There are different stages of onchocerciasis. In earlier stages, you may not have any symptoms.

It can
take up to a year for symptoms to appear and the infection to become apparent.

Once the infection becomes severe, symptoms may include:

• skin rashes

• extreme itching

• bumps under the skin

• loss of skin elasticity, which can make skin appear thin and brittle

• itching of the eyes

• changes to skin pigmentation

• enlarged groin

. cataracts

• light sensitivity

• loss of vision

In rare cases, you may also have swollen lymph glands.

There are no vaccines or medications available to prevent becoming infected with O. volvulus. The best
prevention efforts include personal protection measures against biting insects. This includes wearing
insect repellant such as N,N-Diethyl-meta-toluamide (DEET) on exposed skin, wearing long sleeves and
long pants during the day when blackflies bite, and wearing permethrin- treated clothing.

How it spreads

The disease spreads by the bite of an infectious blackfly. When a blackfly bites a person who has
onchocerciasis, microscopic worm larvae (called microfilariae) in the infected person's skin are ingested
by the blackfly. The larvae develop over approximately one week in the fly to a stage that is infectious to
humans. An infectious blackfly will typically drop larvae when biting a person. The larvae then penetrate
the skin to infect the person. Because the worms reproduce only in humans but need to complete some
of their development inside the blackfly, the intensity of human infection (number of worms in an
individual) is related to the number of infectious bites sustained by an individual. Blindness is usually
seen in the setting of longstanding and intense infection.

What is the impact of onchocerciasis on public health?

Onchocerciasis is the second leading infectious cause of blindness and can cause debilitating and
disfiguring skin disease. However, the worldwide burden of onchocerciasis has been considerably
reduced as the result of very successful disease control programs led by the World Health Organization
(WHO). These programs are based on control of the blackfly population and/or mass administration to
affected communities of an oral drug called ivermectin (Mectizan"), that is donated by Merck & Co., Inc.
As a result of these programs, millions of people are at greatly reduced risk of debilitating itching,
disfigurement, and blindness caused by onchocerciasis. Unfortunately, many people still do not have
access to prevention and treatment measures.

How soon after infection will I have symptoms of onchocerciasis?

After a blackfly bite, it can take up to 12 18 months for the larvae to develop into mature adult worms
inside the human body that are capable of mating and producing new larvae (also called microfilariae)
that can be found in the skin. Each adult female worm, which can live approximately 10-15 years, can
produce millions of new larvae during her lifetime. As it is the larvae that cause most of the symptoms of
onchocerciasis, most people infected with O. volvulus feel well until after the adult worms start
producing large numbers of new larvae.
• The most common method of diagnosis is the skin snip. A 1 to 2 mg shaving or biopsy of the skin is
done to identify larvae, which emerge from the skin snip and can be seen under a microscope when the
shaving or biopsy ("skin snip") is put in physiologic solutions (e.g. normal saline). Typically six snips are
taken from different areas of the body. Polymerase chain reaction (PCR) of the skin snip can allow for
diagnosis if the larvae are not visualized.

• In patients with nodules in the skin, the nodule can be surgically removed and examined for adult
worms.

• Infections in the eye can be diagnosed with a slit-lamp examination of the anterior part of the eye
where the larvae, or the lesions they cause, are visible.

• Antibody tests have been developed to test for infection, though they are not widely available in the
United States. These tests cannot distinguish between past and current infections, so they are not as
useful in people who lived in areas where the parasite exists, but they are useful in visitors to these
areas. Some of the tests are general tests for infection with any filarial parasite and some are more
specific for onchocerciasis.

Treatment

People who are found to be infected with O. volvulus should be treated in order to prevent long-term
skin damage and blindness. The recommended treatment is ivermectin, which will need to be given
every 6 months for the life span of the adult worms (i.e., 10-15 years) or for as long as the infected
person has evidence of skin or eye infection. Ivermectin kills the larvae and prevents them from causing
damage but it does not kill the adults.

There is a promising treatment using doxycycline that kills the adult worms by killing the Wolbachia
bacteria on which the adult worms depend in order to survive. If you are infected, it is possible that your
doctor will want to treat you both with ivermectin and with doxycycline.

Before any treatment is begun, however, you need to make sure that you are not also infected with Loa
loa, another filarial parasite found in central Africa that is sometimes found in the same areas where O.
volvulus is found, because Loa loa can be responsible for severe side effects to the medications used to
treat onchocerciasis.
Note on Treatment in Pediatric Patients

The safety of ivermectin in children who weigh less than 15kg has not been demonstrated. According to
the WHO guidelines for mass prevention campaigns, children who are at least 90 cm tall can be treated
safely with ivermectin. The WHO growth standard curves show that this height is reached by 50% of
boys by the time they are 28 months old and by 50% of girls by the time they are 30 months old, many
children less than 3 years old been safely treated with ivermectin in mass prevention campaigns, albeit
at a reduced dose.

References

Progress report on the elimination of human onchocerciasis, 2017 2018. Weekly Epidemiological Record.
2018; 93(47): 633-48.

Sauerbrey M, Rakers LJ, Richards FO Jr. Progress toward elimination of onchocerciasis in the Americas.
Int Health. 2018; 10: 171-178.

Cantey PT, Roy SL, Boakye D, Mwingira U, Ottesen EA, Hopkins AD, Sodahlon YK. Transitioning from river
blindness control to elimination: steps toward stopping treatment. Int Health. 2018; 10: 17 113.

Zarroug IMA, Hashim K, El Mubark WA, Shumo ZAI, Salih KAM, El Nojomi NAA, Awad HA, Aziz N,
Katabarwa M, Hassan HK, Unnasch TR, Mackenzie CD, Richards F, Higazi TB. The first confirmed
elimination of an onchocerciasis focus in Africa: Abu Hamed

Basáñez MG, Pion SDS, Boakes E, J.A. Filipe, Churcher TS, Boussinesq M. Effect of single-dose Ivermectin
on Onchocerca volvulus: a systematic review and meta analysis. Lancet Infect Dis. 2008;8:310-22.

Walker M, Pion SDS, Fang H, Gardon J, Kamgno J, Basáñez MG, Boussinesq M. Macrofilaricidal efficacy of
repeated doses of ivermectin for the treatment of river blindness. Clin Infect Dis. 2017;65:2026-34.
Abegunde AT, Ahuja RM, Okafor NJ.Doxycycline plus ivermectin versus ivermectin alone for treatment
of patients with onchocerciasis. Cochrane Database Syst Rev. 2016;(1): CD011146. doi:
10.1002/14651858.CD011146.pub 2.