Elimination of Onchocerciasis in Africa

A paper listing its social determinants, analyzing the approaches taken and evaluating results

Manasvini Vimal Kumar10 April 2014

MADS 6642 Global Health and Human Services Systems

Prof. Carlos Leon

Fairleigh Dickinson University

TABLE OF CONTENTS

Topic Page Number

Introduction 2

Background 5

Project purpose and scope 9

Social determinants of health on Onchocerciasis 10

Interventions 13

Special Contributions 22

Impact of interventions 23

Effect on determinants of health 27

Conclusion 30

References 31

2

ELIMINATION OF ONCHOCERCIASIS IN AFRICA

Africa is quite on track towards elimination and consequent eradication of world's second

most common cause of blindness-Onchocerciasis; following closely the example of the Latin

American country- Columbia, where verification of elimination of Onchocerciasis transmission

had been done in 2012, making it the first country in the world to eradicate the nematode

(PAHO,2013). The implacable efforts of Onchocerciasis Control Program since 1974, and, the

perseverance of African Program of Onchocerciasis Control throughout the endemic zones of the

region, have resulted in WHO to determine that all projects in both phases of the APOC program

are making satisfactory progress (WHO, 2014). This project will delve into the study of social

determinants associated with Onchocerciasis, describing the initiatives taken to address it and

their results, the delivery in the health care systems, and, the policy issues related to it.

Allocation of resources towards elimination of Onchocerciasis will also be studied with regard to

its presentation at the end of the year 2013.

Introduction

The importance of studying Onchocerciasis lies in the fact that it is the world's second

leading cause of blindness (WHO, 2014). However, what is more important is that it is

PREVENTABLE. According to the latest figures available, it is prevalent in 36 countries of the

world, out of which African nations make 83.34% i.e 30 countries, followed by Arabian and

South American countries (WHO, 2014). Out of the 120 million people worldwide being at risk

of this disease, 96% are residing in Africa making it more important to study the disease

here(WHO, 2014). And, out of the 18 million people already infected with this disease, 99% are

Africans and have dermal microfilaria (WHO, 2014). Further, it is even more important to

intervene at this point because, though 6.5 million people have dermal disease, yet, a

3

comparatively smaller proportion of them have actually turned blind, and this gives us an

incentive to prevent blindness in the others (WHO, 2014).

Initial prevalence of river blindness in West Africa

The Figure shows endemic areas of prevalence of River Blindness due to Onchocercavolvulus- The red colored areas first attracted the attention of the OCP program, launched in 1975.

Typically, West Africa, Cameroon, Ghana, Central African Republic, and Democratic Republic

of Congo were severely affected with River Blindness.

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

http://www.who.int/apoc/magazine_final_du_01_juillet_2011.pdf?ua=1 Page-21

4

The widespread prevalence of this disease poses a major socio-economic development

hurdle in the continent (WHO, 2014). The obvious reason is because it causes River Blindness

which incapacitates a person to earn his/her basic livelihood, leading to more dependence and

poverty. To end this vicious circle, it is important to hit the target by understanding the life cycle

of the nematode, its transmission, and determinants of the disease, preventive measures and

treatments available.

Additionally, there is an aspect of Neglected Tropical Diseases, that Onchocerciasis is a

part of, that needs to be addressed. This concept was furthered by '10-90 gap' concept by Global

Forum for Health Research in 2000, that emphasizes the gap between the global burden of

disease and the research efforts being undertaken to deal with these (Spiegal, 2010). This

underpins the lack of efforts by the pharmaceutical industry, to develop drugs and vaccines to

treat and prevent them, and also, on the relatively less prevalence of these diseases in the world

and the fact that they are more prevalent or rather endemic to areas of extreme poverty (Spiegal,

2010). This motivated Pecoul to develop DNDi, i.e Drugs for Neglected Diseases initiative in

2003 (Shetty, 2010). Therefore, this paper is aimed at studying these aspects and particularly the

interventions initiated.

