Onchocerciasis control in the Democratic Republic of Congo (DRC): challenges in a post-war environment.

OBJECTIVE: To evaluate onchocerciasis control activities in the Democratic Republic of Congo (DRC) in the first 12 years of community-directed treatment with ivermectin (CDTI). METHODS: Data from the National Programme for Onchocerciasis (NPO) provided by the National Onchocerciasis Task Force (NOTF) through the annual reports of the 21 CDTI projects for the years 2001-2012 were reviewed retrospectively. A hypothetical-inputs-process-outputs-outcomes table was constructed. RESULTS: Community-directed treatment with ivermectin expanded from 1968 communities in 2001 to 39 100 communities by 2012 while the number of community-directed distributors (CDD) and health workers (HW) multiplied. By 2012, there were ratios of 1 CDD per 262 persons and 1 HW per 2318 persons at risk. More than 80% of the funding came from the fiduciary funds of the African Programme for Onchocerciasis Control. The cost of treatment per person treated fell from US$ 1.1 in 2001 to US$ 0.1 in 2012. The therapeutic coverage increased from 2.7% (2001) to 74.2% (2012); the geographical coverage, from 4.7% (2001) to 93.9% (2012). Geographical coverage fell in 2005 due to deaths in loiasis co-endemic areas, and the therapeutic coverage fell in 2008 due to insecurity. CONCLUSIONS: Challenges to CDTI in DRC have been serious adverse reactions to ivermectin in loiasis co-endemic areas and political conflict. Targets for personnel or therapeutic and geographical coverages were not met. Longer term funding and renewed efforts are required to achieve control and elimination of onchocerciasis in DRC.

Ivermectin to reduce malaria transmission: a research agenda for a promising new tool for elimination.

BACKGROUND: The heterogeneity of malaria transmission makes widespread elimination a difficult goal to achieve. Most of the current vector control measures insufficiently target outdoor transmission. Also, insecticide resistance threatens to diminish the efficacy of the most prevalent measures, indoor residual spray and insecticide treated nets. Innovative approaches are needed. The use of endectocides, such as ivermectin, could be an important new addition to the toolbox of anti-malarial measures. Ivermectin effectively targets outdoor transmission, has a novel mechanism of action that could circumvent resistance and might be distributed over the channels already in place for the control of onchocerciasis and lymphatic filariasis. METHODS: The previous works involving ivermectin and Anopheles vectors are reviewed and summarized. A review of ivermectin's safety profile is also provided. Finally three definitive clinical trials are described in detail and proposed as the evidence needed for implementation. Several smaller and specific supportive studies are also proposed. CONCLUSIONS: The use of ivermectin solves many challenges identified for future vector control strategies. It is an effective and safe endectocide that was approved for human use more than 25 years ago. Recent studies suggest it might become an effective and complementary strategy in malaria elimination and eradication efforts; however, intensive research will be needed to make this a reality.

Community-directed interventions for priority health problems in Africa: results of a multicountry study.

OBJECTIVE: To determine the extent to which the community-directed approach used in onchocerciasis control in Africa could effectively and efficiently provide integrated delivery of other health interventions. METHODS: A three-year experimental study was undertaken in 35 health districts from 2005 to 2007 in seven research sites in Cameroon, Nigeria and Uganda. Four trial districts and one comparison district were randomly selected in each site. All districts had established ivermectin treatment programmes, and in the trial districts four other established interventions - vitamin A supplementation, use of insecticide-treated nets, home management of malaria and short-course, directly-observed treatment for tuberculosis patients - were progressively incorporated into a community-directed intervention (CDI) process. At the end of each of the three study years, we performed quantitative evaluations of intervention coverage and provider costs, as well as qualitative assessments of the CDI process. FINDINGS: With the CDI strategy, significantly higher coverage was achieved than with other delivery approaches for all interventions except for short-course, directly-observed treatment. The coverage of malaria interventions more than doubled. The district-level costs of delivering all five interventions were lower in the CDI districts, but no cost difference was found at the first-line health facility level. Process evaluation showed that: (i) participatory processes were important; (ii) recurrent problems with the supply of intervention materials were a major constraint to implementation; (iii) the communities and community implementers were deeply committed to the CDI process; (iv) community implementers were more motivated by intangible incentives than by external financial incentives. CONCLUSION: The CDI strategy, which builds upon the core principles of primary health care, is an effective and efficient model for integrated delivery of appropriate health interventions at the community level in Africa.

