Overview of Onchocerciasis infection in Nigeria: The way forward Anidi MaryStella, MPH Student Walden University PH6165-4 Environmental Health Instructor: Dr. Raymond Thron 4TH Term, 2009 My name is Anidi, MaryStella an MPH student at Walden University. I live in Winnipeg, Manitoba, Canada. We will start with a little ice breaker.

Objectives At the end of this presentation, we would have: Increased understanding of onchocerciaisis. Increased understanding of the devastating impact of onchocerciasis on rural dwellers in Nigeria. Increase our knowledge about best practices and translate such practices into a national strategy for effective prevention and control measures. Increase our knowledge about sustainable strategies for controlling the diseases. Welcome everyone, it is a great privilege for me to present this short detailed presentation. I will begin with the learning objectives for this presentation.

Onchocerciasis Also known as river blindness A chronic disease caused by a filarial nematode Onchocerca volvolus O. volvolus is transmitted to humans by blood-sucking blackflies- Simulium damnosum. O. volvolus infests the eyes and epidermal tissues of humans with microfilaria. This presentation will be a participatory discussion. I believe that as esteemed executives and official of the ministry of health you will have more information to share with us in addition to this presentation. Your participation is highly appreciated. This presentation is very limited compared to the wealth of experience you have about prevention and control of tropical diseases perculiar to Nigeria. We will begin with a review of onchocerciasis. Please can some tell me something about river blindness? Do you think it is a new disease? How many of you have heard something about it lately (on the news, internet etc)? Do you think public health can help in preventing its spread in villages? Before we start thinking about how we can help let us first try to understand the disease, its mechanism of transmission, and the impact it has on our community. Public health is wide and encompasses many different areas which makes disease prevention difficult. One might want to amalgamate various measures and integrate them into disease intervention and prevention strategies. Alonso, L., Murdoch, M., Jefre-Bonet. (2009). Psycho-social economic evaluation of onchocerciasis: a literature review. Social medicine. 4(1)8-31.

Overview of onchocerciasis Blackflies- Simulium damnosum breed only in well oxygenated river especially fast flowing rivers. The larvae requires aquatic life to complete its life cycle. Infective larvae gains entrance to humans via exposed wounded skin. Larvae moves to subcutaneous tissues where they become encapsulated and form nodules. With emerging and re-emerging infectious diseases peculiar to the tropics Onchocerciasis is a big issue that requires urgent attention. But with organized community efforts focused on disease prevention coupled with governmental support; this mission of prevention and eradication of onchocerciasis in our villages will be achieved. World Health Organization. (2009). Onchocerciasis. Retrieved from http://www.who.int/topics/onchocerciasis/en/

Overview of onchocerciasis contd. The microfilariae found in the infected humans fluid and blood are transferred to the fly during blood meal. The larvae immobilizes the hosts cellular immune response. The host immune response to the dead microfilariae results in the formation of nodules. Onwujekwe, O., Shi, E., Nwagbo, D., Akpala, C., Okonkwo, P. (1998). Willingness to pay for community-based ivermectin distribution: A study of three onchocerciasis-endemic communities in Nigeria. Tropical Medicine and International Health. 3(10):802-808.

Overview – life cycle Long speeches can be long, tiring, and very boring and that is not the intention of this presentation. The life cycle summarizes the overview in the two slides earlier presented. Please if you have any questions or concern do kindly communicate that to me. Center for Disease Prevention and Control. (2009). Onchocerciasis. Retrieved from http://www.dpd.cdc.gov/dpdx/hTML/ImageLibrary/A-F/Filariasis/body_Filariasis_il20.htm

Epidemiology According to WHO, (2009) ‘Onchocerciasis is the world’s second leading infectious cause of blindness’ (WHO, 2009). An estimate of 18 million people are infected with Onchocerciasis (Alonso et al, 2009). 99% of infected persons live in Africa (Alonso et al, 2009). The graphical figures about the impact of this infection is explained in this section. Reference 1. Alonso, L., Murdoch, M., Jefre-Bonet. (2009). Psycho-social economic evaluation of onchocerciasis: a literature review. Social medicine. 4(1)8-31. 2. Special Programme for Research & Training in Tropical Diseases (TDR). (2009). Onchocerciasis. Retrieved from http://www.who.int/tdr/svc/diseases/onchocerciasis

Epidemiology Globally, 270,000 preventable blindness resulted in this infection (Alonso et al, 2009). Globally, 500, 000 people are visually impaired as a result of this infection (Alonso et al, 2009). About 40, 000 people become blind annually because of this infection (Alonso et al, 2009). Alonso, L., Murdoch, M., Jefre-Bonet. (2009). Psycho-social economic evaluation of onchocerciasis: a literature review. Social medicine. 4(1)8-31.

