RIVER BLINDNESS (ONCHOCERCIASIS) IN CAMEROON Presented by Ahone Ngujede PhD Student PUBLIC HEALTH Walden University July 28, 2012

PRESENTATION OUTLINE This PowerPoint presentation reviewed River Blindness; considered the mode of transmission, etiology, extent of disease infection, symptoms, control, prevention measures, economic and cultural barriers of the disease. The presentation focused on the Cameroonian community. These will include communities, especially those hardest hit by the disease, public health officials, stakeholders, volunteers, and healthcare providers.

OBJECTIVE OF PRESENTATION Educate Public health officials, volunteers, and the community in particular about river blindness and how to prevent the disease. Encourage those affected by the disease to seek medical help in order to slow down blindness. Help to eradicate the disease, if possible. Encourage stakeholders to help in funding. Promote self-efficacy, sustainability, self-reliance, and local program control.

TARGET AUDIENCE The target audience is the Northern region of Cameroon. This area is most hit by the disease in Cameroon - a lot is not known about river blindness despite its susceptibility. After this presentation, Cameroonians will be able to identify symptoms, control transmission and progression and also see measures in which to prevent the disease. They will protect their families and hopefully some day live in a community free from river blindness.

SELECTED STAKEHOLDERS The Ministry of Public Health in Cameroon. The Fomunyoh Foundation (TFF). Community Agriculture and Environmental protection Association (CAEPA). Breaking Ground Charity in Ngaoundere, Cameroon. Life and Water Development Group (LWDG). Cameroon Association for the Protection and Education of the child. Cameroon Mass media.

RIVER BLINDNESS ETIOLOGY Other names: Onchocerciasis Robles’ disease A roundworm-like parasite called Onchocerca volvulus. Caused by a bite from female blackflies of the genus Simulium. Found near flowing streams and rivers. Center Disease Control and Prevention (2011). Onchocerciasis (River Blindness). Traveler’s Health. Retrieved from http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/onchocerciasis-river-blindness.htm Pennisi, E. (2002). New culprit emerges in river blindness. Science. 295(5561): 1809-1810. doi: 10.1126/science.295.5561.1809 River blindness is a parasite disease that looks like roundworms. It has been regarded as the second leading cause of blindness in the world. Bites from a female blackfly over e period of time causes the disease. It is very common around flowing streams and rivers.

RIVER BLINDNESS ETIOLOGY Continued… A blackfly feeding on the skin of a human host. Photo: WHO/TDR/Stammers. Found mostly in Africa in inter-tropical zones. Considered a vector-borne disease. Attacks the skin and eye. World Health Organization (2012). Onchocerciasis (river blindness)- disease information. Prevention of Blindness and Visual Impairment. Retrieved from http://www.who.int/blindness/partnerships/onchocerciasis_disease_information/en/index.html These flies are mostly found in Africa in the interior places and forests. It attacks the skin and eye of people around these flowing rivers and streams. About 90% of the disease is found in Africa, thus a serious cause for concern.

EXTENT OF RIVER BLINDNESS Worldwide: 2nd main cause of blindness in the world. 90 million estimated to be exposed to Onchocerciasis. About 37 million have been infected. Over 1.5million visually impaired and about 500,000 blind. About 99% of disease found in Africa. Yemen and Latin America are also endangered regions-Mexico, Venezuela, Guatemala, Colombia, Brazil, and Ecuador Winthrop, K. L., Furtado, J. M., Silva, J. C., Resnikoff, S., & Lansingh, V.C. (2011). River Blindness: an old disease on the brink of elimination and control. Journal of Global Infectious Diseases. 3(2): 151-155. . doi: 10.4103/0974-777X.81692 World Health Organization (2012). Onchocerciasis (river blindness)- disease information. Prevention of Blindness and Visual Impairment. Retrieved from http://www.who.int/blindness/partnerships/onchocerciasis_disease_information/en/index.html The second main cause of blindness in the world is caused by Onchocerciasis. It is estimated that 90 million people are exposed to the disease worldwide and about 37 million have been infected. The disease has caused over 1.5 million visual impairment and about 500,00 are blind. Africa is most hardest hit with 99% and other regions to look out for are Yemen and Latin America like Mexico, Ecuador, Brazil, Venezuela, Guatemala, and Colombia.

