The disappearance of onchocerciasis from the Itwara focus, western Uganda after elimination of the vector Simulium neavei and 19 years of annual ivermectin treatments.

The Itwara onchocerciasis focus is located around the Itwara forest reserve in western Uganda. In 1991, annual treatments with ivermectin started in the focus. They were supplemented in 1995 by the control of the vector Simulium neavei, which was subsequently eliminated from the focus. The impact of the two interventions on the disease was assessed in 2010 by nodule palpations, examinations of skin snips by microscopy and PCR, and Ov16 recombinant ELISA. There was no evidence of any microfilaria in 688 skin snips and only 2 (0.06%) of 3316 children examined for IgG4 were slightly above the arbitrary cut off of 40. A follow up of the same children 21 months later in 2012 confirmed that both were negative for diagnostic antigen Ov-16, skin snip microscopy and PCR. Based on the World Health Organization (WHO) elimination criteria of 2001 and the Uganda onchocerciasis certification guidelines, it was concluded that the disease has disappeared from the Itwara focus after 19 years of ivermectin treatments and the elimination of the vector around 2001. Ivermectin treatments were recommended to be halted.

Detection of the filarial parasite Mansonella streptocerca in skin biopsies by a nested polymerase chain reaction-based assay.

To differentiate the skin-dwelling filariae Mansonella streptocerca and Onchocerca volvulus, a nested polymerase chain reaction (PCR) assay was developed from small amounts of parasite material present in skin biopsies. One nonspecific and one specific pair of primers were used to amplify the 5S rDNA spacer region of M. streptocerca. Biopsies with different microfilaria densities obtained from 104 Ugandans living in an area endemic for M. streptocerca were tested using both the nested PCR assay and standard parasitologic assessment of microfilariae. All 82 samples from microfilaria carriers were positive when tested using the nested PCR assay. In addition, M. streptocerca DNA could be detected in 16 samples thought to be microfilaria negative. Furthermore, six days following ivermectin treatment, M. streptocerca DNA was found in 12 of 14 microfilaria-negative biopsies. Control skin samples from patients infected with O. volvulus were all negative in the nested PCR assay. This assay improves the diagnosis of M. streptocerca and will facilitate further epidemiologic studies.

Ivermectin distribution using community volunteers in Kabarole district, Uganda.

Ivermectin mass distribution for the control of onchocerciasis in Uganda began in 1991. This report describes a community based ivermectin distribution programme covering two foci in the Kabarole district which have an estimated 32,000 persons infected and another 110,000 at risk. Through nodule palpation in adult males, 143 villages were identified where nodule prevalence exceeded 20%. Skin snips were also taken from a sample of the population to measure changes in community microfilarial load (CMFL) with treatment. The delivery programme was integrated into the district health management structure, and used community volunteers supervised by medical assistants from adjacent health facilities for annual ivermectin distribution campaigns. After initial efforts by the community to support distributors in-kind proved inadequate, ivermectin distributors earned money retailing condoms as part of the social marketing component of district STD/AIDS programme. Reduction in the CMFL ranged from 40-62% twelve months after the second ivermectin treatment in three villages, and from 69-84% six months after the fourth round of treatment in two villages. After four years of treatment, 85% of eligible persons were receiving ivermectin from community volunteers in each treatment cycle. Drop out rates among volunteers did not exceed 20% over the four years reported here. The direct cost of treatment was US $0.29 per person. Among the reasons for low per-person treatment costs were the strong supervisory structure, the presence of health centres in the foci and a well developed and capable district Primary Health Care management team.

Reduced prevalence of onchocerciasis in Uganda following either deforestation or vector control with DDT.

To determine the prevalence of onchocerciasis in western Uganda following deforestation and vector control, three foci were re-examined 20 years after previous surveys. In the Ruteete focus Simulium neavei had apparently disappeared and the prevalence of onchocerciasis declined in adults from about 70% in 1971 to a standardised prevalence of 12% in 1992. An increase of population density together with extended deforestation was assumed as cause of this strong reduction. In Bugoye, a S. damnosum s.l. focus, the standardised prevalence of microfilaria carriers declined from 62% in 1972 to 4.7% in 1992. Entomological data indicated the absence of man biting blackflies in the nineties. It can be suggested that the vector control using DDT performed during the seventies had lead to a change of the species composition from anthropophilic to non-anthropophilic S. damnosum s.l. In the focus Kicheche environmental changes were insignificant, deforestation was not progressive and S. neavei was abundant. Here the standardised prevalence of microfilaria carriers was still high (61%).

Treatment of human Mansonella streptocerca infection with ivermectin.

We studied the short-term effects of a single dose of 150 micrograms/kg body weight ivermectin on Mansonella streptocerca in an area endemic for streptocerciasis, but not for onchocerciasis, in western Uganda. Six and 12 days after treatment no microfilaria (mf) were found in the skin of 53 out of 96 mf carriers living in 3 villages, and the geometric means of the mf densities of remaining mf carriers were only 33-40% of pretreatment levels. This reduction of mf density was highly significant (P < 0.0001). Immunohistological examination of skin biopsies showed degenerated and disintegrating mf surrounded by activated eosinophils (positive for activated cationic protein), macrophages, and neutrophils (positive for myeloperoxidase and defensin) on day 6 after treatment. Remarkable was the invasion of young, L1 protein-positive macrophages and the release of neutrophil defensin as signs of acute inflammation. We conclude that ivermectin has a strong microfilaricidal activity against M. streptocerca. Common adverse effects were increased pruritus and acute papular dermatitis in 45% of 86 mf carriers on day 6 after treatment. No serious adverse side-effects were noticed in about 700 treated persons.

