Overview of Onchocerciasis infection in Nigeria: The way forward

1
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

2
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.

3
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.

Alonso, L., Murdoch, M., Jefre-Bonet. (2009).
Psycho-social economic evaluation of
onchocerciasis a literature review. Social
medicine. 4(1)8-31.
4
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.

World Health Organization. (2009).
Onchocerciasis. Retrieved from http//www.who.int
/topics/onchocerciasis/en/
5
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.
6
Overview life cycle
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
7
Epidemiology

• According to WHO, (2009) Onchocerciasis is the
  worlds 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).

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/disease
s/onchocerciasis
8
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.
9
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).
• gt 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
10
The figures in Nigeria

• gt 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_wo
rld/west_africa/nigeria/9858.html World Health
Organization. (2009). Nigeria. Retrieved from
http//www.who.int/apoc/countries/nga/en/
11
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.

Abanobi, O., Anosike, J. (2000). Control of
onchocerciasis in Nzerem-Ikem, Nigeria baseline
prevalence and mass distribution of ivermectin.
Public Health. 114 402-406
12
Climatic map of Nigeria
Climate Map of Nigeria         
                                        
                                                 
Climate of map. (2009). Retrieved from
http//www.onlinenigeria.com/maps/climateMap.asp
13
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.

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
14
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.

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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

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
16
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
17
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.

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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.

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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.
20
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.
21
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.
22
National treatment coverage
World Health Organization. (2009). Rapid
epidemiological mapping of onchocerciasis in
Nigeria. Retrieved from http//www.who.int/apoc/c
ountries/ng_web.jpg
23
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.
24
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.

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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.

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Sustainability of CDTI the way forward

• Empowering the CDTI with a multitiered approach
  to address other tropical co-infections.

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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

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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

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30
Questions
31
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.

32
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
• .

33
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.

34
Reference

• Special Programme for Research Training in
  Tropical Diseases (TDR). (2009). Onchocerciasis.
  Retrieved from http//www.who.int/tdr/svc/diseas
  es/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/c
  ountries/ng_web.jpg