EXTENT OF RIVER BLINDNESS Continued.. Cameroon: An estimated 5.1 million people infected About 62% of the population is at risk Almost 60,000 people suffer some degree of visual impairment from Onchocerciasis The Carter Center (2010). Making Inventions Out of Necessity to Fight River Blindness. Retrieved from http://www.cartercenter.org/news/features/h/river_blindness/philippe-nwane-aspirator.html Moeller, D. W. (2011). Environmental health (4th ed.). Cambridge, MA: Harvard University Press. As seen in the presentation, an estimated 5.1 million people are infected in Cameroon and about 62% of the population is at risk of the disease. An alarming 60,000 people suffer some kind of visual damage as a result of the disease.

MODE OF TRANSMISSION AND HOST Female blackflies bite infected human host and draws up nematode larvae Blackflies become infected with nematode larvae of Onchocerca volvulus. Blackflies infect other humans while feeding on them. Infected person develops nodules that look like worms Winthrop, K. L., Furtado, J. M., Silva, J. C., Resnikoff, S., & Lansingh, V.C. (2011). River Blindness: an old disease on the brink of elimination and control. Journal of Global Infectious Diseases. 3(2): 151-155. . doi: 10.4103/0974-777X.81692 Blackflies suck on infected people and these blackflies in turn feed and infect other humans during a blood meal. Infected people begin to develop the disease by producing nodule-like worms. .

CLYCLE OF RIVER BLINDNESS TRANSMISSION Life cycle of the black fly. Photo: CDC, http://www.dpd.cdc.gov/dpdx/HTML/Filariasis.htm

MODE OF TRANSMISSION AND HOST Continued… Female worms reproduces over 1000 microfilariae (MF) a day. Symptoms start showing over a long period of time. Cause skin lacerations (discoloration or ‘Leopard skin’) as they reproduce and mate, and subsequently aim for the eye. Winthrop, K. L., Furtado, J. M., Silva, J. C., Resnikoff, S., & Lansingh, V.C. (2011). River Blindness: an old disease on the brink of elimination and control. Journal of Global Infectious Diseases. 3(2): 151-155. doi: 10.4103/0974-777X.81692 An individual has to be beaten several times to develop symptoms of the disease. So it is possible for symptoms to start showing after an extremely long period of exposure. The worms produce thousands of MF a day, so after a certain period of time, there is a huge buildup in the body. After invading the skin, they eventually aim for the eye, causing eye damage.

SYMPTOMS OF RIVER BLINDNESS Adult worms live up to 15years in humans Lifespan of nematode larvae is 2years On the skin: Nodules under the skin, causing itchy skin rashes. Thinning of the skin and discoloration or “leopard skin;” tough and wrinkled. Elephantiasis of scrotum Swollen limbs (edema) Bleeding patches from scratching Adults worms can live up to 15 years in the body with the larvae having a lifespan of about two years (and continue to reproduce daily for these two years). It is important to be able to identify the symptoms of river blindness-thinning, discoloration, tough and wrinkled skin. Bleeding patches, swollen limbs, and elephantiasis of the scrotum. Individuals need to be able to identify these symptoms on the skin.

SYMPTOMS OF RIVER BLINDNESS Continued… Source: neglecteddisease.gov Source: APOC The pictures show victims of river blindness. The skin is discolored, tough and wrinkled.

SYMPTOMS OF RIVER BLINDNESS Continued… In the eyes: Reversible clouding or cornea Excessive tear formation in eyes Itchy, reddish eyes and blurred vision If not treated, permanent clouding, resulting in blindness Center for Disease Control and prevention, (2010). Disease. Parasites-Onchocerciasis (also known as River Blindness). Retrieved from http://www.cdc.gov/parasites/onchocerciasis/disease.html Nettleman, M. D. (2011). Onchocerciasis. Medscape. Retrieved from http://emedicine.medscape.com/article/224309-overview Source: nhm.ac.uk In the eyes, if not treated the clouding could cause river blindness. The eyes also tend to be itchy, reddish, and blurry. As seen in the photo, the disease is very serious. This picture may be disturbing to some people so viewer discretion is advised.