Epidemiology contd. Globally, an estimate of 80 million are at risk (Abanobi, O., Anosike, J., 2000). Approximately 40 million persons are at risk in Nigeria (Abanobi, O., Anosike, J., 2000). Current estimates indicates that 7 million Nigerians are infected (Abanobi, et al., 2000). > 120,000 Nigerians are suffering from onchocerciasis related blindness. Abanobi, O., Anosike, J. (2000). Control of onchocerciasis in Nzerem-Ikem, Nigeria: baseline prevalence and mass distribution of ivermectin. Public Health. 114: 402-406

The figures in Nigeria > 1,000,000 adults Nigerians are blind An estimate of 3,000,000 are visually impaired Number targeted for therapeutic onchocerciasis treatment 29, 509, 353 (WHO, 2009). Reference Sight saver. (2009). Important new data about blindness in Nigeria. Retrieved from http://www.sightsavers.org/our_work/around_the_world/west_africa/nigeria/9858.html World Health Organization. (2009). Nigeria. Retrieved from http://www.who.int/apoc/countries/nga/en/

Stratification of national endemicity Mesoendemic zones are the savannah zones of the country. Within the mesoendemic zones some areas have high disease burden. Hyperednemicity zone for Onchocerciasis is within the rain forest zone of the country. Some areas within this zone have low disease burden. I would try to show you the spread in Nigeria. This spread indicates the classification of the disease burden according to geopolitical zones. Abanobi, O., Anosike, J. (2000). Control of onchocerciasis in Nzerem-Ikem, Nigeria: baseline prevalence and mass distribution of ivermectin. Public Health. 114: 402-406

Climatic map of Nigeria Climate Map of Nigeria                                                                                                     Climatic map of Nigeria The following areas are the mesoendemic regions – Kaduna, Kano etc The hyperendemic regions include Imo, Abia etc Climate of map. (2009). Retrieved from http://www.onlinenigeria.com/maps/climateMap.asp

Trend of infection in Nigeria The concentration of the infection is highest in rural agricultural communities. Rural dwellers flee from this plaque and migrate to urban cities disrupting the socioeconomic development in their communities. The burden of the disease in rural communities makes this issue an important public problem. Eliminating tropical diseases from rural dwellers will empower them to be self sufficient which increases their autonomy. They can farm extensively and produce food for urban dwellers. Reference 1 Alonso, L., Murdoch, M., Jefre-Bonet. (2009). Psycho-social economic evaluation of onchocerciasis: a literature review. Social medicine. 4(1)8-31. 2. Abanobi, O., Anosike, J. (2000). Control of onchocerciasis in Nzerem-Ikem, Nigeria: baseline prevalence and mass distribution of ivermectin. Public Health. 114: 402-406

Implication of onchocerciasis infection Health Infects multiple organs. Presence of other co-infections like malaria, typhoid, and other tropical diseases can be debilitating . Psychosocial imbalance. Psychological trauma Big burden on the national health system. Socioeconomic consequences Increases the national poverty level. Onchocerciasis infection have a cascading impact on all sectors of country- health, economy,

Impact of onchocerciasis on rural dwellers Underdevelopment. Social marginalization. Sociocultural stigmatization. Settlement. Increased mortality of affected people due to negligence and lack of proper medical care. Lack of resourceful individuals to advocate for the cause of the community. Economic loss The impact of Onchocerciasis in our villages far outweighs what is displayed on this slide. These villagers automatically become aliens in their own country. No near by village will accept the affected villagers as refugees or refugee claimants because culturally people around would consider them as vessels of disease readily to explode and infect others. Cultural belief associated with tropical disease automatically ostracizes the affected villagers from others. The fertile farm lands becomes fallow A healthy community can farm and produce food crops for their immediate family. Reference 1 Alonso, L., Murdoch, M., Jefre-Bonet. (2009). Psycho-social economic evaluation of onchocerciasis: a literature review. Social medicine. 4(1)8-31. 2. Abanobi, O., Anosike, J. (2000). Control of onchocerciasis in Nzerem-Ikem, Nigeria: baseline prevalence and mass distribution of ivermectin. Public Health. 114: 402-406