[Antiparasitic drugs. Review of the useful drugs in the treatment of classic and emergent parasitic diseases]. / Antiparasitarios. Revisión de los fármacos útiles en el tratamiento de parasitosis clásicas y emergentes.

INTRODUCTION: In the 10 last years, the increase of international travels and immigration from low income countries to Spain was related with an increased of prevalence of parasitic diseases. SOURCE: Critical review of the literature. STRUCTURE: Firstly, several general considerations were made on the antiparasitic drugs revised in this paper. Chemical structures and mechanisms of action of the main drugs with antiparasitic effect were considered in the second part of the review. Further, antiparasitic spectrum of selected drugs, main pharmacokinetical characteristics, usual posology, possible side effects and contraindications were detailed. Finally, some practical aspects, such as interactions and the methods for practical obtention of these drugs are indicated. This information is relevant because in Spain many anti-parasitic drugs may be obtained using non conventional methods. CONCLUSION: In Spain, the increase of parasitic diseases necessitates an update on antiparasitics drugs for their treatment.

Operational lessons from 20 years of the Mectizan Donation Program for the control of onchocerciasis.

The donation of ivermectin (Mectizan, Merck & Co., Inc.) to control onchocerciasis (river blindness) was established in 1987 and has since gradually expanded to provide for >570 million treatments cumulatively over the past 20 years. The Mectizan Donation Program (MDP) operates within a broad partnership in 33 endemic countries in need of mass treatment. Particular operational methods and tools are applied to facilitate ivermectin mass treatment. Drug management has been streamlined, including dosing, tablet size and packaging, and monitoring for adverse events. Much of the experience gained in the development of ivermectin mass treatment can be usefully applied in the recent broader perspective of control of neglected tropical diseases. The most important operational lessons of the MDP include: (i) the need to easily define the target population for treatment using rapid, non-invasive techniques; (ii) the value of a broad partnership; (iii) the great potential of working through community-directed treatment; (iv) the need to streamline all drug management aspects and (v) the importance of operations research to tackle new challenges.

Progress toward elimination of onchocerciasis in the Americas.

The Onchocerciasis Elimination Program for the Americas (OEPA) is a regional initiative and international partnership that has made considerable progress toward its goal since it was launched in 1993. Its strategy is based on mass drug administration of ivermectin (Mectizan, donated by MSD, also known as Merck & Co., Inc., Kenilworth, NJ, USA), twice or four times per year, with at least 85% coverage of eligible populations. From 1989 to 2016, 11 741 276 ivermectin treatments have been given in the Americas, eliminating transmission in 11 of 13 foci. The OEPA's success has had a great influence on programs in Africa, especially Sudan and Uganda, which moved from a control to an elimination strategy in 2006 and 2007, respectively. The successes in the Americas have also greatly influenced WHO guidelines for onchocerciasis transmission elimination. With four of the six originally endemic American countries now WHO verified as having eliminated onchocerciasis transmission, and 95% of ivermectin treatments in the region halted, the regional focus is now on the remaining active transmission zone, called the Yanomami Area, on the border between Venezuela and Brazil. Both countries have difficult political climates that hinder the elimination task in this remote and relatively neglected region. As with other elimination efforts, 'the final inch' is often the most difficult task of all.

Diagnostics for onchocerciasis in the era of elimination.

In the past few years, efforts to eliminate onchocerciasis from Africa have intensified. These efforts are primarily based on the mass distribution of the anti-helminthic drug Mectizan™ (ivermectin). This program has led to the development of new guidelines by the World Health Organization for the verification that transmission has been suppressed and eventually eliminated. The requirements of diagnostic tools for this purpose differ in many ways from tests used to diagnose infection in individuals. In this review, we summarize the progress that has been made to identify diagnostics that meet the specialized requirements needed to verify onchocerciasis elimination, discuss why these tests were selected and summarize the needs that still exist to complete the arsenal of diagnostic tools that will be useful as the goal of elimination is achieved.

After 70 years of fighting an age-old scourge, onchocerciasis in Uganda, the end is in sight.