TREATING FOR RIVER BLINDNESS Onchocerciasis disease has no cure. Treatment is available called Ivermectin Brand name is Mectizan First introduced in 1987 by Merck & Co., Inc. Taken orally with a single dose of 150-200ug/kg Very effective and safe treatment with very little side effects. Center for Disease Control and prevention (2011). Onchocerciasis (River Blindness). Traveler’s Health. Retrieved from http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/onchocerciasis-river-blindness.htm Sightsavers International (2010). River blindness. Preventing Blindness. Retrieved from http://www.sightsaversusa.org/our_work/how_we_help/prevention_and_cure/preventing_blindness/16890.html World Health Organization (2012). Onchocerciasis (river blindness)- disease information. Prevention of Blindness and Visual Impairment. Retrieved from http://www.who.int/blindness/partnerships/onchocerciasis_disease_information/en/index.html This disease, does not have any cure, but there was a treatment introduced in 1987 by the medical group Merck & Co., Inc. the brand name for Ivermectin is Mectizan. It is taken orally on a single dose between 150 and 200 micrograms per kilogram. This is determined by the patient’s weight and height. This treatment is said to be very effective and has little to no side effects.

Mectizan/Ivermectin treatment The drug Mectizan/Ivermectin. Mectizan/Ivermectin treatment Source: Adrian Arbib / Sightsavers http://www.sightsaversusa.org/our_work/how_we_help/prevention_and_cure/preventing_blindness/16890.html

TREATING RIVER BLINDNESS Continued… Ivermectin kills up to 95% of larvae of O. volvulus worms. Does not kill adult female worms but suppresses production of microfilariae, which reduces transmission. Relieves extreme skin irritation and itching. Halts disease progression towards blindness. Ivermectin is taken once a year for 16-18 years to break transmission; prevents transmission, morbidity and mortality rate. Basanez, M-G., Pion, S. D., Churcher, T. S., Breitling, L. P., Little, M. P., & Boussinesq, M. (2006). River blindness: a success story under threat? PLoS Medicine. 3(9):1454-1460. doi:10.1371/journal.pmed.0030371 The drug kills up to 95% of the larvae of the worms but it does not kill the adult female worms. It however suppresses them so they reduce the rate of transmission and halts progression of blindness. The medication should be taken once a year to be effective. After 16-18 years it actually reduces transmission rates.

CONTROL AND PREVENTION OF RIVER BLINDNESS No vaccine is available to prevent Onchocerciasis. Most effective measure is to stay away from blackfly infested river areas. Affected areas could also be sprayed with insecticide, thus, controlling the breeding areas Free distribution of Mectizan especially to highly endangered zones The Carter Center (2010). Making Inventions Out of Necessity to Fight River Blindness. Retrieved from http://www.cartercenter.org/news/features/h/river_blindness/philippe-nwane-aspirator.html World Health Organization (2012). Onchocerciasis (river blindness)- disease information. Prevention of Blindness and Visual Impairment. Retrieved from http://www.who.int/blindness/partnerships/onchocerciasis_disease_information/en/index.html River blindness does not have a vaccine so the most effective measure of control and prevention is to avoid areas of blackfly habitats. Affected areas should be sprayed constantly and villagers or inhabitants should be provided Mectizan to suppress or reduce transmission.

Drug distributors working with some of the programs mentioned are seen standing with poles used to measure heights of patients during a mass drug administration. Each dot determines how many tablets of Mectizan will be administered to the patient. Some patients are infants. Source: WHO, Sierra Leone. http://www.neglecteddiseases.gov/target_diseases/onchocerciasis/index.html#symptoms

CONTROL AND PREVENTION OF RIVER BLINDNESS Continued… In order not for River blindness to become a serious public health issue several organizations especially globally are helping to suppress the disease. Some of the widely recognized are: African Programme for Onchocerciasis Control (APOC)-created in 1995. Mectizan Donation program, created in 1987. Onchocerciasis Elimination Programme for the Americas (OEPA)-created in 1992. Onchocerciasis Control Programme (OCP)-created in 1974. River blindness could become a very serious public health issue. Therefore, a lot of international bodies have stepped in and create programs that can help reduce the spread. Some of these programs as mentioned above help distribute medication to the most remote of areas, as well as insecticides. They also send out people to help educate those highly affected.

