ONCHOCERCIASIS

(RIVER BLINDNESS)
 OUTLINE
• The parasite and its vectors
• Life cycle
• Epidemiology
• Clinical features
• Diagnosis
• Treatment
• Prevention
 Onchocerca volvulus
• Onchocerciasis (river blindness) is caused by
Onchocerca volvulus and characterized by
dermatitis, subcutaneous nodules, keratitis,
and choroidoretinitis.
• Onchocerca volvulus is transmitted to humans
by the Simulium blackfly. After a bite, the
larvae penetrate the skin and migrate into the
connective tissues where they develop into
filiform adults.
 Onchocerca volvulus
• The worms are often found tangled in nodules
of subcutaneous tissue.
• Each female produces large numbers of
microfilariae that migrate through the skin
and connective tissues.
 Parasite and its Vectors
• Onchocerca volvulus – Tissue nematodes, one of
the filaria worms, others are Wuchereria
bancrofti, Brugia malayi, B. timori & Loa loa.
• It is transmitted by Simulium blackflies. The
commonest vectors belong to the Simulium
damnosum complex, which live their larval stages
only in clear, fast-running streams.
• The adult flies survive only where there is high
humidity and plenty of streamside vegetation.
 THE VECTOR
• Transfer of worms is affected by feeding behaviour of flies
– Waggle mouth parts during biting to increase wound size & create pool of blood
(‘pool feeders’)
• Main vector = Simulium damnosum
– Complex of >40 sibling species in West & East Africa
– Not all sibling specices transmit worms
– Insecticide applications used to control larvae in
rivers
 Aetiology

Caused by Onchocerca
volvulus
Adult females are up to
500mm long & males up
to 40mm long
Adults have a life span of
8-15years
Restricted to humans (no
known animal reservoirs)
Transmitted by black flies
(Simuliidae)
Larvae live in fast-flowing
water.
Development of
microfilariae in the
blackfly vector takes
about 10 days.
para-lab by l. wafa menawi 8
 MICROFILARIA
The larvae develop
into male and female
worms in
subcutaneous tissue.
Viviparous females
produce unsheathed
microfilariae (lymph
spaces/connective
tissue). ONCHOCERCA VOLVULUS
Microfilariae can
also be in fluids from
nodules.
Microfilariae also
migrate to the eye
and other organs of
the body.
 ONCHOCERCIASIS
(RIVER BLINDNESS)
• Debilitates millions of humans by scarring eyes &
causing permanent blindness
– Affects people along rivers in West & Central
Africa (native) & South America (introduced
via slavery).
– Prevalence 5 – 80% in endemic regions.
– Endemic in 37 countries, (95% in Africa)
– WHO estimate at least 17.7million people are
infected
– with 500,000 visually impaired &
– 270,000 blinded
 Pathogenicity of Onchocerca
• Pathogenic potential -moderate, dependent on
death & decomposition of microfilariae.
• Reservoir hosts: Not known, probably large
domestic animals and others.
• Damage potential low/moderate, depending on
host sensitivity, toxicity of worm ‘strain’,
number and death/decomposition rate of
larvae in eye
• Adult (macrofilaria) clusters cause
subcutaneous nodules, microfilariae cause
blindness.
 Further more…

• In addition to visual impairment or

blindness, onchocerciasis causes skin
disease, including nodules under the
skin or debilitating itching.
• Worldwide, onchocerciasis is second
only to trachoma as an infectious
cause of blindness (WHO).
 Clinical Features of Onchocerciasis
• Black flies ingest microfilariae from
blood
– Move from gut to flight Nodule
muscles & mature into
infective larvae (L3)
– L3 larvae migrate to head &
enter humans via bite wound;
mature thru’ L4 & L5 into
adults (2-4 months)
– Adults (male and female)
accumulate in subcutaneous
nodules (5mm-50mm
diameter) which don’t cause
much damage.
– Nodules are firm, smooth and
rubbery, round or elongated.
– More common around the
pelvis, buttocks and in the
lower limbs.
SKIN CHANGES IN ONCHOCERCIASIS

