Clinical, serological and DNA testing in Bengo Province, Angola further reveals low filarial endemicity and opportunities for disease elimination.

The prevalence of Loa loa, Onchocerca volvulus and Wuchereria bancrofti infections in an under-surveyed area of Bengo Province, Angola, was determined by surveying 22 communities with a combination of clinical, serological and DNA diagnostics. Additional information was collected on participants' duration of residency, access to mass drug administration, knowledge of insect vectors and use of bednets. A total of 1616 individuals (38.1% male: 61.9% female), with an average age of 43 years, were examined. For L. loa, 6.2% (n = 100/16616) individuals were found to have eyeworm, based on the rapid assessment procedure for loiasis (RAPLOA) surveys, and 11.5% (n =178/1543) based on nested PCR analyses of venous blood. L. loa prevalences in long-term residents (>10 years) and older individuals (>60 years) were significantly higher, and older men with eyeworm were better informed about Chrysops vectors. For O. volvulus, 4.7% (n = 74/1567) individuals were found to be positive by enzyme-linked immunosorbent assay (Ov 16 ELISA), with only three individuals reporting to have ever taken ivermectin. For W. bancrofti, no infections were found using the antigen-based immunochromatographic test (ICT) and real-time PCR analysis; however, 27 individuals presented with lymphatic filariasis (LF) related clinical conditions (lymphoedema = 11, hydrocoele = 14, both = 2). Just under half (45.5%) of the participants owned a bednet, with the majority (71.1%) sleeping under it the night before. Our approach of using combination diagnostics reveals the age-prevalence of loiasis alongside low endemicity of onchocerciasis and LF. Future research foci should be on identifying opportunities for more cost-effective ways to eliminate onchocerciasis and to develop innovative surveillance modalities for clinical LF for individual disease management and disability prevention.

Mapping freshwater snails in north-western Angola: distribution, identity and molecular diversity of medically important taxa.

BACKGROUND: This study was designed to determine the distribution and identity of potential intermediate snail hosts of Schistosoma spp. in Bengo, Luanda, Kwanza Norte and Malanje Provinces in north-western Angola. This is an area where infection with Schistosoma haematobium, causing urogenital schistosomiasis, is common but little is yet known about transmission of the disease. Angola has had a varied past with regard to disease control and is revitalising efforts to combat neglected tropical diseases. METHODS: Snails were sampled from 60 water-contact points. Specimens of the genera Bulinus, Biomphalaria or Lymnaea were screened for trematode infections by inducing cercarial shedding. Snails were initially identified using shell morphology; subsequently a cytochrome c oxidase subunit 1 (cox1) gene fragment was amplified from a subset of snails from each site, for molecular identification. Cercariae were captured onto FTA cards for molecular analysis. Specimens of Bulinus angolensis collected from the original locality of the type specimen have been characterised and comparisons made with snails collected in 1957 held at the Natural History Museum, London, UK. RESULTS: In total snails of nine genera were identified using morphological characteristics: Biomphalaria, Bulinus, Gyraulus, Lanistes, Lentorbis, Lymnaea, Melanoides, Physa and Succinea. Significant for schistosomiasis transmission, was the discovery of Bulinus globosus, B. canescens, B. angolensis, B. crystallinus and Biomphalaria salinarum in their type-localities and elsewhere. Bulinus globosus and B. angolensis occurred in two distinct geographical areas. The cox1 sequence for B. globosus differed markedly from those from specimens of this species collected from other countries. Bulinus angolensis is more closely related to B. globosus than originally documented and should be included in the B. africanus group. Schistosoma haematobium cercariae were recovered from B. globosus from two locations: Cabungo, Bengo (20 snails) and Calandula, Malanje (5 snails). Schistosoma haematobium cercariae were identified as group 1 cox1 corresponding to the type common throughout the African mainland. CONCLUSIONS: Various freshwater bodies in north-western Angola harbour potential intermediate snail hosts for urogenital schistosomiasis, highlighting the need to map the rest of the country to identify areas where transmission can occur and where control efforts should be targeted. The molecular phylogeny generated from the samples confirmed that considerable variation exists in B. globosus, which is the primary snail host for S. haematobium in many regions of Africa.