Helicopter spraying insecticide in flowing waters. This picture shows an helicopter attempting to kill blackflies that live around the banks of rivers and streams. This was made possible by joint efforts of organizations and programs to help eradicate river blindness. Source: OCP: African Programme for Onchocerciasis Control. Retrirved from https://apps.who.int/ocp/slides/index.htm Helicopter spraying insecticide in flowing waters.

CONTROL AND PREVENTION OF RIVER BLINDNESS Continued… Sponsors of these programs include: World Bank, World Health Organization, (WHO), Center for Disease Control and Prevention, (CDC), United Nations, (UN), European/Western, African and Latin American countries. They help educate both victims and non-victims of the disease and also encourage those with the disease to seek help. Moeller, D. W. (2011). Environmental health (4th ed.). Cambridge, MA: Harvard University Press. Sightsavers International (2010). River blindness. Preventing Blindness. Retrieved from http://www.sightsaversusa.org/our_work/how_we_help/prevention_and_cure/preventing_blindness/16890.html World Health Organization, (2011). Ivermectin. African Programme for Onchocerciasis Control (APOC). Retrieved from http://www.who.int/apoc/cdti/ivermectin/en All these programs are sponsored by organizations like the World Bank, WHO, UN Food and Agriculture Organization, and UNDP as well as other African and Latin America countries.

BARRIERS IN TREATING RIVER BLINDNESS Socioeconomic barriers The fear of being beaten by the flies caused people to migrate to less fertile lands. It is expensive to spray infected areas; insecticides are not only expensive but short term. Reduces lifespan of victims by 4-10 years, thus making them less capable of taking care of their families. Most of the men contracted the disease while they were fishing. Adeoye, A. O., Ashaye, A. O., & Onakpoya, O. A. (2010). Perception and attitude of people toward Onchocerciasis (river blindness) in South Western Nigeria. Middle East African Journal of Ophthalmology. 17(4): 310-314. doi: 10.4103/0974-9233.71594 Lands near rivers are more fertile and productive, thus, detrimental to agricultural production both for the humans and animals. Insecticides are very expensive so it is usually not very practical to spray these infected areas as many times as possible. Also, most of the men living in these blackfly infested areas are fishermen, so it is part of their job to be constantly in the waters. After a certain period of time, these men contract the disease and become very sick to provide for their families anymore. Some eventually become blind and become a dependent.

BARRIERS IN TREATING RIVER BLINDNESS Continued… Medical barriers Travelling to extremely remote areas for medication distribution and education is difficult because of the bad roads and weather conditions. Most areas are inaccessible. Adult worms can be removed by surgery, but surgeries are expensive, especially in developing countries. Many can barely afford a daily meal. Adeoye, A. O., Ashaye, A. O., & Onakpoya, O. A. (2010). Perception and attitude of people toward Onchocerciasis (river blindness) in South Western Nigeria. Middle East African Journal of Ophthalmology. 17(4): 310-314. doi: 10.4103/0974-9233.71594 Center for Disease Control and Prevention, (2010). Disease. Parasites-Onchocerciasis (also known as River Blindness). Retrieved from http://www.cdc.gov/parasites/onchocerciasis/disease.html Most of these areas are inaccessible. Surgery is expensive and it is almost impossible to completely take out all the female adult worms that cause river blindness.

BARRIERS IN TREATING RIVER BLINDNESS Continued… Cultural/Religious barriers Lack of knowledge about river blindness. Many victims usually believe magic and witchcraft cause the blindness. They usually call it a curse Many seek treatment from traditional healers or herbalists Several communities would rather visit witch doctors than seek medical attention, not only for river blindness but for every other disease. Adeoye, A. O., Ashaye, A. O., & Onakpoya, O. A. (2010). Perception and attitude of people toward Onchocerciasis (river blindness) in South Western Nigeria. Middle East African Journal of Ophthalmology. 17(4): 310-314.. doi: 10.4103/0974-9233.71594 Center for Disease Control and Prevention, (2010). Disease. Parasites-Onchocerciasis (also known as River Blindness). Retrieved from http://www.cdc.gov/parasites/onchocerciasis/disease.html Many African countries especially in the remote areas still practice black magic. They attribute diseases to curses and would rather seek the help of traditional doctors than modern medication. Most of them are usually very hostile to education and change.

