Waging War on Tropical Diseases: A Public Health Perspective

1
Waging War on Tropical DiseasesA Public
Health Perspective

• BY
• MARILEE COLE, MD, DTMH
• PROFESSOR, DEPARTMENT OF MEDICINE
• GEORGETOWN UNIVERSITY HOSPITAL

2
Waging War on Tropical Diseases

• Define tropical diseases
• Highlight recent tropical disease research
  efforts
• Review current tropical diseases management

3
Waging War on Tropical Diseases

• Define tropical diseases
• Highlight recent tropical disease research
  efforts
• Review current tropical diseases management

4
What is a Tropical Disease?
5
Sherry Goldyn, MD, MPH, Ben Levy, MD, Cameroon
05, dont wait to find out!
What is a Tropical Disease?
6
What is a Tropical Disease?

• Infection Plus Malnutrition
• Due to Poverty
• In a Warm Climate

7
What is a Tropical Disease?

• Infection Plus Malnutrition
• Due to Poverty
• In a Warm Climate

8
What are Neglected Tropical Diseases (NTD)?
9
A Neglected Tropical Diseases (NTD)

• Select the answer which is NOT TRUE about
  Neglected Tropical Diseases (NTD)
• 1/6 (1 billion) of world population is infected
  by NTD
• Most NTD are spread by insects or contaminated
• water or contaminated soil
• Guinea worm (dracunculiasis) has decreased from
  3.5 million to 25,000, 98 is now mostly in
  Ghana and Sudan.
• The 6 most common NTD are soil helminths,
  malaria, schistosomiasis, lymphatic filariasis,
  trachoma, leprosy
• All NTD cause severe disability and life long
  impairment

10
A Neglected Tropical Diseases (NTD)

• Select the answer which is NOT TRUE about
  Neglected Tropical Diseases (NTD)
• 1/6 (1 billion) of world population is infected
  by NTD
• Most NTD are spread by insects or contaminated
• water or contaminated soil
• Guinea worm (dracunculiasis) has decreased from
  3.5 million to 25,000, 98 is now mostly in
  Ghana and Sudan.
• The 6 most common NTD are soil helminths,
  malaria, schistosomiasis, lymphatic filariasis,
  trachoma, leprosy
• All NTD cause severe disability and life long
  impairment

11
A Neglected Tropical Diseases (NTD)

• 1/6 (1 billion) of world population is infected
  by NTD
• Most NTD are spread by insects or contaminated
• water or contaminated soil
• Guinea worm (dracunculiasis) has decreased from
  3.5 million to 25,000, 98 is now mostly in
  Ghana and Sudan.
• The 6 most common NTD are soil helminths,
  schistosomiasis, lymphatic filariasis, trachoma,
  onchocerciasis, and Chagas disease
• All NTD cause severe disability and life long
  impairment

12
What is the World-wide Burden of Tropical
Diseases?

• 13 Neglected
• Tropical Diseases
• Ascariasis
• Hookworm
• Trichuriasis
• Schistosomiasis
• Lymphatic filariasis
• Trachoma
• Onchocerciasis
• Chagas disease
• Leishmaniasis
• African trypanosomiasis
• Buruli ulcer
• Leprosy
• Dracunculiasis

• Tropical Diseases, including malaria and the
  thirteen (13) neglected tropical diseases, are
  the leading cause of life-years lost to
  disability and premature death.

13
Disability Adjusted Life Years(DALY)

• DALY YLL YLD
• YLL years of life lost due to
• premature mortality
• YLD years lost due to disability
• for incident cases of the
• health condition

14
Causes of Life-Years Lost to Disability
Premature Death
Disability Adjusted Life Years (millions)
Hotez, NEJM, 2007 357 1018-1027
15
WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

16
Tropical Disease Burden(DALYs in thousands)
Malaria (46,486)
WHO,2004
17
Tropical Disease BurdenDALYs vs. Deaths (in
thousands)
Malaria (1,272)
Malaria (46,486)
DEATHS
DALYs
WHO,2004
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How Are We Waging the War on Tropical Diseases?
20
Waging War on Tropical Diseases

• Define tropical diseases
• Highlight recent tropical disease research
  efforts
• Review current tropical diseases management