A= Skin nodules
(Onchocercoma)
B= Spotted depigmentations
(Leopard’s skin’)
B
C= Inflammatory dermatitis
(intense irritation, raised A
papules and alteration in the
pigmentation).
D = The skin loses its
elasticity- wrinkling (‘elephant D
skin’), patient look more aged.
D= ‘Sowda’ (Black disease)- C
severe allergic response, only
one limb, with darkening of
the skin.
E= Groin area- ‘hanging
groin’/enlarged groin lymph
nodes E
 Ocular onchocerciasis
Mating in nodules produces
microfilariae
• Live under skin causing rashes &
wrinkles
• Found in the cornea and in the
anterior chamber,
• Cause iridocyclitis, choroiditis.
• There is redness and irritation
• Progressive changes caused by
inflammatory reaction around
damaged and dead microfilariae
• Cause sclerosing keratitis which
lead to blindness.
• Cataract and glaucoma can also
result

Destroyed Eye tissues

 DIAGNOSING ONCHOCERCIASIS

This involves
Observation of adults in
prominent subcutaneous nodules
and skin biopsy/snips.
Histologic examination for
microfilariae.
DIAGNOSTIC METHODS/TECHNIQUES
Various techniques may be used for detecting
microfilariae in the skin.
• A skin snip is often used: A needle is used to
raise the skin and a fine piece is shaved off
with a razor blade. A standardised punch
biopsy is also possible. The piece of tissue is
placed in some physiological saline. The
specimen is then examined 15 minutes to 3
hours later to see whether or not microfilariae
have emerged.
 Skin snip contd.
• Typically 6 snips are taken from different areas
of the body (Iliac crest, trapezius regions.
• Polymerase chain reaction (PCR) of the skin
can allow for diagnosis if the larvae are not
visualized.
 SKIN FLUID:
• This is done by means of scarification
with a sterile razor blade. Preferably
several sites are examined (often 4
sites are chosen).
• The fluid obtained can be collected on
a glass slide and stained with Giemsa
to allow identification.
 MAZZOTTI TEST
• If the diagnosis is doubtful, the patient may be given
50 mg DEC orally.
• If microfilariae are present, a severe itching reaction
will occur within 2 hours. This is caused by an allergic
reaction to the proteins released after the rapid
breakdown of microfilariae.
• Because this is very unpleasant, this test should be
used only when strictly necessary.
• Topical use of a DEC-containing cream has also been
described (DEC patch test), in response to which a
limited local skin reaction can occur.
 Diagnostic procedures contd.
• NODULECTOMY: This is both diagnostic and curative
if all the nodule can be surgically removed and
examined for adult worms (macrofilariae)
• SLITLAMP EXAMINATION: 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.This is a non-invasive
test, but requires considerable experience. It is best
to get the patient to lay his/her head on his/her
knees for at least 2 minutes before the examination
to allow more microfilariae to come into the
anterior eye chamber.
 Diagnosis contd.
• SEROLOGY: Serology cannot distinguish
between the various species of filariae and
cannot differentiate present from past
infection, not useful in endemic region but only
for visitors.
• The antigen used is usually extracted from a
different worm: Litosomoides sigmodontis.
 Antigen detection:
• The benefit for individual patients in endemic areas is
probably limited.
• As with any antibody test, the results indicate only that the
patient has been exposed to the disease, but it cannot
determine if the patient has an active infection.
• One advantage of the test is that it can pick up evidence of
infection in the pre-patent stage of infection.
• There are several Onchocerca-specific serologic tests in
existence, such as the OV-16 antigen antibody test and the
OV luciferase immunoprecipitation system (LIPS) assay, but
these are currently only available in the research setting
 Onchocerciasis Therapy
Objectives/Goal:
• Most of the pathogenesis of onchocerciasis is
secondary to microfilariae,
Therapy therefore is aimed at
 Elimination of the microfilarial stage of disease
 Improvement of symptoms,
 Prevention of progression of eye lesions, and
 Interruption of disease transmission.
 Treatment of choice
• The treatment of choice for onchocerciasis is
ivermectin, which has been shown to reduce
the occurrence of blindness and to reduce the
occurrence and severity of skin symptoms.
Ivermectin kills the microfilariae (larvae), but
not the macrofilariae (adult worms).
 Onchocerciasis Therapy
Treatment involves: Surgery and Drugs
Surgical approach: removal of adults
(macrofilariae),
Nodulectomy
 Chemotherapy: mainly for microfilariae;
Diethylcarbamazine (DEC),
Ivermectin (Mectizan)and
Others e.g. Doxycycline, Suramin, etc
Treatments for Onchocerca volvulus
Usage/Drug Adult Dose Pediatric dose
To kill microfilariae:
Ivermectin 150 mcg/kg orally in 150 mcg/kg orally in
one dose every 6 months one dose every 6
months

