Presented by Ijedinma Abanobi, M.P.H Student PUBH Environmental Health Walden University Instructor: Dr. Patrick Tschida Fall, 2011

Topic Presentation Outline This presentation is aimed at educating community leaders and the Nigerian government of the impact of onchocerciasis, while addressing the social and economic burden of the disease in endemic communities in Nigeria. This includes a review of the etiology, mode of transmission, social and economic consequences, control strategies, techniques & challenges. This also includes the role of Non-governmental Organizations, as well as Federal, State and Local Government of Nigeria.

Objectives: Educate and inform community leaders of endemic regions and the Nigerian government of onchcerciasis. Address the social and economic consequences of onchocerciasis. Emphasize on community empowerment, and advocate for social mobilization. Promote partnerships with international NGOs, Foundations, WHO and ministries of health. Promote self-reliance, self-efficacy, sustainability and local control of programs

Target Audience Nigerian government, Policy makers and Stakeholders/NGOs including World Health Organization (WHO), The African Programme for Onchcerciasis Control (APOC) and The Carter Center. Ministries of Health/Department of Public Health Community leaders of affected communities Interested Public

Etiology of Onchocerciasis (River Blindness) Onchocerciasis is a vector-borne disease caused by the filarial worm parasite Onchocerca volvulus. Transmitted by blackflies (Simulum demnosum) which breed in fertile fast flowing rivers. Also known as River Blindness due to its most extreme manifestation and the breeding site of the blackfly. (WHO, 2011; CDC, 2011)

Host and Mode of Transmission Female blackflies bites an infected human host and sucks up larvae of O. volulus Larvae become infective as it develops within the blackfly Infects another human during blood meal Infective larvae migrate and form nodules as they mature Female worm reproduces generating ~1000 microfilariae per day Causes debilitating skin and eye lesions as they migrate and die (WHO, 2011c)

Mode of Transmission Source: River Blindness: A forgotten Disease, The Carter Center. Retrieved from

Magnitude of Onchocerciasis Globally: - second leading cause of blindness - approximately 90 million are at risk of infection - 37 million are infected with the parasite - 500,000 are blind & 1.5 million visually impaired - endemic regions include Africa, Latin America and Yemen In Africa: - 99% of cases present in 27 sub-saharan African countries (WHO, 2011)

Magnitude of Onchocerciasis (Contd) In Nigeria : - Majority are infected with onchocerciasis - 35, 014 hyper-endemic communities - Approximately 28 million individuals reside in these communities (WHO, 2011a: CDC, 2011)

Morbidity Patterns Skin inflammatory response to motile microfilaria causes itching and rashes. Debilitating and disfiguring skin conditions including skin, nodules, hanging groin, leopard skin, thinning of the skin and more. Severe cases impair vision and causes blindness.

Morbidity Patterns (contd.) Skin Nodules - appear when microfilariae forms clusters under the skin - as microfilariae die off, it causes itching within the upper layer of the skin (WHO, 2011c) Image Source: FiLARiA-EU Onchocerciasis Symptoms. Retrieved from

Morbidity Patterns (contd.) Hanging groin - results when microfilariae invades the lymph nodes - destroys skin elasticity as worms migrate to the groin area - this causes loose & hanging folds -more common in men than women Image source: The Filarial Genome Network (2011). Onchocerca volvulus: The Causative Agent of River Blindness.

Morbidity Patterns (contd) Leopard skin - prominent in the lower limbs -intense itching - skin loses elasticity and pigmentation (WHO, 2011) Image Source: APOC. Retrieved from asis/disease/en/index.html

Morbidity Patterns (contd) Impaired vision and blindness - occurs in severe cases when lesions develop in the eye - determined by microfilariae worm load near the eye (WHO, 2011) Image Source: OCP: African Programme for Onchocerciasis Control. Retrieved from

Social Consequences of Onchocerciasis Disruption of family life and relationships - Desertion of from rural to urban parts - affects sexual life of affected couples Limited social interaction - Onset of symptoms reduces self-esteem, reputation - Stigmatization

Social Consequences of Onchocerciasis (contd) Impact on women and children - affects the age of marriage in young women - their choice of their partners - lessens bonding between new mother and child Educational impact on children - children drop out from school to lead blind family members (Ubachukwu, 2006) Image Source: OCP: African Programme for Onchocerciasis Control. Retrieved from

Economic Consequences of Onchocerciasis Direct Costs - include health care costs of rehabilitation Indirect Costs - include costs stemming from the loss of productivity

Economic Consequences of Onchocerciasis Reduces work productivity - individuals afflicted with disabling skin conditions are unable to work - work activities in these communities include farming, fishing, handicraft, trading etc. Urban migration and slum development - unable to access and secure employment - experience extreme poverty and become beggars on the streets - settle in shanty towns and resort to living in slums

