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.

Concurrence of dermatological and ophthalmological morbidity in onchocerciasis.

Prevalence of skin and eye disorders in African onchocerciasis (river blindness) is well documented. However, less is known about their joint occurrence. Information on concurrence may improve our understanding of disease pathogenesis and is required to estimate the disease burden of onchocerciasis. We analysed data from 765 individuals from forest villages in the Kumba and Ngambe Health districts, Cameroon. These data were collected in 1998, as baseline data for the evaluation of the African Programme for Onchocerciasis Control. Concurrence of symptoms was assessed using logistic regression. Onchocerciasis was highly endemic in the study population (63% nodule prevalence among males aged ≥20). Considerable overall prevalences of onchocercal visual impairment (low vision or blindness: 4%), troublesome itch (15%), reactive skin disease (19%), and skin depigmentation (25%) were observed. The association between onchocercal visual impairment and skin depigmentation (OR 9.0, 95% CI 3.9-20.8) was partly explained by age and exposure to infection (OR 3.0, 95% CI 1.2-7.7). The association between troublesome itch and reactive skin disease was hardly affected by adjustment (adjusted OR 6.9, 95% CI 4.2-11.1). Concluding, there is significant concurrence of morbidities within onchocerciasis. Our results suggest a possible role of host characteristics in the pathogenesis of depigmentation and visual impairment. Further, we propose a method to deal with concurrence when estimating the burden of disease.

The African Programme for Onchocerciasis Control: impact on onchocercal skin disease.

OBJECTIVES: To assess the long-term impact of the African Programme for Onchocerciasis Control on itching and onchocercal skin disease (OSD). METHODS: Seven study sites in Cameroon, Sudan, Nigeria and Uganda participated. Two cross-sectional surveys were conducted of communities meso- and hyper-endemic for onchocerciasis before and after 5 or 6 years of community-directed treatment with ivermectin (CDTI). Individuals were asked about any general health symptoms including itching and underwent full cutaneous examinations. Onchocercal skin lesions were documented according to a standard classification. RESULTS: Five thousand one hundred and ninety three people were examined in phase I and 5,180 people in phase II. The presence of onchocercal nodules was a strongly significant (P < 0·001) risk factor for all forms of onchocercal skin disease: APOD (OR 1·66); CPOD (OR 2·84); LOD (OR 2·68); reactive skin lesions (OR 2·38) and depigmentation (OR 3·36). The effect of community-directed treatment with ivermectin was profound. At phase II, there were significant (P < 0·001) reductions in the odds of itching (OR 0·32), APOD (OR 0·28); CPOD (OR 0·34); reactive skin lesions (OR 0·33); depigmentation (OR 0·31) and nodules (OR 0·37). Reduction in the odds of LOD was also significant (OR 0.54, P < 0.03). CONCLUSIONS: This first multi-country report of the long-term impact of CDTI reveals a substantial reduction in itching and OSD. APOC operations are having a major effect in improving skin health in poor rural populations in Africa.

The elimination of the onchocerciasis vector from the island of Bioko as a result of larviciding by the WHO African Programme for Onchocerciasis Control.

The island of Bioko is part of the Republic of Equatorial Guinea and is the only island in the World to have endemic onchocerciasis. The disease is hyperendemic and shows a forest-type epidemiology with low levels of blindness and high levels of skin disease, and the whole population of 68,000 is estimated to be at risk. Control of onchocerciasis began in 1990 using ivermectin and this yielded significant clinical benefits but transmission was not interrupted. Feasibility and preparatory studies carried out between 1995 and 2002 confirmed the probable isolation of the vector on the island, the high vectorial efficiency of the Bioko form of Simulium yahense, the seasonality of river flow, blackfly breeding and biting densities, and the distribution of the vector breeding sites. It was proposed that larviciding should be carried out from January to April, when most of the island's rivers were dry or too low to support Simulium damnosum s.l., and that most rivers would not need to be treated above 500 m altitude because they were too small to support the breeding of S. damnosum s.l. Larviciding (with temephos) would need to be carried out by helicopter (because of problems of access by land), supplemented by ground-based delivery. Insecticide susceptibility trials showed that the Bioko form was highly susceptible to temephos, and insecticide carry was tested in the rivers by assessing the length of river in which S. damnosum s.l. larvae were killed below a temephos dosing point. Regular fly catching points were established in 1999 to provide pre-control biting densities, and to act as monitoring points for control efforts. An environmental impact assessment concluded that the proposed control programme could be expected to do little damage, and a large-scale larviciding trial using ground-based applications of temephos (Abate 20EC) throughout the northern (accessible) part of the island was carried out for five weeks from 12 February 2001. Following this, a first attempt to eliminate the vectors was conducted using helicopter and ground-based applications of temephos from February to May 2003, but this was not successful because some vector populations persisted and subsequently spread throughout the island. A second attempt from January to May 2005 aimed to treat all flowing watercourses and greatly increased the number of treatment points. This led to the successful elimination of the vector. The last biting S. damnosum s.l. was caught in March 2005 and none have been found since then for more than 3 years.