To kill macrofilariae: 200 mg orally daily 200 mg orally daily

for 6 weeks for 6 weeks
Doxycycline
 Ivermectin
• Ivermectin is a fast-acting, safe and effective
microfilaricide.
• It is actually a mixture of two closely related
products (avermectins), prepared from cultures
of the actinomycete Streptomyces avermitilis.
• Ivermectin has little effect on adult worms.
• It does not cure onchocerciasis.
 Ivermectin contd
• Ivermectin has a broad spectrum and is active
against various worms and arthropods
(ectoparasites).
• In onchocerciasis, it is active against the free
microfilariae and those that are still in the
uterus of the female.
• The embryocidal activity is limited to the late
stages of embryogenesis.
• Early embryogenesis is not affected by
ivermectin
 Ivermectin contd.
• It has at present totally replaced DEC.
(Diethylcarbamazine accelerates the development of
onchocercal blindness).
• It can be given in a single oral dose (2 tablets of 6 mg
for an adult) which makes it easy to administer in the
field but must be given repeatedly over 13-20years.
• It reduces the burden of microfilaria and the risk of
complications but does not cure the disease.
• Ivermectin does not penetrate the aqueous humour.
• In areas of Loa loa a slight risk of neurological side-
effects of ivermectin exists.
 Suramin :
• Older treatments for onchocerchiasis, such as suramin
and diethylcarbamazine (DEC) should not be used.
• Suramin has multiple systemic toxicities that limit its
use in the presence of other less toxic and effective
therapies. Suramin was previously used as a
macrofilaricidal agent, it kills adult worm but more
toxic.
• Suramin has at present been abandoned in the
treatment of onchocerciasis
• It is much simpler and safer to give ivermectin
repeatedly.
 Tetracyclines

• Wolbachia, an endosymbiotic rickettsia-like

bacterium that appears to be required for the survival
of the O. volvulus macrofilariae and for
embryogenesis.Targeting endosymbiotic Wolbachia
species has emerged as an exciting new approach in
the control of onchocerciasis. Studies of doxycycline
therapy (100–200 mg/d for 6 wk) have shown great
promise
• Tetracyclines such as vibramycin can kill Wolbachia
endosymbionts of macrofilariae.
• The therapeutic place of vibramycin however has not
been established.
 Doxycycline
• Doxycycline interrupts microfilarial
embryogenesis, dramatically decreasing or
eliminating microfilaria for at least 18 months
after treatment. The drug has modest activity
against adult worms (50%-60% reduction).
• The combination of doxycycline and ivermectin
given together is more effective than either
drug alone.
 SURGICAL APPROACH

• Sometimes there may be

needs for surgical
intervention in the
management of
Onchocerciasis.
 Nodulectomy

• This involves the removal of

superficial nodules and is
popular in Central America.
• It is both diagnostic and
therapeutic (if all the nodules
could be removed)
 Drugs that has been tried….
• There is still no good macrofilaricidal agent
available.
• Development of resistance in O. volvulus is
being closely monitored.
• Alternatives are being studied, including the
derivatives doramectin and moxidectin.
• Amocarzine was shown not to be active in
clinical trials.
 Drugs that has been tried
• Moxidectin has a plasma half-life of 20
days (in contrast to 2 days for ivermectin)
and is macrofilaricidal.
• It is obtained from cultures of
Streptomyces cyanogriseus ssp.
noncyanogenus.
• At present it is only used in veterinary
medicine.
 Prevention and control
• Destruction of Simulium larvae by
Application of insecticides (drip feed
methods in small river / aerial spraying of
larger rivers
Avoiding simulium bites (covering the
body)
Identifying infected persons (nodules on
head or ocular symptoms which may go
blind)
 Finally….
• Thank you for listening, join us to prevent