Impact on onchocerciasis on the economy The socioeconomic development of fertile lands zones is low thereby affecting the productive of cash crops. Gross National Productivity is low. The cumulative average of the national GDP will be less than $2 (US dollar). The poor communities will solely depend on the average and rich communities for their livelihood and sustenance. Onwujekwe, O., Shu, E., Nwagbo, D., Akpala, O., Okonkwo, P., (1998). Willingness to pay for community-based ivermectin distribution: A study of three onchocerciasis-endemic communities in Nigeria. Tropical Medicine and International Health 3(10):802- 808

Impact of onchocerciasis on the health system The rural health and medical system is in dire need of help. The most affected communities are medically underserved. They presence of co-infection rapidly depletes the limited allocated funds for treating other related illness. This constitutes huge burden of the health system- burden includes cost of treatment, care, and support. Healthcare providers are easily overwhelmed by this infection leading to huge gaps in service delivery. Most healthcare workers in rural areas migrate to urban cities leaving rural dwellers with limited access to medical care. In places where onchocerciasis is prevalent patients grope trusting that some day something good will happen to the health system.

Evidence based practice Village-level education sessions has been proven to be the best practice in addressing tropical diseases because of the following: It empowers villagers with information about disease trend and transmission. It reduces the psychosocial stress and stigma associated with infection. It enables villagers to be actively involved in prevention measures thereby minimizing the burden of the disease. This is important because donor funds allocated for prevention is limited and has no therapeutic funds that will enable people to address the psychological and social effect of infection.

Evidence based practice The prophylactic distribution and administration of ivermectin to villagers and communities in endemic areas is one evidence that reduces the burden of the disease. Treatment adherence is evidentially achievable through proper village-level education. Shu, E., Onwujekwe, O., Lokili, P., Okonkwo, P., (2000). A health club for a community school in south-eastern Nigeria: influence on adult perception of onchocerciasis and compliance with community-based ivermectin therapy. Tropical Medicine and International Health . 5(3):222-226.

Evidence based practice The use of community-directed treatment with ivermectin (CDTI) adopted to eliminated onchocerciasis as a disease of public health importance in tropical regions have been proven to treat millions of people and avert blindness. Evidentially effective use CDTI will be the only profitable approach to eliminate onchocerciasis in Nigeria. Adeboye, G., Akinsanya, B., Otubanjo, A., Ibidapo, C., Atalabi, T., Okwuzu, J., Adejai, E., Braide, E. (2008). Prevalence of loiasis in Ondo State, Nigeria, as evaluated by the rapid assessment procedure for loiasis (RAPLOA). Annal sof Tropical Medicine and Parasitology. 102(3):215-227.

Evidence based practice Effective interruption of transmission of the parasite requires intermittent repeated treatment for many years with the dose of ivermectin rather than an annual dose. Emukah, G., Enyinnanya, U., Olaniran, N., Akpan, E., Hopkins, D., Miri, E., Amazigo, U., Okoronkwo, C., Stanley, A., Rakers, L., Richards, F., Katabarwa, M. (2008Factors affecting the attrition of community-directed distributors of ivermectin, in an onchocerciasis-control programme in the Imo and Abia states of south-eastern Nigeria. Annals of Tropical Medicine and Parasitology. 102(1):45-51.

National treatment coverage From this map it is evident that we need to engage more CDTI to cover those uncovered areas. We also need to sustain the CDTI activities in Nigeria to avoid disease relapse. World Health Organization. (2009). Rapid epidemiological mapping of onchocerciasis in Nigeria. Retrieved from http://www.who.int/apoc/countries/ng_web.jpg

Significance of onchocerciasis infection The national treatment coverage indicates that most areas are not covered. In 2003 it was reported that ivermectin coverage reached its national peak of 70%. This rapidly declined in 2004 to 60.7%. This rapid decline is significantly high and indicates that coverage needs to be sustained Adeboye, G., Akinsanya, B., Otubanjo, A., Ibidapo, C., Atalabi, T., Okwuzu, J., Adejai, E., Braide, E. (2008). Prevelance of loiasis in Ondo State, Nigeria, as evaluated by the rapid assessment procedure for loiasis (RAPLOA). Annal of Tropical Medicine and Parasitology. 102(3):215-227.

