Coverage and impact

disease-specific progress
Name of NTD

Deadline for submission 9 March

Onchocerciasis

Disease description
Provide a short description of the epidemiology of the disease
(max 600 characters)
Onchocerciasis, or river blindness, is caused by infection by the filarial worm Onchocerca volvulus which is
transmitted by female black flies of the genus Simulium. Onchocerciasis occurs in 30 countries of the tropical
subSaharan Africa, the African onchocercal belt extending from Senegal in the west to Ethiopia in the east.
Onchocerciasis also occurs to a much lesser degree in Central and South America, and Yemen. Among the 169
million people living in areas where onchocerciasis is endemic, an estimated 37 million were infested. Of these,
4 million patients have skin manifestations and 2 million are blind or severely visually impaired. Symptoms vary
with geographic location; epidemiological studies indicate that onchocerciasis manifests in two main forms,
usually termed savanna and forest. Patients living in the western savanna woodland have a high prevalence of
blindness, whereas cutaneous symptoms are more prevalent in the rainforest and in the East African highlands
extending from Ethiopia to Malawi. (1,2) Onchocercal depigmentation is less commonly seen in patients from
East Africa; lymphadenopathy is more common in the rainforest; and severe skin atrophy is commonly
encountered in the savanna, where the microfilarial load tends to be greater.(3) These clinical differences may
be due to variability in parasite strains and their pathogenicity, differences of vectors and their biting
proclivities, altered host factors associated with genetic susceptibility or host immunity, and history of
coinfection by other parasites. Travelers may acquire the disease during their stay in areas where
onchocerciasis is endemic. (4) However, disease is mostly associated with continuous infection and therefore
longer term stay in endemic areas.
Symptoms
Provide a list of common disease-specific symptoms
(max 300 characters)

Screening methodology
Underline relevant methods, adding any missed descriptions in the space provided

Antigens (native)
Antigens (recombinant)
Blood tests

Clinical criteria
Surveillance
Urine tests

other

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Prevention and treatment

Underline relevant methods, adding any missed descriptions in the space provided

Awareness raising
Behavioural changes
Environmental improvements (communal)
Environmental changes (domestic)
Improved nutrition

other

Medication (PCT)
Medication (antiparasitic)
Medication (symptomatic)
Surgery
Vector control

Skin snip parasitology test

Number of people at risk

Provide details on the total number of people at risk from infection
(max 175 characters)
Recent analyses by the African Programme for Onchocerciasis Control (APOC) estimated more than 169
million people are at risk of infection in 30 African countries south of the Sahara.

Number of treatments provided

Provide details on the total number of disease-specific treatments provided in 2014
(max 175 characters)
In 2013, a total of 1209 health districts in 24 countries reported treatment data out of 28 endemic countries
where regular treatment is implemented. Ivermectin distribution did not take place in CAR due to civil unrest.
Angola implemented CDTI but is yet to submit data. In Nigeria, 3 States (38 districts) are yet to submit data. In
Chad, 13 districts out of 20 are yet to submit data. Overall, 106,822,706 persons out of a total population of
169,196,267 at risk were treated giving 63.2% therapeutic coverage.

Human impact
Provide details of key disease-specific statistics showing impacts to quality of life
(max 175 characters)
Between 1995 and 2010 APOC has averted 8.9 million DALYs (5.1 million due to itch, 70 thousand due to
visual impairment, and 3.7 million due to blindness), and it will avert another 10.1 million DALYs between 2011
and 2015. Impact of annual ivermectin mass treatment on off-target infectious diseases between 1995 and
2010, annual ivermectin mass treatment has cumulatively averted about 500 thousand DALYs from coendemic STH infections, LF, and scabies. This impact comprised an additional 5.5% relative to the total burden
averted from onchocerciasis (9 million DALYs), and indicates that the overall cost-effectiveness of APOC is even
higher than previously reported.
Epidemiological evaluations of the impact of MDA with ivermectin in 13 endemic countries across Africa were
conducted in 1,170 villages examining 256,204. The results showed that country wide elimination of
onchocerciasis infection has been achieved in 3 countries (Burundi, Chad and Malawi) while in the remaining 8
(Central African Republic, Cameroon, Congo, Ethiopia, Equatorial Guniea, Nigeria, Uganda, Tanzania)
elimination has been achieved in specific foci. These results provide further evidence but on a much wider
scale that ivermectin treatment alone can eliminate onchocerciasis infection and probably disease
2

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transmission in Africa.