[African programme for onchocerciasis control (APOC): entomological aspects of Onchocerca volvulus transmission by Simulium neavei in the Basin of Sankuru (Eastern Kasai, Democratic Republic of Congo)]. / Aspects entomologiques de la transmission d'Onchocerca volvulus par Simulium neavei dans le bassin du Sankuru (Kasaï oriental, République Démocratique du Congo).

As part of a study to evaluate the long-term impact of community-directed treatment with ivermectin (CDTI), baseline entomological data on the transmission of onchocerciasis in the forest zone of the Eastern Kasai Province were collected from July 1998 to January 1999. Species of the Simulium neavei complex were the only vectors found in the site during the study. Nuisance activity was low with a mean biting rate of only 32.5 bites/man/day. The mean parturity rate was 29.4%, the mean rate of infected females was 14.5% and the mean number of infective Onchocerca larvae per 1000 parous flies was 659. These findings clearly show that the S. neavei population at the study site has high vector capability and constitutes a large microfilarial reservoir. The entomological features found in the study area are consistent with a hyper-endemic zone.

[Epicardial atrial pacing using an active fixation bipolar endocardial lead in children].

Good performance was observed over 10 years after implantation of bipolar epicardial atrial pacing using an active fixation bipolar endocardial lead in 3 pediatric patients with congenital heart block. The bipolar endocardial lead which was supposed to be fixed transvenously was implanted on the atrial surface by first screwing the lead's helix into the myocardium. The catheter was then laid down on the atrial surface, and both electrodes were wrapped by the atrial tissue. The good performance of this pacing lead seemed to depend on stable positioning of the electrode. This lead is superior to the commercially available, and steroid eluting epicardial bipolar pacing lead, on the point of its small size in head and body, and could be applied to dual chamber pacing in smaller children.

[Onchocerciasis in the area of Lastourville, Gabon. Clinical and entomological aspects]. / L'onchocercose dans la région de Lastourville, Gabon. Aspects cliniques et entomologiques.

The African Programme for Onchocerciasis Control (APOC) has implemented a series of surveys aimed at evaluating the long-term impact of its activities. The region of Lastourville (Gabon) is one of the selected sites for this study. A total of 886 persons was examined for skin lesions, and 459 out of them participated in detailed ocular examinations. Blackflies were collected during one year and dissected. Although the focus was found to be hypoendemic (prevalence of nodules: 7.7%), the frequency of onchodermatitis was relatively high. The lesions of the anterior segment of the eye were rare, but the prevalence of optic nerve disease, and of choroido-retinal lesions reached 5.2 and 2.7%, respectively. The annual transmission potential (2,171 infective larvae per man) was high, when compared with the results recorded in the human population. This may be due to the presence of Onchocerca spp. of animal origin in the blackflies. These results indicate that in the area of Lastourville, though regarded as the main focus of onchocerciasis in Gabon, the disease is relatively mild.

[African Programme for Onchocerdasis Control (APOC): Onchocerca Simulium squamosum in two regions in the Republic of Cameroon]. / Programme africain de lutte contre l'onchocercose (APOC): intensité de la transmission d'Onchocerca volvulus par Simulium squamosum dans deux régions de la République du Cameroun.