21
TROPICAL DISEASE RESEARCH (TDR)
Sujoy Tagore, MD, MPH, Cam 06, working in the lab
22
TROPICAL DISEASE RESEARCH (TDR)

• Tropical Disease Research (TDR) focuses
• on neglected infectious diseases that
  disproportionately affect poor and
  marginalized populations
• Co-sponsored by the United Nations Childrens
  Fund (UNICEF), UN Development Program (UNDP), the
  World Bank, and the World Health Organization
  (WHO)
• Established in 1975

23
TROPICAL DISEASE RESEARCH (TDR)

• Basic knowledge
• Improved tools
• Intervention methods
• Improved strategies   

24
TROPICAL DISEASE RESEARCH (TDR)

• Basic knowledge
• Improved tools
• Intervention methods
• Improved strategies   

25
Drugs Brought to Registration

• 13/1393 of all new drugs were for tropical
  diseases (1975-1995)
• TDR developed 50 new tropical diseases drugs in
  the last 25 years
• TDR played a key role in the development of
  ivermectin and DEC for filaria elimination
• The Drugs for Neglected Diseases Initiative
  (DNDi) was recently instituted with Gates support

Pecoul, B. Access to essential drugs in poor
countries A lost battle? Journal of the
American Medical Association, 1999, 281(4)
361-367
26
New Tropical Diseases Drugs(1975-1995)
Pecoul, B. Access to essential drugs in poor
countries A lost battle? Journal of the
American Medical Association, 1999, 281(4)
361-367
27
Kumbo valley during the Hamartan
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Waging War on Tropical Diseases

• Define tropical diseases
• Highlight recent tropical disease research
  efforts
• Review current tropical diseases management

30
WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

31
WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

Trophozoite (Plasmodium falciparum)
32
Number of Malaria Cases and Deaths in 2007?
Anopheles gambiae
33
Number of Malaria Cases and Deaths in 2007?
500,000,000 cases/year gt1,000,000 deaths/year

(WHO, 2007)
34
P. Knowlesi, a 5th species of malaria, was
previously confined to monkeys
35
MALARIA
1998 Goal ½ malaria by 2010
500,000,000 cases/year gt1,000,000 deaths/year
36
MALARIA
1998 Goal ½ malaria by 2010
Artemisinin Combination Therapy Rapid
Diagnosis Insecticide Impregnated
Bednets Intermittent Preventive Therapy
500,000,000 cases/year gt1,000,000 deaths/year
37
B Artemisinins

• Select the answer which is NOT TRUE
• about Artemisinins
• Artemisinins are less efficacious than quinine in
  severe P. falciparum malaria due to evolving
  resistance
• 2. Artemisinins reduce parasites by 10(4)/ cycle
• Artemisinins have activity against all parts
• of the intraerythrocytic life cycle
• Neurotoxicity has been reported in animals,
• but not humans
• Artemisinin binds iron in malaria pigment to
  produce free radicals that damage parasite protein

38
B Artemisinins

• Select the answer which is NOT TRUE
• about Artemisinins
• Artemisinins are less efficacious than quinine in
  severe P. falciparum malaria due to evolving
  resistance
• 2. Artemisinins reduce parasites by 10(4)/ cycle
• Artemisinins have activity against all parts
• of the intraerythrocytic life cycle
• Neurotoxicity has been reported in animals,
• but not humans
• Artemisinin binds iron in malaria pigment to
  produce free radicals that damage parasite protein

39
B Artemisinins

• Artemisinins are as efficacious as quinine in
  severe P. falciparum malaria. There is no
  documentation of clinically significant
• artemisinin resistance.
• 2. Artemisinins reduce parasites by 10(4)/ cycle
• Artemisinins have activity against all parts
• of the intraerythrocytic life cycle
• Neurotoxicity has been reported in animals,
• but not humans
• Artemisinin binds iron in malaria pigment to
  produce free radicals that damage parasite protein

40
MALARIA
Artemisia annua

Artemisinin Combination Therapy
41
Artemisinin Combination Therapy(ACT)

• AS 200 mg AQ 612 mg
• daily x 3 days
• AS 200 mg daily x 3 days
• SP 1500/75 day 1
• AS 200 mg daily x 3 days
• MQ 1 g day 2, .5 g day 3
• Am 20mg / Lu 120 mg bid
• x 3 days
• DP