Progress and challenges

Identify key indicators of progress towards the achievement of WHO Roadmap and London Declaration
objectives; and note key challenges (e.g. resource availability, health, political, environmental) preventing
fulfilment of the goals of the WHO Roadmap and the London Declaration
(max 2100 characters)
Progress
More than 106 million people in 28 countries under regular ivermectin treatment
500,000 DALYs per year averted
More than 181,000 communities mobilized and Workforce of 650,000 community directed
distributors (CDDs) trained and available for other programmes and more than 95,760 health
workers trained on CDTI
Economic Rate of Return of 17%
US $ 7 per DALY averted
Focal and nationwide onchocerciasis infection elimination has been observed in a number of
countries and confirmation will be made using entomological evaluation. Some of the prospective
countries for nationwide elimination are: Malawi, Burundi, Chad, Niger, Senegal, Mali, Guinea Bissau,
Guinea Equatorial, Togo and Benin. Focal elimination has been observed in Tanzania, Nigeria, Burkina
Faso, Guinea, Ethiopia, Republic of Congo and Cameroon.
Challenges
Resource availability: The program has huge resource gap to achieve the new objective of elimination of the
disease in Africa where possible.
Cross border issues: Cross border collaboration is important in achieving and sustaining progress towards
elimination. As a vector borne disease which does not know administrative border cross border collaboration
to accelerate elimination of the disease has been a challenge particularly due to different implementation
capacity and security situation across the border countries.
Loa loa coendemicity: Loiasis has also been an important obstacle to more rapid implementation of national
programmes in areas co-endemic with onchocerciasis because of Severe Adverse Effects (SAEs) that have
followed treatment with ivermectin, in particular in individuals with high parasitic loads.
Conflict and post conflict situation: A major obstacle to the ability of APOC to achieve its goal has been the
impact of conflict on onchocerciasis control, which has occurred in a number of APOC countries. In regions of
conflict, a fractured political climate has led to postponement, interruption, or the slowing of project
implementation, resulting in a need for extra time and money in order to establish successes.
Ebola virus disease outbreak: Three onchocerciasis endemic countries namely Liberia, Serra Leone and Guinea
have been hit by recent Ebola virus disease outbreak halting the implementation of CDTI in 2014. However,
the CDTI network has been used to fight the Ebola outbreak in case identification, contact tracing and
surveillance.

Notes

Duke BO. Geographical aspects of onchocerciasis. Ann Soc Belge Med Trop 1981;61:179- 86.
Woodruff AW, Anderson J, Pettitt LE, Tukur M, Woodruff AH. Some aspects of onchocerciasis in Sudan
savanna and rain-forest. J Trop Med Hyg 1977;80:68 - 73.
Anderson J, Fuglsang H, Hamilton PJ, de Marshall TF. Studies on onchocerciasis in the United
Cameroon Republic. II. Comparison of onchocerciasis in rain-forest and Sudan-savanna. Trans R Soc
Trop Med Hyg 1974;68:209- 22.
McCarthy JS, Ottesen EA, Nutman TB. Onchocerciasis in endemic and nonendemic populations:
differences in clinical presentation and immunologic findings. J Infect Dis 1994;170:736- 41.
Third Progress Report on the London Declaration
submit to uniting@sightsavers.org

Murdoch ME, Hay RJ, Mackenzie CD, et al. A clinical classification and grading system of the
cutaneous changes in onchocerciasis. Br J Dermatol 1993;129:260- 9.
Hagan M. Onchocercal dermatitis: clinical impact. Ann Trop Med Parasitol 1998;92(Suppl 1):S85 - S96.
Enk CD, Anteby I, Abramson N, et al. Onchocerciasis among Ethiopian immigrants in Israel. Isr Med
Assoc J 2003;5:485 - 8.
Ramachandran CP. Improved immunodiagnostic tests to monitor onchocerciasis control
programmesa multicenter effort. Parasitol Today 1993;9:77 - 9.
Nutman TB, Zimmerman PA, Kubofcik J, Kostyu DD. A universally applicable diagnostic approach to
filarial and other infections. Parasitol Today 1994;10:239- 43.
Zimmerman PA, Guderian RH, Aruajo E, et al. Polymerase chain reactionbased diagnosis of
Onchocerca volvulus infection: improved detection of patients with onchocerciasis. J Infect Dis 1994;
169:686- 9.
Stingl P, Ross M, Gibson DW, Ribas J, Connor DH. A diagnostic bpatch testQ for onchocerciasis using
topical diethylcarbamazine. Trans R Soc Trop Med Hyg 1984;78:254- 8.
Newland HS, Kaiser A, Taylor HR. The use of diethylcarbamazine cream in the diagnosis of
onchocerciasis. Trop Med Parasitol 1987; 38:143 - 4.
Don N. Udall Recent Updates on Onchocerciasis: Diagnosis and Treatment Clinical Infectious Diseases
2007; 44:5360
WHO/APOC: JAF20.5 The World Health Organization Year 2014 Progress Reportv1st September 2013
31st August 2014
Coffeng LE, Stolk WA, Zour HGM, Veerman JL, Agblewonu KB, et al. (2013) African Programme for
Onchocerciasis Control 19952015: Model-Estimated Health Impact and Cost. PLoS Negl Trop Dis 7(1):
e2032. doi:10.1371/journal.pntd.0002032

Contact
Dr Jane-Batiste Roungou, Director APOC, WHO (roungouj@who.int)

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