Onchocerciasis causes severe itching, serious skin disease and ocular damage leading to visual impairment or permanent blindness. It is associated with hanging groin, epilepsy, Nakalanga dwarfism and, most recently, nodding disease. This disease affected communities in 17 transmission foci in 37 districts of Uganda, where about 6.7 million people are once at risk. The efforts against onchocerciasis in Uganda commenced in the late 1940s, when vector control was launched using dichlorodiphenyltrichloroethane; by 1973, Simulium damnosum had been eliminated in the Victoria focus. Success outside of the Victoria focus was short-lived due to changes in government priorities and the political upheavals of the 1970s and 1980s. With the return of political stability, annual treatment with ivermectin through mass drug administration was launched in the early 1990s. Control of the disease has been successful, but there has been failure in interrupting transmission after more than 15 years. In 2007 Uganda launched a nationwide transmission elimination policy based on twice-per-year treatment and vector control/elimination, with a goal of eliminating river blindness nationwide by 2020. By 2017, 1 157 303 people from six foci had been freed from river blindness. This is the largest population ever declared free under World Health Organization elimination guidelines, providing evidence that elimination of river blindness in Africa is possible.

Onchocerciasis in Yemen: moving forward towards an elimination program.

The onchocerciasis focus in Yemen has been known for many years as an endemic area with unique characteristics, notably the atypical and most severe form of onchodermatitis, known as sowda or reactive onchodermatitis (ROD). The national effort to control the disease began in 1992 as an individual case treatment program by administering ivermectin to those presenting with ROD. The challenging geography of the endemic area and the current political and military unrest both underscore a need for special approaches when attempting to eliminate onchocerciasis from this country. An assessment of the national situation regarding this disease was carried out in 2011-2013 aimed at defining the best approach for moving from individual clinical case treatment to elimination of transmission. The history of the control efforts and the current status of the disease are reviewed and the essential changes needed to a mass drug administration (MDA) approach are identified as the national program addresses elimination. Yemen, despite the current troubles, has shown that it can successfully implement MDA programs despite many difficulties and therefore should be supported in its efforts towards countrywide elimination of this infection; however, success will need renewed national and international efforts.

Oral drug therapy for multiple neglected tropical diseases: a systematic review.

CONTEXT: The neglected tropical diseases include 13 conditions that occur in areas of extreme poverty and are poverty promoting. The neglected tropical diseases produce a disease burden almost as great as that associated with human immunodeficiency virus/AIDS, tuberculosis, or malaria, yet are virtually unknown by health care workers in North America, because they occur almost exclusively in the poorest regions of the world. Seven of the most prevalent diseases have existing oral drug treatments. Identifying treatments that are effective against more than 1 disease could facilitate efficient and inexpensive treatment. OBJECTIVES: To systematically review the evidence for drug treatments and to increase awareness that neglected tropical diseases exist and that treatments are available. DATA SOURCES AND STUDY SELECTION: Using a MEDLINE search (1966 through June 2007), randomized controlled trials (RCTs) were reviewed that examined simultaneous treatment of 2 or more of the 7 most prevalent neglected tropical diseases using oral drug therapy. DATA SYNTHESIS: Twenty-nine RCTs were identified, of which 3 targeted 4 diseases simultaneously, 20 targeted 3 diseases, and 6 targeted 2 diseases. Trials were published between 1972 and 2005 and baseline prevalence of individual diseases varied among RCTs. Albendazole plus diethylcarbamazine significantly reduced prevalence of elephantiasis (16.7% to 5.3%), hookworm (10.3% to 1.9%), roundworm (34.5% to 2.3%), and whipworm (55.5% to 40.3%). Albendazole plus ivermectin significantly reduced prevalence of elephantiasis (12.6% to 4.6%), hookworm (7.8% to 0%), roundworm (33.5% to 6.1%), and whipworm (42.7% to 8.9%). Levamisole plus mebendazole significantly reduced prevalence of hookworm (94.0% to 71.8%), roundworm (62.0% to 1.4%), and whipworm (93.1% to 74.5%). Pyrantel-oxantel significantly reduced hookworm (93.4% to 85.2%), roundworm (22.8% to 1.4%), and whipworm (86.8% to 59.5%), while albendazole alone significantly reduced prevalence of hookworm (8.1% to 1.3%), roundworm (28.4% to 0.9%), and whipworm (51.9% to 31.9%). No RCT examined treatment of river blindness or trachoma as part of an intervention to target 2 or more neglected tropical diseases. Adverse events were generally inadequately reported. CONCLUSIONS: At least 2 of the most prevalent neglected tropical diseases can be treated simultaneously with existing oral drug treatments, facilitating effective and efficient treatment. Increasing awareness about neglected tropical diseases, their global impact, and the availability of oral drug treatments is an essential step in controlling these diseases.