Background

Onchocerciasis, also called River Blindness, is caused due to an infection with

Onchocerca volvulus, a nematode measuring about a meter in length, usually found under the

skin in a coiled form with the opposite sex (Jamison, Feachem, Makgoba,2006). The main vector

is blackfly or Simulium damnosum sensus lato, which breeds around rivers. It picks up immature

nematodal larvae from an infected person during its bite and becomes a host for their

development into sexually mature forms, which then get transmitted into a healthy person

5

through the fly's bite, mature into adult forms in the human body, mate and produce immature

larvae again and rest in encapsulated forms under the skin or in the infected person's eye, causing

blindness, severe irresistible itching, shabby looking skin and ostracism (Jamison, Feachem,

Makgoba,2006). Repeated exposure causes the number of adult worms and microfilaria to rise in

the blood stream and thus more widespread disease takes place (Nettleman, M.D., 2013)

First, a papular rash occurs which causes repeated itching called onchodermatitis

(Nettleman, M.D.,2013). The skin becomes lichenified over time and rather sags down, called

'hanging groin'(Nettleman, M.D., 2013). It also causes patchy de-pigmentation, usually on legs,

called 'leopard skin'(Nettleman, M.D., 2013). 'Sowda' is the name given to the severe pruritis

with de-pigmentation (Nettleman, M.D., 2013).A pictoral reference to Sowda can be seen in

Figure (a). Chronic onchocerciasis in the eyes causes sclerosing keratitis, iridocyclitis and then

river blindness which is the ultimate result of this infection, affecting almost one third of the

infected population (Jamison, Feachem, Makgoba, 2006). The Onchocerciasis Control Program,

that was the first program initiated in 1974, had addressing the issue of blindness as its main

focus (Jamison, Feachem, Makgoba, 2006). The other concerning issue was OSD-

Onchocerciasis Skin Disease which is more prevalent in forest areas where blindness is relatively

less (Jamison, Feachem, Makgoba, 2006). APOC has been able to avert one million DALYs per

year (WHO, 2014). In this paper, focus will be on the policies, interventions and results of

APOC's initiative against Onchocerciasis and I will try to establish that elimination of

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Onchocerciasis is not far from being realized soon.

River Blindness causes- itching, blurred vision, redness, photophobia, and, ultimately blindness

due to dead worms initiating an inflammatory response (Hall, L.R. & Pearlman, E. 1999).

Manifestations of eye disease include anterior and posterior eye disease (Hall, L.R. & Pearlman,

E. 1999). Retinal pigment epithelium atrophies, ultimately leading to sub retinal fibrosis and

blindness (Hall, L.R. & Pearlman, E. 1999). Evidence of cross reactive proteins and auto

immune reactions is also there (Hall, L.R. & Pearlman, E. 1999).

7

Hall, L.R. & Pearlman, E. (1999).Pathogenesis of onchocercal keratitis (River

Blindness).PMC. Retrieved from:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC100248/

Hyperpigmentation due to Onchocerciasis

Severe itching leading to leopard Papular eruptionspatches on skin

8

Source-http://www.bing.com/images/search?q=pictures+of+onchocerciasis&qpvt=pictures+of+onchocerciasis&FORM=IQFRML#view=detail&id=2E1E2B1879C01E5ED1F3B29CC7B956A24DA7D4E0&selectedIndex=29

Nodule formation

Source-http://www.bing.com/images/search?q=pictures+of+onchocerciasis&qpvt=pictures+of+onchocerciasis&FORM=IQFRML#view=detail&id=2E1E2B1879C01E5ED1F3B29CC7B956A24DA7D4E0&selectedIndex=29

Project purpose and scope-

The purpose of this paper is to understand the incidence and prevalence of

Onchocerciasis in Africa in the past, the social determinants of the disease, measures taken by

WHO and other concerned organizations and the effects of these measures on the disease at

present, policy issues concerning it, decision models, and, also estimating its eradication in the

future.

Scope of the paper is limited to:

Analyzing the issue of Onchocerciasis in Africa

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Understanding the social determinants, government and public health care policies

adopted by WHO and decision models affecting the progression/regression of the disease

Evaluation of the methods adopted to deal with the disease and the progress made

Estimating the time and potential for its eradication from Africa

Stumbling blocks for the progress of elimination process

This paper does not focus on:

Onchocerciasis affecting other countries of the world

Approaches taken by other nations to get rid of the disease

Other neglected tropical diseases in Africa

Social Determinants of Health for Onchocerciasis-

1. Poverty- Poverty disables people affected with the disease to be able to seek medical

attention, afford medication or even understand that there is treatment available.