WHO Malaria Treatment Guidelines, 2006
42
MALARIA
Artemisinin Combination Therapy (ACT)
43
What Malarious Countries Lack a National ACT
Policy?
Malarious countries with national ACT policies
Artemisinin Combination Therapy (ACT)
44
What Malarious Countries Lack a National ACT
Policy?
M
M
M
Malarious countries with NO ACT national policies
M
M
M
M
M
M
Artemisinin Combination Therapy (ACT)
45
Fatou Kama, MD, Cam 08, and her Banso
Hospital medical colleagues happily prescribe ACT
for malaria
46
MALARIA
1998 Goal ½ malaria by 2010
OptiMAL
Artemisinin Combination Therapy Rapid
Diagnosis Insecticide Impregnated
Bednets Intermittent Preventive Therapy
ParaSightF
47
NOW Malaria Rapid Diagnostic Test

• Differentiates P. falciparum from other
  Plasmodium circulating antigens in
• 15 minutes
• P. f. sensitivity 99.7
• P. f. specificity 99.8
• P. v. sensitivity 93.5
• P. v. specificity 94.2
• FDA approved on 6/26/07

Plasmodium falciparum parasitemia levels gt5,000
(parasites/ul).
48
MALARIA
1998 Goal ½ malaria by 2010
OptiMAL
Artemisinin Combination Therapy Rapid
Diagnosis Insecticide Impregnated
Bednets Intermittent Preventive Therapy
ParaSightF
49
MALARIA
1998 Goal ½ malaria by 2010
Artemisinin Combination Therapy Rapid
Diagnosis Insecticide Impregnated
Bednets Intermittent Preventive Therapy
50
Percent of Insecticide-Treated Bednets Used the
Prior Night
bednets used the prior night
Baume, C. AJTMH, 2007 963-971
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Please Knock Before Entering
Please knock before entering
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Malaria Burden in AfricaMeasuring the Progress

• Increasing levels of malaria morbidity and
  mortality estimated, due to deterioration of the
  malaria situation during the 1990s
• 23/53 countries are now using ACT
• 22/53 countries using home management of malaria
  for children
• 14/53 countries have 10x increase
  insecticide-impregnated bednets

54
MALARIA
1998 Goal ½ malaria by 2010
OptiMAL
Artemisinin Combination Therapy Rapid
Diagnosis Insecticide Impregnated
Bednets Intermittent Preventive Therapy
ParaSightF
55
Malaria Prophylaxis during Pregnancy

• By
• Amy Sorensen, GT4,
• Marilee Cole, MD, DTMH
• Tom Welty, MD, MPH

2004-2005
56
Malaria at Banso Hospital in Kumbo, Cameroon
Plasmodium falciparum Malaria in Adults

• Most Common
• Outpatient Diagnosis
• Second Most Common
• Cause of Inpatient Deaths

(2005)
57
Risk Populations to Malarial Disease

• Children under 5
• Pregnant women
• Visitors, immigrants, refugees
• Sickle cell anemia
• HIV/AIDS

58
Complications of Malaria in Pregnancy

• Maternal anemiagt 10,000 maternal deaths per
  year, in Africa alone
• Intrauterine growth retardation (IUGR) from
  impaired nutrient transfer
• Low birth weight (LBW) babies are the single
  greatest risk factor for infant death

59
Malaria Prophylaxis during Pregnancy
Fansidar

• chloroquine

60
Intermittent Preventive Therapy (IPT)

• Sulfadoxine/pyrimethamine
• (Fansidar)
• 500/25 x 3 po stat
• at 24 weeks and 2832 weeks
• of pregnancy
• OR
• if patient entered prenatal care
• after 24 weeks
• Recommended by WHO

61
Malaria Risk Factors in CBCHB Pregnant Cohort

• 95 Women, nearing or recently post-delivery in
  the hospital
• 1st or 2nd pregnancy 53
• adolescent 17
• HIV/AIDS gt 7

62
Medication Choices in CBCHB Cohort

• 60 of CBCHB Cohort took Fansidar
• 30 took adequate Fansidar dosage/s
• 30 took chloroquine, 7 adequately
• 30 either took malaria prophylaxis too late or
  not at all

63
Adequacy of Malaria Prophylaxis in CBCHB Cohort

• 13 of mothers on adequate dosages of Fansidar
  experienced an episode of malaria (a 75
  reduction in malaria incidence).
• 40 of mothers who took adequate dosages of
  chloroquine had an episode of malaria.
• 48 of mothers on no malaria prophylaxis
  developed malaria.