Development of antiparasitic drugs in the 21st century.

Prospects for discovering new antiparasitic drugs for veterinary medicine in the coming century will be determined by economic, social and scientific factors. Consolidation in the pharmaceutical industry in general, and the animal health industry in particular, changes the business conditions in which drug discovery for veterinary medicine occurs. Social pressures on traditional animal agriculture and companion animal ownership have shifted the interest of animal companies primarily to pet medicine. Antiparasitic drug discovery is more than ever targeted to the most lucrative market segments, but the excellence of available drugs, and the apparent lack of resistance in important parasites, reduces industrial motivation to invest in parasitology. Veterinary parasitologists in academia will still have the chance to interact with their industrial counterparts in the traditional ways of supporting drug discovery and development. Nonetheless, there are many new opportunities to expand the research horizons of veterinary parasitology to strengthen the case for retaining a significant presence in the animal health industry.

Why do we have so many molecules and biodiversity but so few antiparasite medicines? / Porqué tenemos tantas moléculas bioactivas y biodiversidad pero tan pocas medicinas antiparasitarias?

Natural products are isolated from biodiversity, that is, from plants, microorganisms, insects, and marine organisms; most of the biodiversity is found in about 10-12 countries located around the Equator. For a long time, people chose this option to alleviate diseases and the industry to discover new medicines; however, from the 70's onwards synthetic products have displaced them. Today there is a rebirth of natural products research and annually hundreds of new natural and synthetic bioactive molecules are reported in specialized journals. On the other hands, new drugs are continually required and especially there is a deficit of them to treat the so-called Neglected Diseases, which affect and threaten the health of billions of people in the world. These diseases paradoxically affect almost all megadiverse countries. Thus, the richest countries in biodiversity do not benefit from the use of natural products because research, development and production of new medicines are carried out in more technologically advanced countries. Why do we have so many molecules in biodiversity and journals but so few medicines? How could new antiparasite drugs be developed quickly and cheaply in the countries affected by Neglected Diseases? A feasible alternative is the Mining in Press, that is, the search of molecules in scientific literature. In this paper we analyze the reasons why these valuable substances have not become drugs and remain curiosities of laboratories and libraries, and the advantages of using this approach as a source of drugs or templates to other bioactive molecules.

Los productos naturales son aislados de la biodiversidad, es decir, de plantas, microorganismos y organismos marinos; gran parte de la biodiversidad se encuentra en cerca de 10-12 paises localizados alrededor del Ecuador. Por mucho tiempo, la gente ha seleccionado esta opción para aliviar sus enfermedades y la industria para descubrir nuevas medicinas; sin embargo, desde los años 70s los productos sintéticos los han desplazado. Hoy hay un renacimiento de la investigación de productos naturales y anualmente cientos de nuevas moléculas naturales y sintéticas bioactivas son reportados en las publicaciones especializadas. De otro lado, continuamente se requieren nuevas drogas y especialmente hay un déficit de ellas para tratar las llamadas Enfermedades Olvidadas, que afectan y amenazan la salud de miles de millones de personas en el mundo. Estas enfermedades paradójicamente afectan casi todos los países megadiversos. De esta manera, los países más ricos en biodiversidad no se benefician del uso de productos naturales, ya que la investigación, el desarrollo y la producción de nuevas medicinas se lleva a cabo en países tecnológicamente avanzados. Por qué tenemos tantas moléculas en la biodiversidad y en las publicaciones, pero tan pocas medicinas? Cómo podrían las drogas antiparasitarias ser desarrolladas de manera mas rápida y barata en los países afectados por las Enfermedades Olvidadas? Una posible alternativa es la Minería de las Publicaciones, es decir, la búsqueda de moléculas en la literatura científica. En este artículo nosotros analizamos las razones por la cuales esas valiosas sustancias no han llegado a ser drogas y permanecen como curiosidades de los laboratorios y bibliotecas, y las ventajas de usar esta aproximación como una fuente de drogas o modelos de otras moléculas bioactivas.