According to WHO, 50% of the African and Asian population does not have access to

medicines that are available and for diseases that are curable (WHO, 2004).Not the

poverty alone, even the distances and therefore access to treatment is extremely difficult

due to huge expanse of area and scattered population (WHO,2004). Hence, innovation is

not a problem, it is the lack of access to available medication that is a problem

(WHO,2004).

2. Lack of education-basic knowledge about threatening symptoms of diseases helps even

people belonging to poorest strata of the society to get vigilant and report these symptoms

to health care providers. But, lack of education, important signals that body gives before

going into morbidity are missed and when it is discovered that a person is ill, it is already

too late and generally, nothing much can be done then. If only the population knew that

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the simulium fly is dangerous because it causes Onchocerca larvae to enter the body

during its bite, it is possible that they could have innovated or locally developed a method

to avoid the fly somehow.

3. Inequity of wealth- Besides the fact that poorer the person, he is more likely to be

unhealthy because of unavailability of resources and inaccessibility to resources; it is

important to emphasise that inequity of wealth at individual level alone does not only

affect the outcomes of diseases, it is basically that the inequity of wealth lies at

international level. According to a WHO article, 'Diseases of the poverty and 10/90 gap',

it is evident that the inequity of wealth is being created by the conservative governments

of African and Asian nations, by not allowing privately funded Research and

Development due to their rules and regulations about owning and transferring property,

keeping their countries from international trade, levying excessive taxes in a way,

discouraging investors, leads to shareholders' uncertainty of earning returns from

investments, and , hence, no investment means 'things will continue the way they are' and

there will be no pharmaceutical research and if there is, it will be according to the

government's broad standards (WHO,2004). For instance, in 1980s, WHO writes that US

Agency for International Development initiated a research for a vaccine for malaria

which costed $ 60 million but with no effective outcome because the pharmaceutical

company had to give out results and the progress report with broad understanding, and

rather generous optimism because they were publically funded (WHO,2004)

4. Poor water and sanitation facilities- The fact is that the climate of Africa is anyway hot

and dry or humid, giving an absolute environment for proliferation of larvae of vectors.

Further, with lack of proper connections of safe drinking water and sanitation systems,

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that have to use any natural resource of water that is available and thus have to go to the

river coasts, where the black fly is abundant in numbers and, so is the prevalence of

Onchocerciasis.

5. Clustered housing- Crowding leads to infection being carried over sooner than if the

population density is lesser. As the simulium flies carry thousands of larvae, so in visit at

a place, they are likely to bite more than just one person, if many people are living

together, hence, transmitting the larvae in a number of people together. Moreover, people

tend to flock around the rivers anyway, giving a huge variety of potential blood meals to

the countless number of flies.

6. Nomadic life- Lack of proper housing facilities and availability of resources leads people

to keep shifting their habitats, thus, spreading the disease over a wider geographical area

too.

7. Disaster and conflicts among states- Specially in the case of Onchocerciasis, APOC

intervention program had to be put on hold in the Central African Republic due to civil

wars, which led to this area being put behind in comparison to its neighbors as regards

the reach for ivermectin treatment was concerned (APOC, 2012). In Sierra Leone also,

the OCP program had to be stopped for 10 years due to civil wars (WHO, 2014).

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Table 22.1 DALYs Lost, by Disease and World Bank Region (thousands)

Disease (date of information)

East Asia and the Pacific

Europe and Central Asia

Latin America and the Caribbean

Middle East and North Africa

South Asia

Sub-Saharan Africa

High-income countries Total

Chagas disease (2001)

  0 1 583 0   0     0   1 585

LF (2001) 373 1   9 4   2,412 1,656 212 4,667

Onchocerciasis (2003)

  0 0   2 0.4 0   481   0 484

Onchocerciasis(latest APOC data)

  0 0   2 0.4 0 1,487   0 1,490

Leprosy (2001)  34 0  18 2   113    24   1 192

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

INTERVENTIONS-

1. Onchocerciasis Control Program 1974-2002

For the very first time, The Onchocerciasis Control Program was started in 1974 in West Africa

and lasted till 2002 (WHO, 2014).