64
Does Timing of Maternal Malaria Alter Infant
Birth Weight?

• Average Infant Birth Weight was 10 lower when
  the mother had malaria before 24 weeks
• ...and 16 lower when after 24 weeks of
  gestation, compared to infants with no maternal
  malaria.

65
MALARIA
1998 Goal ½ malaria by 2010

OptiMAL
Artemisinin Combination Therapy Rapid
Diagnosis Insecticide Impregnated
Bednets Intermittent Preventive Therapy
ParaSightF
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WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

68
WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

Microfilaria (Wuchereria bancrofti)
69
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Geographic Distribution of Lymphatic Filariasis
71
Tropical Disease Burden(DALYs in thousands)
DALYs (thousands)
LF L S AT CD O

WHO,2004
72
LYMPHATIC FILARIASIS
Elephantiasis
Culex mosquito

• 5,644,000 DALYs
• Lymphangitis with insufficient drainage
• for years
• Transmitted by Culex or Anopheles mosquitoes

73
LYMPHATIC FILARIASIS
Elephantiasis

• What is the treatment
• strategy for countries burdened with
• lymphatic filariasis?

74
C Ivermectin

• Select the one correct answer
• Ivermectin therapy in co-endemic areas
• for Onchocerca volvulus and Loa loa
• Eliminates the endosymbiotic Wolbachia bacteria
• Causes nephropathy with high Onchocerca volvulus
  microfilaria (mf) load
• Eliminates both adult worms
• Causes encephalopathy with high Loa loa mf load
• Eliminates Onchocerca volvulus mf

75
C Ivermectin
Loa loa
Onchocerca volvulus

• Select the one correct answer
• Ivermectin therapy in co-endemic areas
• for Onchocerca volvulus and Loa loa
• Eliminates the endosymbiotic Wolbachia bacteria
• Causes nephropathy with high Onchocerca volvulus
  microfilaria (mf) load
• Eliminates both adult worms
• Causes encephalopathy with high Loa loa mf load
• Eliminates Onchocerca volvulus mf

76
C Ivermectin
Loa loa
Onchocerca volvulus

• Ivermectin therapy in co-endemic areas
• for Onchocerca volvulus and Loa loa
• Does not eliminate Wolbachia bacteria
• Does not cause nephropathy with high Onchocerca
  volvulus microfilaria (mf) load
• Does not eliminate either adult worms
• Causes encephalopathy with high Loa loa mf load
• Impairs release of microfilariae from the gravid
  Onchocerca volvulus adult worm

77
Treatment Strategies for Lymphatic Filariasis

• For countries co-endemic for onchocerciasis,
  treat with albendazole plus ivermectin yearly to
  decrease microfilaria (mf)
•  

ivermectin
albendazole
78
Treatment Strategies for Lymphatic Filariasis

• For countries without onchocerciasis
  (River Blindness), treat with albendazole and
  DEC yearly to
• decrease microfilaria (mf)
•  

albendazole
DEC
79
Treatment Strategies for Lymphatic Filariasis

• Treat yearly with albendazole plus
• ivermectin (if co-endemic for
• onchocerciasis) or DEC to decrease
• microfilaria (mf) burden
•  

or

ivermectin
albendazole
DEC
80
LYMPHATIC FILARIASIS (LF)
Elephantiasis

• Mass Drug Administration (MDA) treatment goals
  are 85 coverage and eradication by 2020
• In Africa, Global Program to Eliminate Lymphatic
  Filariasis (PELF) treats 4060

Culex mosquito
81
Lymphatic Filariasis Program Status by Region in
2004
82
Gopi Manthripragada, MD, and Palak Shah, MD, Cam
07, bring Southeast Asias perspective
to Africas medical challenges
83
LYMPHATIC FILARIASIS (LF)
Approved Treatments for Lymphatic Filariasis
Elimination
84
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WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

