar) biodiversity, as well as the diversity of insecticides applied during OCP, produced a diversity of effects on the non-target invertebrates, as well as on the potential predation pressure on the vector from the predators among these non-target invertebrates. Finally two biological products, a microfilaricide drug (ivermectin) enabling chemotherapy of humans, and a biological larvicide (Bt H-14) that became available during OCP, contributed considerably to the success of OCP and provide more examples about the role of greater biodiversity in the more effective control of onchocerciasis. The biomonitoring approach designed to evaluate the environmental effects of OCP activities was also the first, longest, and largest scale biomonitoring programme ever implemented in the tropics. We discuss the criteria used to implement the long-term biomonitoring, as well as problems encountered in operational larviciding and how these were solved. Over the long term, biomonitoring faced various unexpected factors or events that made the interpretation of the results more difficult than thought at the beginning. Some of these factors could have been identified at the beginning of OCP but were underestimated, whereas others could     

The status of Simulium oyapockense and S.limbatum as vectors of human onchocerciasis in Brazilian Amazonia

In an attempt to explain the current distribution of onchocerciasis in the forests of northern Brazil (Moraes et al., 1979, 1986), and its potential for dispersal to other areas, this study compares the vector status of Simulium oyapockense Floch and Abonnenc, 1946 in both a hypoendemic and an onchocerciasis free area with that of S. limbatum Knab, 1915 in the latter area. Both species allowed the full development of Onchocerca volvulus (Leuckart) to the infective L3 stage after experimental infection with microfilariae. Their vector competence was significantly lower than for other efficient vector species in South America and Africa because of the lethal effect of the cibarial armature on ingested microfilariae. The low vector capacity of S. oyapockense, together with the low prevalence and intensity of infection of O. volvulus, probably explains why onchocerciasis has not significantly increased in intensity over the last 10 years in the hypoendemic part of the Amazonian focus. Omnipresence of both vector species in the adjacent savanna region, however, could facilitate the spread of onchocerciasis if human population movements continue from the hyperendemic part of the onchocerciasis focus.     

Population biology of human onchocerciasis.

Human onchocerciasis (river blindness) is the filarial infection caused by Onchocerca volvulus and transmitted among people through the bites of the Simulium vector. Some 86 million people around the world are at risk of acquiring the nematode, with 18 million people infected and 600,000 visually impaired, half of them partially or totally blind. 99% of cases occur in tropical Africa; scattered foci exist in Latin America. Until recently control programmes, in operation since 1975, have consisted of antivectorial measures. With the introduction of ivermectin in 1988, safe and effective chemotherapy is now available. With the original Onchocerciasis Control Programme of West Africa coming to an end, both the new African Programme for Onchocerciasis Control and the Onchocerciasis Elimination Programme for the Americas, rely heavily on ivermectin self-sustained mass delivery. In consequence, the need for understanding the processes regulating parasite abundance in human and simuliid populations is of utmost importance. We present a simple mathematical framework built around recent analyses of exposure- and density-dependent processes operating, respectively, within the human and vector hosts. An expression for the basic reproductive ratio, R0, is derived and related to the minimum vector density required for parasite persistence in localities of West Africa in general and northern Cameroon in particular. Model outputs suggest that constraints acting against parasite establishment in both humans and vectors are necessary to reproduce field observations, but those in humans may not fully protect against reinfection. Analyses of host age-profiles of infection prevalence, intensity, and aggregation for increasing levels of endemicity and intensity of transmission in the Vina valley of northern Cameroon are in agreement with these results and discussed in light of novel work on onchocerciasis immunology.     

Cytological approaches to simuliid biosystematics in relation to the epidemiology and control of human onchocerciasis

This paper presents an overview of advances in cytological research on the biosystematics of vector simuliid complexes in the areas of identification, age grading, and the evolution of resistance in relation to the epidemiology and control of human onchocerciasis. Systematic theory is discussed and relevant examples are given to show its application in predicting and resolving current problems in species identification for New World and Old World vector complexes. These complexes include Simulium damnosum s.l. and S. neavei s.l. from Africa and S. exiguum s.l., S. metallicum s.l., S. ochraceum s.l., and S. oyapockense s.l. from Latin America. The evolution of resistance in S. damnosum s.l. and the need for future molecular research as part of resistance management strategies are discussed.     