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Program details:

The OCP provided treatment for 25 years and covered an area of 1,200,000 sq. km (Stanford,

2004). Its goal was to improve living conditions with socio-economic upliftment (Stanford,

2004). Earlier, no treatment was known and only preventive measures were taken – Aerial,

environmental-friendly larvicide was sprayed in endemic areas along sides of rivers under

guidance from satellites (Stanford, 2004). In 1987- Ivermectin was orally administered along

with spraying larvicides (Stanford, 2004).The OCP delivered Ivermectin drug and trained local

health workers and administrators on it (Stanford, 2004). The action of Ivermectin was seen on

killed microfilaria, but not adult worms so disease progression was only stopped, but not it’s

transmission (Stanford, 2004). Spraying continued and was extended to the neighboring parts of

the endemic areas to prevent re-visits by blackflies (Stanford, 2004)

Accomplishments

The program could stop the transmission in all areas under operation except Sierra Leone due to

Civil War (Stanford, 2004). It eradicated the disease completely in Kenya and protected 30

million people in 11 countries from contracting the disease which translates into 600, 000 people

been prevented from blindness (Stanford, 2004) .18 million children born in the endemic areas

were not at risk of infection (Stanford, 2004). Also, ATP- Annual Transmission Potential, i.e. the

number of larvae received by a person in at an 'insect capture point' during one year, by the

blackflies, fell from 800 to 100 which was an acceptable limit (Stanford, 2004).

Merck and Company donated Ivermectin (Trade name- Mectizan) with a commitment ''as long as

needed and as much as needed'', and, 25 million hectares were made safe and good for

cultivation allowed resettlement due to larvicidal treatment (Stanford, 2004)

Effects of intervention on social determinants-

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The effects on OPC on poverty attribute to the prevention of potential cases of blindness and

treatment of cutaneous cases that made earning livelihood easier. Resettlement along river's

coasts allowed the original inhabitants to gain back their lands, houses, cultivate crops and

eventually earn money thus ending their nomadic lives and containing the spread of the

infection.

The OCP program provided free medication and even larvicidal sprays in the affected

areas, irrespective of whether it belonged to the rich or the poor and if they could afford the

treatment themselves or not, thus having a positive impact on the social determinant of

‘inequity’. By training the local health care providers and administrators about the important

aspects of the disease, and conferring fellowships on African scholars working on the project and

people training the citizens, it also addressed the ‘lack of education’ part (Stanford, 2004)

A survey conducted in Nigeria showed the effects of community education about

Onchocerciasis, through the following results-

Knowledge of Onchocerciasis aetiology increased in 4 regions from previous levels of

79.8% from 48.5%, 71.8% from 48.7%, 74% from 34% and 45% (Manafa, O.U.,

Awolola, T.S., Isamah, A.N. , 2003)

Though the program in Sierra Leone could not halt the transmission, yet, the results obtained

were 10-20% more than those expected (Stanford, 2004). Also, though the program did not

address ‘poor water and sanitation facilities ‘directly, but the spray of eco-friendly larvicides

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made the river water better consumable and settlement easier (Stanford, 2004).

The figure above shows the distribution of WHO supported control programs against Onchocerciasis, in different parts of the world.

OCP-Onchocerciasis Control Program-shaded in black, was the program first started in highly

endemic region of West Africa in 1974 and finished in 2002

APOC-African Program for Onchocerciasis Control-shaded in grey, was started in 1995 and is

still running, it has covered most part of Africa

OEPA- shaded in dark grey was PAHO's attempt to eliminate Onchocerciasis from 6 endemic

countries of Central and South America, it was launched in 1992.

Source- WHO,2014. Retrieved from; http://www.who.int/mediacentre/factsheets/fs095/en/

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OPC Stopped- Although there is no information available as to why the OCP program was

stopped, but, it seems that the primary aim was to stop the transmission of the larvae from the

simulium flies to the people, and since they completed their sprays in the West African area,

except Sierra Leone, therefore, they stopped the program in the endemic region of West Africa,

only to learn from its outcomes and at a later stage, to continue it with more vigor under the

name of APOC-as mentioned below, but with an inovation- that Ivermectin is effective to

remove the vectors too, whereas, earlier it was only known that the drug could be useful for

removal of larvae alone from the blood (WHO,2014). APOC is better than OCP with regards to

the area- it covers 19 countries and uses Ivermectin doses through community involvement

approach, in the form of CDTi i.e Community Directed Treatment with Ivermectin approach,

where people of the community were asked to become a part of the health system and hence

wider areas could be reached with the drug(WHO, 2014).