86
WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

Leishmania amastigote
87
LEISHMANIASIS

88
D What is the ratio of asymptomatic symptomatic
leishmaniasis?
1. 110 2. 11 3. 101 4. 1001 5. 10001

89
D What is the ratio of asymptomatic symptomatic
leishmaniasis?
1. 110 2. 11 3. 101 4. 1001 5. 10001

90
LEISHMANIASIS

• 12 million infected
• Transmitted by sandfly
• Asymptomatic symptomatic
• infections, from 101 to 1001

sandfly
91
LEISHMANIASIS New and improved tools

• Poor response to 28 day antimony treatment
• --regions of increased antimony
• resistance (India)
• --HIV co-infected
• In 2002, TDR fostered the development of
  miltefosine for 28d, a new oral drug
• for visceral leishmaniasis

Kala azar
Sundar, S. Oral Miltefosine for Indian Visceral
Leishmaniasis, NEJM, 2002 347(22) 17391746.

92
LEISHMANIASIS New and improved tools

28 Surveillance Centers for Leishmania and HIV
Co-Infections
Kala azar

93
LEISHMANIASIS New and improved tools

28 Surveillance Centers for Leishmania and HIV
Co-Infections
34 Countries Report Leishmania and
HIV Co-Infection Worldwide
. . . . . . . . . . .
Kala azar

94
Marked Price Reduction of Liposomal Amphotericin

• Price reduced from US 150 ? US 20
• for a 50 mg vial for the treatment of
• visceral and mucosal leishmaniasis
• by Gilead in May, 2007
• Full course at 20 mg/kg now costs
• US 280 for a patient of 35 kg
• Reduced price still too high for
• developing countries treatment programs

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WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

97
WHO Tropical Diseases
Schistosoma Mansoni egg

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

98
SCHISTOSOMIASIS
99
Geographic Distribution of Schistosomiaisis

• t

200,000,000 infected worldwide
100
SchistosomiasisControl Strategy

• 1. What 2 drugs are given to children yearly to
  control schistosomiasis?
• 2. Goal of treatment?
• What drug delivery system
• is used?

101
SchistosomiasisControl Strategy

• 1. Cheaper drugs cost 0.50 per year/per child
  for praziquantel and albendazole (for soil
  transmitted helminths)

102
SchistosomiasisControl Strategy

• 1. Cheaper drugs cost 0.50 per year/per child
  for praziquantel and albendazole (for soil
  transmitted helminths)
• Reduce worm intensity
• 3. Piggy back on the school system for long term
  stability

Partners for Parasite Control (PPC), WHO, 2001
103
Where Is the Schistosomiaisis Control Initiative
(SCI)?

• t

104
Where Is the Schistosomiaisis Control Initiative
(SCI)?

• t

first site
SCI 2006
105
Schistosomiaisis Control Initiative (SCI)

• SCI, as a founding partner of the Global Network
  for Neglected Tropical Disease Control, expanded
  its mission to integrating control or elimination
  of seven NTD
• By 2007, SCI delivered 40 million praziquantel
  treatments against schistosomiasis, and even more
  albendazole doses, plus assisted
• 6 countries to establish national control
  programs

106
A Cautionary Note

• The recent proposal to combine albendazole,
  ivermectin, and praziquantel at a low dose in a
  single tablet and to distribute it to virtually
  all school-age children in the developing world
  risk the emergence of Antihelminthic Resistance.
• Some experts judge the risk to be insignificant,
  but veterinary experiences dictate otherwise.
• The recently published reports on Antihelminthic
  Resistance in human helminths must thus be taken
  seriously and examined critically.

Geerts, S. Drug Resistance in Human Helminths
Current Situation and Lessons from Livestock,
Clinical Microbiology Reviews, April, 2000 13
(2) 207-222.
107
Dr. Susan Kim, Cam 08, and her Cameroon medical
colleague are pleased to take this 8 year old
warning seriously.
108
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109
WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

110
WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

Trypomastigote (Trypanosoma brucei)
111
AFRICAN TRYPANOSOMIASIS

• 100,000 Africans infected
• Much antigenic drift
• East African variant, stage II, treated with
  arsenical
• Tsetse fly attracted to motion, black and blue

112
AFRICAN TRYPANOSOMIASIS

• 3 Epidemics 1896,
• 1920, 1970
• Prevalence in some
• villages in Angola,
• DRC, S. Sudan
• 2050
• Cameroon is an
• endemic area
• Control through
• surveillance and
• networks for treatment