MAIN FOCUS OF PRESENTATION (CONCLUSION) River blindness should not become a serious public health issue. It is controllable and preventable. Stakeholders need to join efforts to help eradicate this disease. Eradicating river blindness in Cameroon will be a successful story of public health improvement in the nation. The focus of this presentation is to expose stakeholders to the problems and severity of river blindness. It is a disease that can be eradicated and controlled, for those who already have it. As mentioned earlier, about 1.5 million people are exposed to this disease. Not only do international organizations need to get involved, but the community as well as stakeholders. This is a very important venture, that, with the help of everyone, Cameroon can one day be free from River Blindness.

REFERENCES Adeoye, A. O., Ashaye, A. O., & Onakpoya, O. A. (2010). Perception and attitude of people toward Onchocerciasis (river blindness) in South Western Nigeria. Middle East African Journal of Ophthalmology. 17(4): 310-314. doi: 10.4103/0974-9233.71594 Basanez, M-G., Pion, S. D., Churcher, T. S., Breitling, L. P., Little, M. P., & Boussinesq, M. (2006). River blindness: a success story under threat? PLoS Medicine. 3(9):1454-1460. doi:10.1371/journal.pmed.0030371 Carter Center (2010). Making Inventions Out of Necessity to Fight River Blindness. Retrieved from http://www.cartercenter.org/news/features/h/river_blindness/philippe-nwane-aspirator.html Center for Disease Control and Prevention-CDC, (2010). Disease. Parasites-Onchocerciasis (also known as River Blindness). Retrieved from http://www.cdc.gov/parasites/onchocerciasis/disease.html Center for Disease Control and Prevention-CDC (2011). Onchocerciasis (River Blindness). Traveler’s Health. Retrieved from http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/onchocerciasis-river-blindness.htm Moeller, D. W. (2011). Environmental health (4th ed.). Cambridge, MA: Harvard University Press. Nettleman, M. D. (2011). Onchocerciasis. Medscape. Retrieved from http://emedicine.medscape.com/article/224309-overview Pennisi, E. (2002). New culprit emerges in river blindness. Science. 295(5561): 1809-1810. doi: 10.1126/science.295.5561.1809 Sightsavers International (2010). River blindness. Preventing Blindness. Retrieved from http://www.sightsaversusa.org/our_work/how_we_help/prevention_and_cure/preventing_blindness/16890.html Winthrop, K. L., Furtado, J. M., Silva, J. C., Resnikoff, S., & Lansingh, V.C. (2011). River Blindness: an old disease on the brink of elimination and control. Journal of Global Infectious Diseases. 3(2): 151-155. doi: 10.4103/0974-777X.81692 World Health Organization-WHO (2012). Onchocerciasis (river blindness)- disease information. Prevention of Blindness and Visual Impairment. Retrieved from http://www.who.int/blindness/partnerships/onchocerciasis_disease_information/en/index.html World Health Organization-WHO (2011). Ivermectin. African Programme for Onchocerciasis Control (APOC). Retrieved from http://www.who.int/apoc/cdti/ivermectin/en

SOURCES FOR FURTHER READING Ubachukwu, P. O., (2006). Socioeconomic impact of Onchocerciasis with particular reference to females and children: a review. Animal Research International; 3(2), 494-504. Retrieved from http://www.zoo-unn.org/ARI%20vols/vol3/vol3-2/Ubachukwu.pdf Hunter, J. M. (2010). River blindness revisited. Geographical Review. 100(4): 559-582. Retrieve from http://www.highbeam.com/doc/1G1-240107733.html Benton, B., Bump, J., Sékétéli, A., & Liese, B. (2002). Partnership and promise: evolution of the African river-blindness campaigns. Annals of Tropical Medicine & Parasitology. 96(1): 5-14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12081251 Center for Disease Control and Prevention (2010). Resources for health professionals. Parasites - Onchocerciasis (also known as River Blindness). Retrieved from http://www.cdc.gov/parasites/onchocerciasis/health_professionals/index.html