2. The African Program on Onchocerciasis Control -1995 till date

From 1989 to 1994, there was free mass distribution of Ivermectin by Nongovernmental

Development Organizations, called Ivermectin Distribution Program (IDP) (Stanford, 2004).

After this, in 1991, NGDO Coordination Group for Onchocerciasis was established at UN

Headquarters and then, this group with its past experience of OCP, and with local governments,

other NGOs, launched a program in 1995 called African Program for Onchocerciasis Control

with more concentrated efforts to eradicate the disease from Africa (WHO, 2014).

Program details

This program has 19 African countries as partners in this combined effort. Merck and Co. Inc.

continued the supply of Ivermectin, donor countries and UN agencies helped this program

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(WHO, 2014). Among 19 APOC countries, only 4 areas had shown favorable conditions for

vector control in Uganda, United Republic of Tanzania and Equatorial Guinea (WHO, 2014) and

in these areas, 2-3 year long ground larvicidal, in contrast to aerial larvicidal operations have

been carried out and finished in 2005 (WHO, 2014). Monitoring and finding evidence for

etymological surveillance is under way for confirmation of vector elimination (WHO, 2014)

Interventions-

The approach of distributing the medicine is called Community Directed Treatment with

Ivermectin or CDTi, which became the basis of success against Onchocerciasis (WHO, 2014).

Community Self-Monitoring was also carried out by the people, and is still continuing, and being

helped by PersPective-NGO (APOC, 2012). Community Directed Distributors (CDD) is

employed to dispense and train the people. The involvement of the community has progressed

from 1CDD to 1395 people in 1997 to 1 CDD to 201 in 2009 (APOC, 2012). The local people

are empowered to get a better place for themselves by preventing re- infection and stop the

transmission (WHO, 2014). Rapid Epidemiological Mapping of Onchocerciasis (REMO) was

used to form a guide map of CDTi treatment and areas were divided into Definite CDTi, No

CDTi and Possible CDTi areas (APOC, 2011).

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The figure shows Rapid Epidemiological Mapping of Onchocerciasis (REMO) in countries covered by APOC, 2008, using 3 color scheme marking severity

RED-–HIGHLY ENDEMIC, so, Priority areas for CDTi approach

GREEN- Mass treatment is not required, prevalence of skin nodes </= 20%

YELLOW- Results are not clear here and rapid epidemiological surveys and assessment is required

Source- 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/

19

The target population is 90 million people per year in 19 countries, and making another 115

million free from risk of contraction and 40,000 cases of blindness (WHO, 2014). In 2009, as a

result of the research by Tropical Diseases Research, WHO, in association with APOC; the

realization came with fresh evidence that River Blindness transmission can be actually

eliminated also (WHO,2009). After 5 years of treatment with Ivermectin, 29,000 people and

500,000 black flies were tested for microfilaria and there was no evidence found of renewed

transmission (WHO, 2014).

In 2005, 3 multi-country researches were initiated in Cameroon, Nigeria and Uganda to

understand the importance and effectiveness of CDI approach and thereby, to extend it to

treatments of other diseases as well in the form of integrated delivery system (WHO, 2014).

Other basic health interventions along with treatment for malaria and other tropical diseases were

also extended (APOC, 2014). Micronutrients like vitamin A, and health care items like

insecticide treated bed nets are also dispensed (APOC, 2014). The Program duration has been

extended to 2015 in order to meet objectives of elimination of transmission in war-hit areas

(APOC, 2014).

Effects on Social Determinants of Health

The APOC program covered 19 countries, thus increasing the chances of treating people who

would have moved away from their original places and hence reducing the transmission risks due

to spreading nomadic life. The reason that APOC became a major success was, that there were

many helping hands to promote and ensure that treatment was being taken, especially so because

Ivermectin is required in repeated dosage, sometimes up to several times a year (APOC, 2014)

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The program had been especially extended through the next year for Sierra Leone and other war-

inflicted areas where treatment could not be sent or was interrupted (APOC, 2014). In Central

African Republic also, war halted APOC's activities from 2003 until 2007 (APOC, 2011).