Loa loa vectors Chrysops spp.: perspectives on research, distribution, bionomics, and implications for elimination of lymphatic filariasis and onchocerciasis.

BACKGROUND: Loiasis is a filarial disease caused Loa loa. The main vectors are Chrysops silacea and C. dimidiata which are confined to the tropical rainforests of Central and West Africa. Loiasis is a mild disease, but individuals with high microfilaria loads may suffer from severe adverse events if treated with ivermectin during mass drug administration campaigns for the elimination of lymphatic filariasis and onchocerciasis. This poses significant challenges for elimination programmes and alternative interventions are required in L. loa co-endemic areas. The control of Chrysops has not been considered as a viable cost-effective intervention; we reviewed the current knowledge of Chrysops vectors to assess the potential for control as well as identified areas for future research. RESULTS: We identified 89 primary published documents on the two main L. loa vectors C. silacea and C dimidiata. These were collated into a database summarising the publication, field and laboratory procedures, species distributions, ecology, habitats and methods of vector control. The majority of articles were from the 1950-1960s. Field studies conducted in Cameroon, Democratic Republic of Congo, Equatorial Guinea, Nigeria and Sudan highlighted that C. silacea is the most important and widespread vector. This species breeds in muddy streams or swampy areas of forests or plantations, descends from forest canopies to feed on humans during the day, is more readily adapted to human dwellings and attracted to wood fires. Main vector targeted measures proposed to impact on L. loa transmission included personal repellents, household screening, indoor residual spraying, community-based environmental management, adulticiding and larviciding. CONCLUSIONS: This is the first comprehensive review of the major L. loa vectors for several decades. It highlights key vector transmission characteristics that may be targeted for vector control providing insights into the potential for integrated vector management, with multiple diseases being targeted simultaneously, with shared human and financial resources and multiple impact. Integrated vector management programmes for filarial infections, especially in low transmission areas of onchocerciasis, require innovative approaches and alternative strategies if the elimination targets established by the World Health Organization are to be achieved.

Rapid integrated clinical survey to determine prevalence and co-distribution patterns of lymphatic filariasis and onchocerciasis in a Loa loa co-endemic area: The Angolan experience.

The Republic of Angola is a priority country for onchocerciasis and lymphatic filariasis (LF) elimination, however, the co-distribution of the filarial parasite Loa loa (loiasis) is a significant impediment, due to the risk of severe adverse events (SAEs) associated with ivermectin used in mass drug administration (MDA) campaigns. Angola has a high risk loiasis zone identified in Bengo Province where alternative interventions may need to be implemented; however, the presence and geographical overlap of the three filarial infections/diseases are not well defined. Therefore, this study conducted a rapid integrated filarial mapping survey based on readily identifiable clinical conditions of each disease in this risk zone to help determine prevalence and co-distribution patterns in a timely manner with limited resources. In total, 2007 individuals from 29 communities in five provincial municipalities were surveyed. Community prevalence estimates were determined by the rapid assessment procedure for loiasis (RAPLOA) and rapid epidemiological mapping of onchocerciasis (REMO) together with two questions on LF clinical manifestations (presence of lymphoedema, hydrocoele). Overall low levels of endemicity, with different overlapping distributions were found. Loiasis was found in 18 communities with a prevalence of 2.0% (31/1571), which contrasted to previous results defining the area as a high risk zone. Onchocerciasis prevalence was 5.3% (49/922) in eight communities, and LF prevalence was 0.4% for lymphoedema (8/2007) and 2.6% for hydrocoeles (20/761 males) in seven and 12 communities respectively. The clinical mapping survey method helped to highlight that all three filarial infections are present in this zone of Bengo Province. However, the significant difference in loiasis prevalence found between the past and this current survey suggests that further studies including serological and parasitological confirmation are required. This will help determine levels of infection and risk, understand the associations between clinical, serological and parasitological prevalence patterns, and better determine the most appropriate treatment strategies to reach onchocerciasis and LF elimination targets in the loiasis co-endemic areas. Our results also suggest that the utility of the earlier RAPLOA derived maps, based on surveys undertaken over a decade ago, are likely to be invalid given the extent of population movement and environmental change, particularly deforestation, and that fine scale micro-mapping is required to more precisely delineate the interventions required defined by these complex co-endemicities.