Demographic patterns of human antibody levels to Simulium damnosum s.l. saliva in onchocerciasis-endemic areas: An indicator of exposure to vector bites

BackgroundIn onchocerciasis endemic areas in Africa, heterogenous biting rates by blackfly vectors on humans are assumed to partially explain age- and sex-dependent infection patterns with Onchocerca volvulus. To underpin these assumptions and further improve predictions made by onchocerciasis transmission models, demographic patterns in antibody responses to salivary antigens of Simulium damnosum s.l. are evaluated as a measure of blackfly exposure.Methodology/Principal findingsRecently developed IgG and IgM anti-saliva immunoassays for S. damnosum s.l. were applied to blood samples collected from residents in four onchocerciasis endemic villages in Ghana. Demographic patterns in antibody levels according to village, sex and age were explored by fitting generalized linear models. Antibody levels varied between villages but showed consistent patterns with age and sex. Both IgG and IgM responses declined with increasing age. IgG responses were generally lower in males than in females and exhibited a steeper decline in adult males than in adult females. No sex-specific difference was observed in IgM responses.Conclusions/SignificanceThe decline in age-specific antibody patterns suggested development of immunotolerance or desensitization to blackfly saliva antigen in response to persistent exposure. The variation between sexes, and between adults and youngsters may reflect differences in behaviour influencing cumulative exposure. These measures of antibody acquisition and decay could be incorporated into onchocerciasis transmission models towards informing onchocerciasis control, elimination, and surveillance.     

Identification of Human Semiochemicals Attractive to the Major Vectors of Onchocerciasis

Background

Entomological indicators are considered key metrics to document the interruption of transmission of Onchocerca volvulus, the etiological agent of human onchocerciasis. Human landing collection is the standard employed for collection of the vectors for this parasite. Recent studies reported the development of traps that have the potential for replacing humans for surveillance of O. volvulus in the vector population. However, the key chemical components of human odor that are attractive to vector black flies have not been identified.

Methodology/Principal Findings

Human sweat compounds were analyzed using GC-MS analysis and compounds common to three individuals identified. These common compounds, with others previously identified as attractive to other hematophagous arthropods were evaluated for their ability to stimulate and attract the major onchocerciasis vectors in Africa (Simulium damnosum sensu lato) and Latin America (Simulium ochraceum s. l.) using electroantennography and a Y tube binary choice assay. Medium chain length carboxylic acids and aldehydes were neurostimulatory for S. damnosum s.l. while S. ochraceum s.l. was stimulated by short chain aliphatic alcohols and aldehydes. Both species were attracted to ammonium bicarbonate and acetophenone. The compounds were shown to be attractive to the relevant vector species in field studies, when incorporated into a formulation that permitted a continuous release of the compound over time and used in concert with previously developed trap platforms.

Conclusions/Significance

The identification of compounds attractive to the major vectors of O. volvulus will permit the development of optimized traps. Such traps may replace the use of human vector collectors for monitoring the effectiveness of onchocerciasis elimination programs and could find use as a contributing component in an integrated vector control/drug program aimed at eliminating river blindness in Africa.     

Progress in controlling the reinvasion of windborne vectors into the western area of the Onchocerciasis Control Programme in West Africa

Since vector control began in 1975, waves of Simulium sirbanum and S. damnosum s.str., the principal vectors of severe blinding onchocerciasis in the West African savannas, have reinvaded treated rivers inside the original boundaries of the Onchocerciasis Control Programme in West Africa. Larviciding of potential source breeding sites has shown that these 'savanna' species are capable of travelling and carrying Onchocerca infection for at least 500 km northeastwards with the monsoon winds in the early rainy season. Vector control has, therefore, been extended progressively westwards. In 1984 the Programme embarked on a major western extension into Guinea, Sierra Leone, western Mali, Senegal and Guinea-Bissau. The transmission resulting from the reinvasion of northern C?te d'Ivoire and Burkina Faso has been reduced by over 95%, but eastern Mali has proved more difficult to protect because of sources in both Guinea and Sierra Leone. Rivers in Sierra Leone were treated for the first time in 1989 and biting and transmission rates in Sierra Leone and Guinea fell by over 90%. Because of treatment problems in some complex rapids and mountainous areas, flies still reinvaded Mali, though biting rates were approximately 70% lower than those recorded before anti-reinvasion treatments started. It was concluded that transmission in eastern Mali has now been reduced to the levels required to control onchocerciasis.     

The thermal constant of the onchocerciasis vector Simulium damnosum s.l. in West Africa

The minimum water temperature for development (t(0)) and the thermal constant (K) for the development of immature stages of Simulium damnosum s.l. (Diptera: Simuliidae) in West Africa were estimated as 20.1 °C and 93 day-degrees, respectively, based on analyses of published data on development rates of eggs, larvae and pupae at different water temperatures (24.0 °C and 31.5 °C). Thus, at a constant water temperature of 30.0 °C (approximately 10 °C above t(0)), adult flies would emerge about 9 days after oviposition. Analysis of a dataset probably restricted to S. damnosum s.s., but for which the temperature for the egg stage varied, revealed a much lower t(0) (16.3 °C) and a much higher K (181 day-degrees), suggesting that the insects' thermal relations may be cytoform-specific. The results will aid control decisions and predictions of possible effects of climate change on sizes and geographic distributions of populations of onchocerciasis vectors in West Africa.