Newsdesk
River blindness elimination in Columbia
The recent announcement that Columbia has eliminated disease caused by Onchocerca volvulus
highlights the dicult task ahead in endemic regions of Africa, Talha Burki reports.
In 1996, Columbia began a mass
drug administration programme
to eliminate onchocerciasis (river
blindness). By 2007, transmission of
onchocerciasis had ceased in the last
remaining focus of infection, Lpex
de Micay, an isolated community in
the southwest of the country, and
drug distribution was discontinued.
On July 29, 2013, WHO announced
that it had veried the elimination of
onchocerciasis from Columbiathe rst
country to eliminate the disease.
Other countries in South America
are not far behind. Transmission of the
infection has either been interrupted or
eliminated in 11 of the regions 13 foci.
Ecuadorlong-thought to have one
of the most intractable onchocerciasis
epidemics among South Americas six
nations with endemic diseasehopes
to attain elimination status some time
next year, subject to a WHO review.
Guatemala and Mexico should follow
soon after, which just leaves Brazil and
Venezuela, where the disease persists
in a nomadic tribe in the remote border
regions among the Amazon rainforest.
WHOs announcement is testament
to South Americas sustained effort,
spearheaded by the Carter Center, to
tackle onchocerciasis. In 1991, the Pan
American Health Organization issued
CNRI/Science Photo Library
Onchocerca volvulus parasitic worms
922
a resolution calling for its elimination
in South America. The population
requiring mass drug administration
is now little more than 20 000, down
from more than 500 000, and the last
new case of blindness attributable to
...perhaps 38 million people are
infected with the parasite,
1 million of whom are blind or
suer serious visual impairment
Onchocerca volvulus occurred in 1995.
Although Columbias achievement is
certainly impressive, its signicance can
be overstated.
Onchocerciasis is an easier problem
to solve in the South American endemic
environment, concedes Mark Taylor
(Liverpool School of Tropical Medicine,
UK). More than 98% of the worldwide
burden of onchocerciasis is in Africa,
in an endemic belt that stretches
from Senegal to Ethiopia (crossing
some of the poorest countries in the
world). Here, there are problems of
resources and accessibility that are not
comparable to those in South America.
Current estimates suggest that
worldwide there are around 123 million
people at risk of onchocerciasis in three
dozen or so endemic countries; perhaps
38 million people are infected with the
parasite, 1 million of whom are blind or
suer serious visual impairment.
Ivermectin is the centrepiece of the
onchocerciasis control efforts. Since
1987, it has been freely donated to
the campaign by Merck, meaning
the cost of distribution is between
US$010070, depending on location.
Although there are hints that drug-
resistance may be developing, Thomas
Unnasch (University of South Florida,
FL, USA) does not believe that this
will be a major problem. There
are biological reasons why we are
unlikely to see resistance develop, he
www.thelancet.com/infection Vol 13 November 2013
explained. It takes many generations
of the parasite for resistance to become
signicant. With onchocerciasis, the
generation time is 2 years, Unnasch
pointed out. Most of the programmes
are talking of 78 years, and three to
four generations really is not long
enough for resistance.
Although this is a crucial advantage,
there are shortcomings to an
elimination programme that relies
exclusively on the distribution of
ivermectin. Chief among these is the
issue of co-infection with Loa loa (eye
worm). For these patients, ivermectin
can trigger adverse events: severe
or fatal encephalopathy. It is one of
the key barriers to success in Africa,
explains Taylor. Moreover, although
ivermectin suppresses the larval
stage, it does not kill adults. Given the
longevity of the parasite, this means
that the drug has to be continually
given for, according to some models,
up to 17 years (other models have even
suggested up to 40 years). Treating
the infection with antibiotics that
target the parasites bacterial symbiont
wolbachia, thereby killing the parasite,
could be more effective, obviating
the need for a long-term presence
(although there are issues of cost).
The South American elimination
eorts were based on distributing two
doses of ivermectin every year. This
breaks transmission in a much shorter
time frame than the annual dosage
which is currently the main strategy in
Africa, said Taylor. A lack of resources
and problems with accessing the
aected population, particularly during
the rainy season, make a two-dose
regimen trickier to apply in Africa, but
Taylor believes it is a crucial next step.
Two doses have been shown to be very
successful in Columbia and elsewhere,
the African programme has to move
more rapidly to endorse this strategy.
 Newsdesk