Control of Onchocerciasis: Strategies, Techniques and Challenges Vector Control: - ground application or aerial spraying of larvicide in breeding waters of the blackflies Limitations -expensive - concern of the effect of chemicals on the environment including vegetation, aquatic life and the air. Image Source: OCP: African Programme for Onchocerciasis Control. Retrirved from

Control of Onchocerciasis: Strategies, Techniques and Challenges (contd.) Ivermectin (Mectizan®) - Potent and cost- effective - one oral dose annually for 16 – 18 years - gradually destroys and inactivates microfilariae - suppresses reproduction of adult worms (WHO, 2011c) Image Source: WHO, (2011) Ivermectin. Retrieved from en/index.html

Control of Onchocerciasis: Strategies, Techniques and Challenges (contd.) Ivermectin benefits - effective against other intestinal parasites - relieves itching, improves skin texture and less ill health - increase physical vitality and performance (Abanobi et al., 1993; Akogun et al., 2000)

Status of Onchocerciasis Control in Nigeria Initial launch of community-directed treatment with ivermectin (CDTI) project was in 1997 As of 2007, 27 active CDTI projects present Only a single national onchocerciasis task force (NOTF)-secretariat supported projects No vector elimination projects (WHO, 2011a)

Status of Onchocerciasis Control in Nigeria (contd) Ivermectin distribution (as of 2007) - treatment target was , and so far communities have been treated with ivermectin. - covering 96% of endemic communities in 2006 Therapeutic coverage (as of 2007) - treatment target was people, so far people have been treated with ivermectin - covering 79.5% of the infected population Training (as of 2007) are trained or retrained community-directed distributors people per community-directed distributor trained or retrained health workers

Profile of Onchocerciasis in Nigeria Image source: WHO, (2011) African Programme for Onchocerciasis Control (APOC). Retrieved from

Role of International NGOs APOC and OCP by the WHO - Promote control strategies via aerial spraying and donation of Mectizan - Empowering communities in delivery of ivermectin in endemic regions - Work with the government and community leaders in educating and training health workers (WHO, 2011)

Role of Nigerian Federal and State Governments Federal and State Government - Commit, allocate, and manage resources including financial and human resources - Form collaborations and partnerships with NGOs to achieve success - Educate and train health workers in the distribution of ivermectin - Inform local government and community leaders of goals and plans

Role of Local Government and Community Leaders Mobilize community members and health workers in the mass distribution of ivermectin Organize training workshops managed by NGOs and ministries of health Inform community members when ivermectin distribution will take place. Develop self-reliance and self-efficacy of implementing the program Ensure sustainability and local control of programs

Conclusion Successful control of Onchocerciasis possible due to: - the use of a comprehensive regional approach - community participation and empowerment -sustained long-term partnerships (Levine, 2006) More efforts needed: - sustainability of control programs - improvement in the county’s health care system

REFERENCES 1. Abanobi, O.C., Anosike, J.C., Edungbola, L.D., (1993). Observation on the Deworming Effect of Mectizan on Gastro-intestinal Helminths during Onchocerciasis Mass Treatment in Imo State Nigeria. Nig. J. Parasitology 14, Akogun, O. B., Akogun, M. K., Audu, Z., (2000). Community- Perceived Benefits of Ivermectin Treatment in North-Eastern Nigeria. Social Science & Medicine 50: CDC, (2011) Parasites – Onchocerciasis. Retrieved from 4. Levine, R., (2007). Case Studies in Global Health: Millions Saved. Sudbury, MA: Jones and Bartlett 5. Opara, K. N., Fagbemi O. B., Ekwe, A., Okenu D.M.N., (2005). Status of Forest nchocerciasis in the Lower Cross River Basin, Nigeria: Entomologic Profile after Five Years of Ivermectin Intervention. Am. J. Trop. Med. Hyg., 73(2), 371– Ubachukwu, P. O., (2006). Socio-Economic Impact Of Onchocerciasis With Particular Reference To Females And Children: A Review. Animal Research International; 3(2)

REFERENCES (contd) 6 Ubachukwu, P. O., (2006). Socio-Economic Impact Of Onchocerciasis With Particular Reference To Females And Children: A Review. Animal Research International; 3(2), WHO, (2011). Onchocerciasis Control Programme in West Africa (OCP). Retrieved from 8 WHO, (2011a). Afican Programme for Onchocerciasis Control (APOC) Nigeria: Onchocerciasis status. Retrieved from 9 WHO, (2011b). APOC: Life Cycle of Onchocerca volvulus. Retrieved from ml 10 WHO, (2011c). APOC: Ivermectin. Retrieved from