113
Screening and Cases of African Trypanosomiasis
114
Screening and Cases of African Trypanosomiasis

• From 1998 to 2004, with reinforced surveillance,
  the number of new cases throughout the continent
  fell from 37,991 to 17, 616
• In 2005, major outbreaks have been observed in
  Angola, the Democratic Republic of Congo and
  Sudan
• The estimated number of cases is currently
  between 50,000 and 70,000

115
Dr. Jessica Rosen, Cam 06, and Dr. Francine
Tchintseme agree that strong surveillance is
required to control African trypanosomiasis
116
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117
WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

118
CHAGAS DISEASE
Reduviid bug

• Disease of poverty
• and poor housing
• 70 infected for life
• 30 chronic disease
• 10 die

Trypanosoma cruzi
119
CHAGAS DISEASE
Trypanosoma cruzi
Reduviid bug

• Treat early acute disease with nifurtimox x
  90-120 d
• Treatment no benefit in chronic late disease
• Southern Cone houses sprayed yearly

120
Waging War on Tropical Diseases

• Define tropical diseases
• Highlight recent tropical disease research
  efforts
• Review current tropical diseases management

121
Effect of Hurricane Isidore on Triatoma
dimidiata Distribution and Chagas Disease
Transmission Risk in the Yucatan Peninsula of
Mexico
Yucatan Peninsula
Triatoma dimidiata
AJTMH, 2005, 73(6) 1019-1025
122
Maps of T. dimidiata Domestic Abundance Before
and After Hurricane Isidore
Collected bugs village (for Jan-Mar
interpolated for the entire Yucatán
Peninsula)
Sept., 2002
AJTMH, 2005, 73(6) 1019-1025
123
Collections of T. dimidiata Before and After
Hurricane Isidore
P O S T - H U R R I C A N E
P R E - H U R R I C A N E
P R E - H U R R I C A N E
Plt0.05
Plt0.05
AJTMH, 2005, 73(6) 1019-1025
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WHO Tropical Diseases

• Malaria
• Lymphatic Filariasis
• Leishmaniasis
• Schistosomiasis
• African Trypanosomiasis
• Chagas Disease
• Onchocerciasis

126
ONCHOCERCIASIS or River Blindness
127
ONCHOCERCIASIS or River Blindness

• Simulium damnosum needs running water to reproduce

Black fly
128
ONCHOCERCIASIS or River Blindness
Nodules over big joints
Chronic sclerosing keratitis
Leopard skin
Onchocerca volvulus
129
O n c h o c e r c i a s i s needs to be
treated with intermittent ivermectin for the
12--15 year duration of the life of the adult
worm to prevent production of microfilaria which
cause blindness.
130
ONCHOCERCIASIS or River Blindness

• 1974 OCP
• 30M in 11 countries
• 600,000 cases of blindness prevented

ivermectin
The wide-ranging benefits of this achievement
include 600 000 cases of blindness prevented, 18
million children born in now-controlled areas
spared from the risk of river blindness and 25
million hectares of land safe for cultivation and
resettlement. OCP clearly demonstrated the
important role of partnership in health and
socioeconomic development in remote and neglected
areas.
131
ONCHOCERCIASIS or River Blindness

• 1974 OCP 30M in 11 countries
• 1995 APOC 34/90M in 19 countries

ivermectin
132
ONCHOCERCIASIS

• Improved strategies
• Development of strategies for sustainable drug
  delivery post Onchocerciasis Control Program
  (OCP) with insecticide and ivermectin,
  
  
• and African Program for Onchocerciasis
  Control (APOC) with ivermectin

133
Waging War on Tropical Diseases

• Define tropical diseases
• Highlight recent tropical disease research
  efforts
• Review current tropical diseases management

134
How Are We Waging the War on Tropical Diseases?
135
Eliminating Tropical Diseases Takes the
Combined Efforts of Drs. Kim, Kama, Arega, and
Sarin, Cam 08
136
P. S.
137
Nations with Five, Six, or Seven Neglected
Tropical Diseases to Be Targeted for Integrated
Preventive Chemotherapy
Hotez P et al. N Engl J Med 20073571018-1027
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Hotez P et al. N Engl J Med 20073571018-1027
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General Guidelines for Preventive Chemotherapy
for the Seven Most Prevalent Neglected Tropical
Diseases
Hotez P et al. N Engl J Med 20073571018-1027