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

Interpretation: As we can see, the prevalence of 'Itching' symptom Onchocerciasis is expected

to be almost negligible by 2015.The number of people affected by 'low vision' due to infection

with Onchocerca volvulus, is expected to be decreased by 50% by 2015

The number of people being blinded by the infection would have reduced by 70% by 2015

Those suffering from the infection itself are likely to be reduced to just 15%.

So, major areas to be worked upon are-Low vision and Blindness

Source-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

21

Special Contributions –

1. According to The International Federation of Pharmaceutical Manufacturers and

Associations, In 2011, there was a 40% increase in the research and development on drugs for

diseases affecting the people in the low and middle income group countries (IFPMA, 2012). In

the 2012 status report of IFPMA, there have been 162 projects on NTDs, out of which 86%, i.e.

140 projects are under Product Development Partnership (IFPMA, 2012). IFPMA members have

pledged a donation of 1.4 billion treatments per year for 10 years from 2011 to 2020 to eradicate

9 major Neglected Tropical Diseases (IFPMA, 2012). Merck-Mectizan Donation Program

introduced in 1987, pledged by Merck& Co. to donate as much Ivermectin in the form of

Mectizan, as required and for however long required and since its inception, 1 billion treatments

have already been donated.

They are currently providing 100 million treatments annually in Latin America, Africa and

Yemen and have proposed a combination treatment of Albendazole and Ivermectin in endemic

areas of NTDs to get 2 aims with 1 shot (IFPMA, 2012).

2. European and Developing Countries Clinical Trials Partnership- is a European

organization that was created in 2003 to give European contribution to 3 major diseases-

Tuberculosis, HIV/AIDS and Malaria. However, now it has turned its focus to Neglected

Tropical Diseases

Partnership is the basis of the organization, the 14 European Union countries, Norway and

Switzerland have partnered with some North African countries for research and development

(EDCTP, 2012). All its R&D partnerships are with sub-Saharan countries (EDCTP, 2012). It

funded $ 3.05 billion in 2011 for research and development of NTDs (EDCTP, 2012)

It has been following the collaborative framework with partner organizations.

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IMPACT OF INTERVENTIONS

Kaduna, Zamfara and Ebonyi states of Nigeria have achieved elimination and, Taraba and Cross

River, are also on the way to elimination (APOC, 2012). 25 million hectares of arable has been

regained for agriculture (APOC, 2014). 4 million children born after the start of control efforts

are free from the risk of infection (APOC, 2012). Infact, CDTi structure is being used to deliver

treatments of Vitamin A deficiency and Lymphatic Filariasis also (APOC, 2012). OCP started in

7 West African countries and later spread to 11, saving 600, 000 people from blindness and the

success of OPC enabled the formation of MDSC-Multi Disease Surveillance Centre (APOC,

2012). NGDO group has provided following treatments during 1989-2009

460 million in APOC countries

116 million in ex-OCP countries

In Sudan, from 10% coverage of geographical and therapeutic area in 2004, there has been a 9

fold increase to 90% geographical coverage and 50% therapeutic coverage in 2009 (APOC,

2012). In Sierra Leone, The National Onchocerciasis Control Program was gradually improved

over 2003-2009 after the civil war (APOC, 2012).

Therapeutic coverage has increased from 54.8% in 2005 to more than 65% since 2006

(APOC, 2012)

Geographical coverage has increased from 64.3% in 2005 to 100% now (APOC, 2012).

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West Africa

Year/Numbers 1975 2014

Affected 1 million None

Blinded 35,000 300,000

prevented

Serious Eye Problems 100,000

Negligible re-infection is a guide towards progress.

5 years' post treatment blood tests in 29,000 people and 500,000 black flies shows no

evidence of re-infection (WHO,2014).

The Average Disability weight of selected diseases-(Boutayeb & Boutayeb, 2009)

Onchocerciasis Blindness =0.600

Onchocerciasis itching= 0.068

Onchocerciasis low vision = 0.260

Burden of Disease- in 19 APOC Countries (WHO, 2014)

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

(GRAPH)

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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

The cost estimated for community based interventions with Ivermectin is U.S $ 145 million

through the international donors in APOC countries. Further, an additional 64 million are

donated by Health Departments of States and Non-governmental collaborating organizations

(Jan. H. F., Remme, Finestra, and P.) and as the disease is preventable, and is capable of being

eradicated, The Carter Centre had declared its goal of ‘Eliminating River Blindness’ in 2013

(Staub. E., 2013).