In 1998, the African Programme for Onchocerciasis Control (APOC) decided to launch a long-term impact assessment of its operations. This paper reports the baseline entomological data collected throughout a whole year in two sites of Cameroon (Kahn and Bolo). The Simulium populations of the two study sites were characterized by parous rates of 7.2% and 33.5% respectively and infectivity by O. volvulus of 31 and 190 infective larvae per 1000 parous flies respectively The Annual Transmission Potentials (ATP) were respectively 523 and 9972 infective larvae per man and per year in Kahn and in Bolo. The Simulium populations studied in both sites, even though the ATP in Kahn is 19 times lower than that of Bolo, showed a pattern of an onchocerciasis hyperendemic zone in terms of vector capacities and entomological indices.

[African Program for Onchocerciasis Control (APOC): Onchocerca volvulus transmission by Simulium damnosum s. l. in two regions of the Central African Republic]. / Programme africain de lutte contre l'onchocercose (APOC): transmission d'Onchocerca volvulus par Simulium damnosum s. l. dans deux régions de la République Centrafricaine.

Entomological baseline data were collected in the villages of Zinga and Boali-Falls in Central African Republic (CAR) in view of the long term impact assessment of community-directed treatment with ivermectin (CDTI). Morphological determinations revealed that flies caught in both sites belong to the sub-group Sou/Sq. In Boali, the nuisance was relatively high with biting rates averaging 243 bites/man/day, with a parous rate of 61.6% and a crude annual transmission potential (ATP) of 8,259 infective larvae/man/year; and the average number of infective larvae per 1,000 parous flies was 177. In Zinga, the mean biting rate was 191 bites/man/day, with a parous rate of 51.6%, a crude ATP of 3,422, and 86 infective larvae per 1,000 porous flies. In conclusion, the vectorial capacity and the entomological indices recorded are characteristic of high onchocerciasis transmission zones. However, some of the infective larvae found, maybe of animal origin, need identification to better determine the real level of endemicity.

[Cor triatriatum diagnosed in adulthood; report of a case].

Cor triatriatum is a rare congenital cardiac anomaly especially in adulthood. A 68-year-old female was diagnosed as a cor triatriatum classified to Lucas-Schmidt IA, severe degree of mitral regurgitation and atrial fibrillation. Resection of the abnormal diaphragm in the left atrium and miral valve replacement were performed. Although the reason of sudden death of this patient after discharge is unknown, surgical intervention for atrial fibrillation should have performed to prevent a thromboembolism in such cases.

[Delayed onset malignant hyperthermia after a closure of ventricular septal defect].

An 18 month-old girl was diagnosed as ventricular septal defect (VSD) with mild aortic valve prolapse. She underwent a closure of VSD. Intra-and early postoperative course was uneventful. However, 20 hours after surgery, sudden bradycardia led to cardiac arrest and strong muscle rigidity was seen. Hyperkalemia and metabolic acidosis rapidly progressed and resuscitation was failed. Extracorporeal life support and continuous hemodialysis were initiated, but the patient died with multiple organ failure on 5th postoperative day. Her clinical course supported the diagnosis of delayed onset malignant hyperthermia. Histopathological findings of muscle biopsy were consistent with rhabdomyolysis, and immunopathological stains demonstrated changes as in a Duchenne type muscular dystrophy carrier. Delayed onset malignant hyperthermia is an extremely rare complication of general anesthesia. We should be aware of this lethal condition, which occurs with a certain time lag after surgery, especially when the patient has possible background of myopathy.

[Leaflet extension technique in a congenital aortic valve regurgitation].

A 17-year-old boy who was diagnosed as congenital aortic valve regurgitation underwent the leaflet extension technique in 3 aortic leaflets using glutaraldehyde-preserved autologous pericardium. Intraoperative transesophageal echocardiography and postoperative cardiac catheter revealed grade I regurgitation and the patient has been doing well for more than 4 months after the surgery. The leaflet extension technique is considered to be an acceptable surgical treatment for aortic valve disease especially in young patients to whom valve replacement or Ross procedure might not be suitable. A careful long-term follow-up will be necessary to evaluate the durability of the leaflet extension technique with autologous pericardium.