Early campaigns in West Africa (which
launched its antionchocerciasis eorts
in the mid 1970s) were predicated on
controlling the black y vector, spraying
insecticide along the rivers where the y
breeds. Such campaigns are expensive
and potentially environmentally
damaging, but other forms of vector
control could still play an important
part in future campaigns. In Uganda,
they do ivermectin distribution with
vector control, and it appears to be
an incredibly potent combination,
Unnasch told TLID. Unlike mosquitoes,
black flies can only breed in heavily
oxygenated water, which can only be
found alongside rapids. Hence the
breeding sites are easy to identify and
very specific. The Ugandan efforts
involve community workers wading
into rivers and spraying likely looking
sites. We are seeing clearance and
interruption of transmission in 23 years
rather than 56, adds Unnasch.
Indeed, across the continent, Africas
efforts over the past 30 years have
shown much success. There is evidence
of long-term interruption in Mali,
Chad, Senegal, and Nigeria, and seven
of Ugandas 18 foci seem to have
eliminated transmission. There has
been a lot of progress in Africa, arms
Unnasch. David Molyneux (Liverpool
School of Tropical Medicine) points out
that 50% of the communities reached
by the onchocerciasis campaigns are
more than 20 km from the nearest
health-care facility.
Problem countries remain, chiefly
the Democratic Republic of the
Congo. Without any real working
infrastructure, limited resources
and civil unrest, this is an extremely
challenging environment for those
tasked with drug distribution.
One possibility would be for the
government to take on more
responsibility for the campaign, or to
recruit non-governmental agencies
willing and able to work in the region,
but this is easier said than done.
Molyneux believes that the goal of
elimination as a public health issue,
which has proved problematic in
other neglected tropical diseases, is
appropriate for an infection such as
onchocerciasis. It is a disease that does
not kill anyone, and no-one we are
treating with ivermectin is likely to go
blind. For this year, funding will not be
a problem, but Unnasch worries about
the future. There are storm clouds on
the horizon: moving onwards through
201415, there is going to have to be a
renewed emphasis and commitment.
But there is plenty to suggest that
things are moving in the right direction,
and this is a disease that might die
out on its own once reduced to a few
hundred cases. Acquisition requires
sustained exposure to infected black
ies, and there is high mortality among
the infected larva. In most places we
go, we never see infection after weve
had 3 or 4 years of good high coverage
drug treatment in the community, said
Unnasch. The main thing is to sustain
current eorts. If we cant deliver free
drugs, then I dont think we have any
chance with the more challenging
areas of public health in the tropics,
concluded Molyneux.
Talha Burki

Infectious disease surveillance update

Polio in the Horn of Africa
An outbreak of wild poliovirus in the
Horn of Africa has cause 174 cases in
Somalia, 14 in Kenya, and three in
Ethiopia. As of Oct 1, 2013, three more
suspected cases have been repoted in
South Sudan. The patients suspected
to have the disease are from North
Bahr El Gazal state (close to the border
to Sudan) and Eastern Equatoria state
bringing the total number of cholera
cases in the country to 79 since the rst
case was detected on Sept 5. Ten of the
new cases were reported in the state
of Hidalgo, where a total of 77 cases
of cholera have been reported so far.
Neighbouring countries Nicaragua and
Guatemala remain in state of alert.
E coli O157:H7 in Canada
Labrador, Prince Edward Island, Nova
Scotia, New Brunswick, and Ontario.
Measles in Europe
The Netherlands and Germany have
reported ongoing outbreaks of measles
in the past months. 1540 measle cases
were reported since May 2013 in the
Netherlands, and in Germany, 1520
cases had been reported as of Sept 11.
For more on wild poliovirus in
South Sudan see http://www.
who.int/csr/don/2013_10_01/
en/index.html
For more on cholera in Mexico
see http://www.laprensa.com.
ni/2013/10/04/ambito/164982-
mexico-reporta-79-casos
For more on E coli in Canada see
http://www.cbc.ca/news/burger-
recall-expands-nationally-over-
e-coli-concerns-1.1930971

(close to the border with Kenya and
Uganda). The samples are awaiting
conrmation by genetic sequencing. An
emergency outbreak response is being
organised, including an immediate
supplementary immunisation activity
in and around the aected regions.
Cholera in Mexico
Mexican Authorities have announced
that 12 more cases of cholera have been
reported between Sept 26, and Oct 1,
Health ocials in southwestern Ontario
have announced a link between three
cases of Escherichia coli O157:H7 in
London (ON, USA) and Compliments
brand Super 8 Beef Burgers, which were
recalled on Oct 1. The three patients are
currently recovering. 1 week later, the
recall was expanded to Compliments
brand Super 6 burgers, Presidents
Choice Thick and Juicy burgers, and
Webers Bucket of Burgers. The burgers
were distributed in Newfoundland and
According to WHO, 20 601 measles
cases were reported in 34 countries of
the WHO European Region in the rst
half of 2013. In Wales, 200 students in
a secondary school in Neath Port Talbot
are being oered the MMR vaccination
after one conrmed case and four
suspected cases of measles were
recorded. It comes 3 months after the
end of Wales biggest measles outbreak.
Olaya Astudillo
For more on measles in Europe
see http://www.ecdc.europa.eu/
en/press/news/_layouts/forms/
News_DispForm.
aspx?List=8db7286c-fe2d-476c-
9133-184cb1b568&ID=872&R
For more on measles in Wales
see http://www.wales.nhs.uk/
sitesplus/888/news/29137
ootFolder=%2Fen%2Fpress
%2Fnews%2FLists%2FNews
&Source=http%3A%2F%
2Fwww%2Eecdc%2Eeuropa%
2Eeu%2Fen%2FPages%2Fhome
%2Easpx&Web=86661a14-f

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