Significance of onchocerciasis infection The national treatment coverage indicates that most areas are not covered. This is significantly important because it gives an insight of the estimated cost required to cover such areas. It also indicates the urgency required in reaching the uncovered areas to avoid spread and treatment relapse/resistance. This most importantly signifies that government needs to act immediately. Based on the map showing the treatment coverage in Nigeria

Sustainability of CDTI: the way forward The government can provide incentives for communities and CDTI to sustain the activity. Incentives helps heals and compensates burn out. Structure a formal channel of supervision for the CDTI and support from the health system. Impact the CDTIs with skills in other public health areas . This community development approach will empower them to be useful resources in addressing other tropical diseases.

Sustainability of CDTI: the way forward Empowering the CDTI with a multitiered approach to address other tropical co-infections. Do have suggestions about the way forward? Please kindly share your thoughts and ideas with us? Thanks for those wonderful thoughts and ideas. These information you have provided indicates that experience gives valid insights for future program development. Thanks

Food for thought Collaboratively we can work together to sustain the CDTI initiative. The amalgamation of all approaches and our efforts will lead to the elimination of onchocerciasis as a disease of public health importance in Nigeria No man is an island. Communities can not do this alone. We can not solely do it for the community. In fact if government embarks on this without community involvement abuse is inevitable.

Conclusion We can make a difference in Nigeria. Nigeria can be recreated to become a safe haven for the future generation. Lets work together to make this happen

Questions

Reference Abanobi, O., Anosike, J. (2000). Control of onchocerciasis in Nzerem-Ikem, Nigeria: baseline prevalence and mass distribution of ivermectin. Public Health. 114: 402-406. Adeboye, G., Akinsanya, B., Otubanjo, A., Ibidapo, C., Atalabi, T., Okwuzu, J., Adejai, E., Braide, E. (2008). Prevelance of loiasis in Ondo State, Nigeria, as evaluated by the rapid assessment procedure for loiasis (RAPLOA). Annals of Tropical Medicine and Parasitology. 102(3):215-227. Alonso, L., Murdoch, M., Jefre-Bonet. (2009). Psycho-social economic evaluation of onchocerciasis: a literature review. Social medicine. 4(1)8-31.

Reference Emukah, G., Enyinnanya, U., Olaniran, N., Akpan, E., Hopkins, D., Miri, E., Amazigo, U., Okoronkwo, C., Stanley, A., Rakers, L., Richards, F., Katabarwa, M. (2008Factors affecting the attrition of community-directed distributors of ivermectin, in an onchocerciasis-control programme in the Imo and Abia states of south-eastern Nigeria. Annals of Tropical Medicine and Parasitology. 102(1):45-51. Center for Disease Prevention and Control. (2009). Onchocerciasis. Retrieved from http://www.dpd.cdc.gov/dpdx/hTML/ImageLibrary/A-F/Filariasis/body_Filariasis_il20.htm .

Reference Onwujekwe, O., Shu E., Nwagbo, D., Akpala, C., Okonkwo, P. (1998). Willingness to pay for community-based ivermectin distribution: A study of three onchocerciasis-endemic communities in Nigeria. Tropical Medicine and International Health. 3(10):802-808 Shu, E., Onwujekwe, O., Lokili, P., Okonkwo, P., (2000). A health club for a community school in south-eastern Nigeria: influence on adult perception of onchocerciasis and compliance with community-based ivermectin therapy. Tropical Medicine and International Health . 5(3):222-226.

Reference Special Programme for Research & Training in Tropical Diseases (TDR). (2009). Onchocerciasis. Retrieved from http://www.who.int/tdr/svc/diseases/onchocerciasis. World Health Organization. (2009). Onchocerciasis. Retrieved from http://www.who.int/topics/onchocerciasis/en/ World Health Organization. (2009). Rapid epidemiological mapping of onchocerciasis in Nigeria. Retrieved from http://www.who.int/apoc/countries/ng_web.jpg