[Right-sided infective endocarditis with a large size vegetation].

A 2-year-old boy with ventricular septal defect(VSD) had suffered from right-sided infective endocarditis with a vegetation 1.0 cm in size, involving pulmonary valve. Resection of the vegetation and partial resection of the pulmonary valve and patch closure of the VSD was performed after 3 weeks intravenous antibiotic therapy. In right-sided infective endocarditis, it is still unclear, however, which factors may be useful in predicting outcome or determining the need of surgical intervention. We recognize that following factors are the risk for need of surgical intervention. 1. persistent infection, 2. sever right-sided heart failure, 3. multiple embolic episodes, 4. infected by Staphylococcus aureus, 5. infection involving the annulus of the valve, 6. infection of prosthetic valve, 7. vegetation which is floppy and greater than 1.0 cm in size.

[Management of mediastinitis after pediatric cardiac surgery with continuous closed irrigation method].

Two cases are presented as a successful management for mediastinitis with the continuous closed irrigation method after pediatric cardiac surgery. The continuous closed irrigation method has significant advantages over conventional open irrigation method or muscle flap in pediatric cases, because the system is simple to handle and easy to wash out any infectious tissue debris without additional invasive intervention. However, adequate duration of the irrigation and subsequent antibiotic regimen is still unclear. We conclude that the continuous closed irrigation method is an effective management which is applicable to most of mediastinitis cases after pediatric cardiac surgery.

The achievements and challenges of the African Programme for Onchocerciasis Control (APOC).

The main strategy of APOC, of community-directed treatment with ivermectin (CDTI), has enabled the programme to reach, empower and bring relief to remote and under-served, onchocerciasis-endemic communities. With CDTI, geographical and therapeutic coverages have increased substantially, in most areas, to the levels required to eliminate onchocerciasis as a public-health problem. Over 20 million people received treatment in 2000. APOC has also made effective use of the combination of the rapid epidemiological mapping of onchocerciasis (REMO) and geographical information systems (GIS), to provide information on the geographical distribution and prevalence of the disease. This has led to improvements in the identification of CDTI-priority areas, and in the estimates of the numbers of people to be treated. A unique public-private-sector partnership has been at the heart of APOC's relative success. Through efficient capacity-building, the programme's operations have positively influenced and strengthened the health services of participating countries. These laudable achievements notwithstanding, APOC faces many challenges during the second phase of its operations, when the full impact of the programme is expected to be felt. Notable among these challenges are the sustainability of CDTI, the strategy's effective integration into the healthcare system, and the full exploitation of its potential as an entry point for other health programmes. The channels created for CDTI, could, for example, help efforts to eliminate lymphatic filariasis (which will feature on the agenda of many participating countries during APOC's Phase 2). However, these other programmes need to be executed without compromising the onchocerciasis-control programme itself. Success in meeting these challenges will depend on the continued, wholehearted commitment of all the partners involved, particularly that of the governments of the participating countries.

Rapid epidemiological mapping of onchocerciasis (REMO): its application by the African Programme for Onchocerciasis Control (APOC).

One of the fundamental challenges that the African Programme for Onchocerciasis Control (APOC) has had to face is how to identify the endemic communities where its mass ivermectin-treatment operations are to be carried out in conformity with its stated objective of targetting the most highly endemic, affected and at-risk populations. This it has done by adopting a technique, known as the rapid epidemiological mapping of onchocerciasis (REMO), that provides data on the distribution and prevalence of onchocerciasis. Integration of the REMO data into a geographical information system (GIS) enables delineation of zones of various levels of endemicity, and this is an important step in the planning process for onchocerciasis control. Zones are included in (or excluded from) the APOC-funded programme of community-directed treatment with ivermectin (CDTI), depending on whether or not their levels of onchocercal endemicity reach the threshold set by APOC. This review describes the application of the REMO/GIS technique by APOC in its operations, and identifies the remaining related challenges.

The challenges of community-directed treatment with ivermectin (CDTI) within the African Programme for Onchocerciasis Control (APOC).