Health care at the end of the road: opportunities from 20 years of partnership in onchocerciasis control.

The unprecedented decision of Merck & Co., Inc., to donate ivermectin through the Mectizan(R) Donation Program, has catalysed an exemplary partnership, to distribute the drug to the communities at risk of onchocerciasis, and empower them to take charge of the drug distribution themselves. Integration with other activities has always been part of the plan, but has been accelerated in recent years because of the need to strengthen primary health care, and to meet the challenges of integrating the rapid impact of Neglected Tropical Disease programmes. Activities that have been integrated include provision of vitamin A capsules, elimination of lymphatic filariasis, the distribution of insecticide-treated nets, and comprehensive eye health. Although these integrated activities show promising results for all programmes involved, challenges still remain. The risk of overburdening communities with multiple activities, and the problem of remuneration at the community level, are the major concerns, as is the need for effective coordination. The expanded onchocerciasis control partnership is a model of translating the eighth Millennium Development Goal (MDG), namely 'develop a global partnership for development', into action and also addresses other key MDGs. In 2006, the partnership provided more than 62 million treatments for onchocerciasis control, and offers a firm foundation from which to deliver other needed health interventions while safeguarding the achievements of onchocerciasis control thus far.

Community-directed treatment of lymphatic filariasis in Kenya and its role in the national programmes for elimination of lymphatic filariasis.

We conducted a prospective, cross-sectional study to examine and compare treatment coverage of lymphatic filariasis by the health system (HST) and a health system implemented, community-directed treatment for the control of lymphatic filariasis (ComDT / HS) in 44 randomly selected villages in coastal Kenya. Demographic information on the villages and peripheral health facilities to guide design and implementation was obtained from a situation analysis phase of this study. A series of interactive training sessions on basic biology of lymphatic filariasis, concept and philosophy of ComDT / HS were given to members of the District Health Management Team (DHMT), peripheral health staff, community leaders and community drug distributors (CDDs) prior to ivermectin distribution. An intensive sensitization process of the community by the trained peripheral health staff and community leaders followed before selection of the CDDs. Quantitative and qualitative data for evaluation of the study were collected by coverage surveys of randomly selected households, focus group discussions and interviews, immediately after the drug distribution. Treatment coverage of all eligible persons was 46.5 and 88 % in HST and ComDT/HS villages, respectively, P < 0.001. In comparing treatment coverage by the two study arms in relationship to the distance from a health facility, coverage among HST and not ComDT / HS villages was influenced by distance. In Kenya, ComDT / HS can effectively be implemented by the regular health system and can attain coverage levels compatible with the global filariasis elimination goal.

Developing drugs for developing countries.

Infectious and parasitic diseases create enormous health burdens, but because most of the people suffering from these diseases are poor, little is invested in developing treatments. We propose that developers of treatments for neglected diseases receive a "priority review voucher." The voucher could save an average of one year of U.S. Food and Drug Administration (FDA) review and be sold by the developer to the manufacturer of a blockbuster drug. In a well-functioning market, the voucher would speed access to highly valued treatments. Thus, the voucher could benefit consumers in both developing and developed countries at relatively low cost to the taxpayer.

Waterborne infectious diseases--could they be consigned to history?

The development of water resources, particularly in Africa, has changed the face of the continent, opening up land for agriculture, providing electric power, encouraging settlements adjacent to water bodies, and bringing prosperity to poor people. Unfortunately, the created or altered water bodies provide ideal conditions for the transmission of waterborne diseases and a favorable habitat for intermediate hosts of tropical parasitic infections that cause disease and suffering. The recent progress in control of these waterborne and vector-borne diseases, such as guinea worm, schistosomiasis, lymphatic filariasis, and onchocerciasis, suggests that many of them could be controlled effectively by 2015, which is the target for reaching the Millennium Development Goals. Donations of safe and effective drugs by several pharmaceutical companies, funds for delivering these donated drugs from foundations and bilateral donors, and effective global health partnerships should make these diseases history.