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The graph is an illustration of the effect of involvement of the community, in the form of CDD-

Community Directed Distributors- whose efforts formed the cornerstone of the success of the

African Program of Onchocerciasis Control, by reaching unapproachable remote villages

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

http://www.who.int/apoc/magazine_final_du_01_juillet_2011.pdf?ua=1

Page-15

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How determinants of health changed with interventions-

While the interventions did not affect the determinants of health directly, yet, the effect that

poverty had- that the people were not able to reach medical help or procure medicines, was

removed. Now, with Merck's voluntary donation of free Ivermectin and the efforts of the

community outreach program, they were able to reach the remotest of the areas with the

medicine (APOC, 2012). Next, the lack of education was simultaneously improved as the

community involvement happened, so, they had to train the community people to reach the

common man, and so, in a way knowledge about the disease was spread and more and more

people came to know about the mode of spread, and that treatment was available (APOC, 2012).

The OCP virtually stopped the spread of the disease by spraying insecticide over all the regions

near the rivers, making it arable and useful, so, the nomadic pattern of life could be discontinued

(APOC, 2012). The effect of inequity of wealth was dealt with, in two ways. First, the poor

people received equal treatment with respect to medication and check us etcetera as the rich did;

also, there was significant governmental cooperation for removal of the disease under the APOC

program, where 19 countries fought as one, against the disease and the result is, that they are on

the verge of elimination of Onchocerciasis, expected by 2020, 'itch' is expected to get eliminated

by 2015 (WHO, 2014).

The economic conditions of the affected populations is expected to change after the

interventions, as, the people will be more fit, physically, to do work and earn for themselves and

thus, the interventions not only decreased the burden of disease, but, also, decreased

significantly, the number of DALYs associated with them (Ref- Graphs, page ). Onchocerciasis

led to 400 000 DALYs, leading to loss of economic productivity(African Union, 2013).The

APOC program has been instrumental in averting 1million DALYs annually and prevented 8.9

27

million cases (African Union, 2013).According to statistics, it covered 68.4 million people in

2009, in effect, reached 71% population at high risk, and geographically, covered 91% area

(African Union, 2013). The treatment with Ivermectin is estimated to cost $14-$30 per DALY

averted (African Union, 2013).Also, the rate of return of treatment with Ivermectin, with CDTi

approach, has been calculated to amount to 24% which is very encouraging (African Union,

2013).

The APOC program has been a learning opportunity for the continent's administrations,

to develop public- private partnerships and defeat the very idea of Neglected Tropical Diseases

as they are called due to the comparative neglect they have been receiving at the hands of the

government and the pharmaceutical industries. The African Union has estimated that the

interventions have been able to improve the health of the people such that there has been an

increase in the agricultural and labour productivity amounting to $3.7 billion in the past 39 years

(African Union, 2013).

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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

PURPLE LINES- No of DALYS Averted with APOC (in millions)

GREEN LINES-No of DALYS Lost due to visual impairment, decreasing from 1995 to 2014

RED LINES- No. of DALYS Lost due to blindness, decreasing from 1995 to 2014

BLUE LINES- No. of DALYS Lost due to itch, decreasing from 1995 to 2014 Source of information; 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

29

Conclusion-

In conclusion, there is definitive evidence that not only can the transmission of Onchocerciasis

be halted in Africa, but, the APOC program can eliminate the disease as well (WHO, APOC,

2014). In fact, according to WHO's estimates, at least the dermal i.e. pruritic part of the disease

will be completely eliminated from Africa by 2015 (WHO, 2014). Besides, it is being estimated

that with the progress that Ivermectin treatment has shown under the CDTi regimen, the disease

may be eliminated completely from the continent by 2020 (WHO, APOC 2014). The World

Bank, The Carter Center, The Bill and Melinda Gates Foundation, The US Agency for

International Development and The World Health Organization are financing the project (The

World Bank, 2012).

30

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