The principal strategy adopted by the African Programme for Onchocerciasis Control (APOC), for the control of onchocerciasis in the 19 countries of Africa that now fall within the programme's remit, is that of community-directed treatment with ivermectin (CDTI). Halfway through its 12-year mandate, APOC has gathered enough information on the main challenges to guide its activities in Phase 2. An analysis of reports and other documents, emanating from consultants, scientists, monitors and national and project-level implementers, indicates that there are three broad categories of challenge: managerial; technical; and socio-political. Under these three categories, this review identifies the most pertinent concerns that APOC must address, during Phase 2, to enhance the prospects of establishing sustainable systems for ivermectin distribution. The major challenges include: (1) maintaining timely drug-collection mechanisms; (2) integrating CDTI with existing primary-healthcare services; (3) strengthening local health infrastructure; (4) achieving and maintaining an optimal treatment coverage; (5) establishing and up-scaling community self-monitoring; (6) designing and implementing operations research locally; (7) ensuring the adequacy of community-directed distributors; (8) increasing the involvement of local non-govemmental develop organizations in the programme; (9) achieving financial sustainability; (10) implementing equitable cost-recovery systems; and (11) engaging in effective advocacy. The implications of the challenges and suggestions about how they are being (or could be) addressed are also highlighted in this brief review, which should be of value to other programmes and agencies that may be contemplating the adoption of this unique strategy.

Gender issues in the community-directed treatment with ivermectin (CDTI) of the African Programme for Onchocerciasis Control (APOC).

This paper reviews the issues relating to compliance and participation among the men and women of three countries within the remit of the African Programme for the Control of Onchocerciasis (APOC): Cameroon, Nigeria and Tanzania. Project-monitoring data from 109 focus-group discussions, 6069 household-survey respondents and 89 interviews with ivermectin distributors were analysed to gain an insight into the attitudes and behaviours of men and women in relation to ivermectin treatment and their participation in the programme. Although there are no statistically significant gender differences in coverages for ivermectin treatment, culturally prescribed gender relationships influence the ways in which men and women express and experience treatment-related behaviours. Gender roles also affect participation in the programme. Decision-making in communities on the selection of distributors tends to follow socio-cultural hierarchies based upon patriarchy and gerontocracy. Relatively few ivermectin distributors (21%) are women. Although they receive less support than their male counterparts, the female distributors are just as willing to continue ivermectin distribution in the community, and they perform as well or better than men in this regard. The terms 'community-directed', 'community participation' and even 'compliance' obfuscate important gender differences that are inherent in the implementation of onchocerciasis control. Development of strategies that recognize these gender differences will have important implications for long-term adherence to treatment and for the overall quality and sustainability of the programme.

Monitoring community-directed treatment programmes for sustainability: lessons from the African Programme for Onchocerciasis Control (APOC).

Community-directed treatment is a relatively new strategy that was adopted in 1997 by the African Programme for Onchocerciasis Control (APOC), for large-scale distribution of ivermectin (Mectizan). Participatory monitoring of 39 of the control projects based on community-directed treatment with ivermectin (CDTI) was undertaken from 1998-2000, with a focus on process implementation of the strategy and the predictors of sustainability. Data from 14,925 household interviews in 2314 villages, 183 complete treatment records, 382 focus-group discussions, and the results of interviews with 669 community leaders, 757 trained community-directed drug distributors (CDD) and 146 health personnel (in 26 projects in four countries) were analysed. The data show that CDD dispensed ivermectin to 65.4% of the total population (71.2% of the eligible population), with no significant gender differences in coverage (P > 0.05). Treatment coverage ranged from 60.2% of the eligible subjects in Cameroon to 76.9% in Uganda. There was no significant relationship between the provision of incentives to CDD and treatment coverage (P > 0.05). The frequency of treatment refusal was highest in Cameroon (29.2%). Although most (72.1%) of the communities investigated selected their CDD on the basis of a community decision at a village meeting, only 37.9% chose their distribution period in the same way. There is clearly a need to improve communication strategies, to address the issues of absentees and refusals, to emphasise community ownership and to de-emphasise incentives for CDD. The investigation of the 'predictor indicators' of sustainability should enable APOC to understand the determinants of project performance and to initiate any appropriate changes in the programme.