Occurrence and diagnosis of Mansonella streptocerca in Uganda.

During filaria surveys Mansonella streptocerca was found for the first time in Uganda, in 12 widely scattered villages in the Bundibugyo district between the Ruwenzori mountains and the Ituri forest, an area not endemic for Onchocerca volvulus. The crude prevalence in 806 examined adult persons ranged from 5 to 89% with an average of 61%. In 148 children the prevalence was 36%. The geometric mean of microfilaria (mf) densities in adult mf carriers was 1.7 mf/mg skin and the community microfilarial loads ranged from 1.0 to 13.7 mf/skin snip. In 476 persons skin snips from the shoulder contained mf in 58% and those from the buttocks in 48%. Skin snips from 68 persons digested with collagenase showed that only 30-37% of the mf emerged during 24 h incubation at 30 degrees C in isotonic salt solution. An itching acute or more often chronic papular dermatitis, predominantly on the upper parts of the body, was the typical skin lesion observed in 24% of 177 M. streptocerca mf carriers.

Strain differentiation of Onchocerca volvulus from Uganda using DNA probes.

Polymerase chain reaction (PCR) combined with non-radioactive DNA hybridization was applied for the detection and characterization of a 150 bp tandem repeat of Onchocerca volvulus. DNA of worms from western Uganda was amplified and then probed with a digoxygenin-labelled oligonucleotide, specific for the forest form of O. volvulus and compared to samples from various African countries. Hybridization was only observed with PCR products from the forest in Liberia, south-eastern Ghana, Benin and southern Cameroon, but not with worms from Uganda or the savannah in Burkina Faso and northern Ghana. A nested PCR using primers derived form the forest form-specific DNA sequence confirmed these results. Morphometric studies revealed length differences between the microfilariae of Ugandan O. volvulus to those of West Africa, especially to those of the savannah in Burkina Faso. It is concluded that the forest/savannah classification of O. volvulus from West Africa is not suitable for Simulium neavei-transmitted O. volvulus from Uganda.

Impaired antibody responses and loss of reactivity to Onchocerca volvulus antigens by HIV-seropositive onchocerciasis patients.

The impact of concomitant human immunodeficiency virus (HIV) infection on the antibody response of onchocerciasis patients to Onchocerca volvulus antigens (OvAg) was studied by Western blotting and enzyme linked immunosorbent assay (ELISA). Immunoglobulin G (IgG) antibodies in sera from 45 HIV-sero-positive O. volvulus microfilariae (mf) carriers (HIV+/Ov+) recognized significantly fewer distinct O. volvulus antigenic bands, and responded less frequently to all detected bands compared to sera from 61 matched HIV-seronegative mf carriers (HIV-/Ov+). 29% of 31 follow-up sera from the HIV+/Ov+ patients failed to react to many of the antigenic bands recognized by initial sera from the same patients. Among 4 HIV+/Ov+ persons examined for total CD4+ cells, loss of reactivity corresponded with low CD4+ total cell counts. In an OvAg ELISA, sera from the HIV+/Ov+ individuals had significantly lower IgG+IgM antibody levels than sera from the HIV-/Ov+ persons, and the sensitivity of the assay was 87% for the HIV+/Ov+ subjects compared to 100% for those who were HIV-/Ov+. It is concluded that HIV-infected onchocerciasis patients exhibit significantly impaired antibody responses to O. volvulus antigens, and tend to lose their reactivity to these antigens over time due to immune response abnormalities caused by the concomitant HIV infection.

Prevalence of Mansonella perstans in western Uganda and its detection using the QBC-fluorescence method.

The prevalence of the apathogenic filaria Mansonella perstans was studied in four parishes in western Uganda as part of an onchocerciasis control programme to avoid futile treatment. Blood samples from 1543 persons aged over 14 years from 19 villages were examined for the presence of microfilariae using a modified Knott method. The prevalence of microfilaraemic persons ranged between the parishes from 39% (95% CI 35.9-42.0%) to 81% (95% CI 76.2-84.8%). With exception of single microfilariae of Onchocerca volvulus no other filaria species was detected. Onchocerciasis mass treatment campaigns did not reduce the prevalence of M. perstans infection, since 6-12 months after treatment with a single dose of 150 micrograms/kg ivermectin the prevalence in 124 persons was about the same as before treatment. The QBC-fluorescence technique was employed for the detection of microfilariae in samples from outpatients of the government hospital in Fort Portal: in 16% of 120 children and 24% of 369 adults microfilariae of M. perstans were detected.

The Nakalanga syndrome in Kabarole District, Western Uganda.

An acquired condition resulting in arrested growth was reported in the 1950s and 1960s from along the Nile near Jinja in eastern Uganda. This became known as Nakalanga dwarfism, and an association with onchocerciasis was postulated. After control of onchocerciasis through larvaciding in this area some 30 years ago, no new cases have been noted. We now report this condition from western Uganda where its appearance seems to be a relatively recent event. Thirty-one persons with short stature, 15 years of age and older, were identified through household surveys in an area of Kabarole district with a high prevalence of onchocerciasis. Cases identified were matched with controls selected for age and sex from the nearest household. Cases of Nakalanga syndrome weighed significantly less and were shorter than controls. The Z scores for weight-for-age, weight-for-height, height-for-age, and body mass index were significantly less among cases. Other clinical features observed among cases included absence of secondary sexual characteristics, skeletal deformities, dental caries, and mental retardation. All cases and 22 (79%) controls had microfilariae of Onchocerca volvulus in skin snips. All community members interviewed were aware of the Nakalanga syndrome, and 93% believed it to be acquired sometime after birth. The possible association with onchocerciasis is discussed.