GLOBAL PUBLIC HEALTH Osher Lifelong Learning Institute at
GLOBAL PUBLIC HEALTH Osher Lifelong Learning Institute at Berkshire Community College Winter Session 2021, Katherine M. Kidd, Ph. D
Class Objectives • Learn about onchocerciasis (river blindness) including disease vectors, symptoms and long-term effects and geographic spread • Understand the dynamics of how river blindness could be combatted • Consider the key actors on the team to combat river blindness • Discuss the time lines and the scale of the program • Analyze the benefits of ending river blindness
What is river blindness? • Disease caused by the parasitic worm Ochocerca volvuluss • Symptoms – itchy skin, disfiguring skin conditions, visual impairment • Disease prevalence • 99% of cases are in Sub-Saharan Africa • 1974 (estimates) 42 million infected, 2. 1 million vision loss • 2017 20. 9 million, 1. 15 million vision loss • Reduction of disease while population in endemic zones increased from 30 to 85 million people • Individuals with river blindness die on average 13 years earlier than others in the same country due to chronic inflammation and weakened immune response
The disease cycle
Why is river blindness difficult to control? • Black flies have a range of 400 kilometers • Flies become resistant to the pesticides used • Breaking the human/fly disease vector takes 13 -15 years. Original estimate was 20 years. • Regional approach is essential • Poor health infrastructure and civil conflict inhibit full coverage • Re-infestation is possible from countries that are not implementing controls or are implementing controls at less than 100% • There is no cure but vaccines are in human trial phase in 2020
Geography of river blindness
International efforts against river blindness • Colonial and national efforts at control failed due to regional nature of disease • 1968 – first regional Onchocerciasis Control Program (OCP) guidelines codified – funding was inadequate • 1972 Robert Mc. Namara visited West Africa and championed OCP • 1974 OCP launched with four lead agencies – WHO, World Bank, UN Development Program (UNDP) and Food and Agriculture Organization. • Recognized that river blindness was not just a health issue • First large scale health program ever funded by the World Bank • Insecticide spraying continued even during civil conflict
Invermectin – the medical breakthrough • 1978 Dr. William Campbell and Dr. Kenneth Brown discovered ivermectin, an anti-parasitic agent to treat horses and cows. Dr. Satoshi Omura, working in Tokyo made parallel discoveries. • Ivermectin was also effective against the family of worms in the that cause river blindness. Clinical trials sponsored by the WHO and Merck were successful. • One dose per year could relieve symptoms and kill 95% of the microfilia, tiny worms that breed beneath the skin
William Campbell, Ph. D
Invermectin - the political breakthrough • Neither the WHO nor USAID would accept donations of Mectizin from Merck • William Foege agreed to manage the donation through the Carter Center and the Task Force for Child Survival and Development. Agreement announced in 1987 • Merck agreed to continue donation to cover the full need until the medication was no longer needed • Foege created Mectizin Expert Committee to manage distribution of medication • Ministries of health, NGOs, foundations, medical mission groups could all participate
Invermectin – the administrative breakthrough • Initial program goal was 1 million doses given annually for six years. Goal was exceeded. • Uptake was very high and voluntary. Mectizin worked almost immediately to relieve itchy skin, nodule growth and first vision problems. • Mectizin also worked against intestinal worms, scabies and head lice which enhanced uptake • River Blindness Foundation provided grants for distribution by NGOs
International efforts against river blindness • OCP focused on 11 countries in West Africa (1974 – 2002) • Benin, Burkina Faso, Cote d’Ivoire, Ghana, Guinea Bissau, Mali, Niger, Senegal, Sierra Leone, Togo • Transmission nearly halted • 1. 5 million people no longer have symptoms • 600, 000 cases of blindness prevented • 22 million children will no longer get river blindness • Annual cost was less than $1/person treated • 27 total donors who went the entire distance • Economic impact – an additional $3. 7 billion in economic activity • 25 million arable hectares returned to production, enough to feed 17 million people
Extending the effort • 1995 African Program for Onchocerciasis Control (APOC) began • Extended program to 19 more countries in across Africa • Angola, Burundi, Cameroon, Central African Republic, Chad, DR • • Congo , R Congo, Equatorial Guinea, Ethiopia, Gabon, Kenya, Liberia, Malawi, Mozambique, Nigeria, Rwanda, Sudan, Tanzania, and Uganda 15 year program under leadership of the WHO, UNDP and FAO 21 international donors 30 NGOS 100, 000 community-based implementing groups
APOC Successes • APOC ended in 2015 • Uganda and Sudan achieved sufficient control to not require annual doses of invermectin • Trained more than 100, 000 community health workers and strengthen local ability to combat public health challenges in culturally appropriate ways • By 2010, APOC was completely implemented by African health workers • Com. DT workers also distributed vitamin A, antibiotics to prevent trachoma and did other preventive health care especially for maternal health
APOC Successes • Complete mapping of the disease has made program more effective – completed by 2010 • Demonstrated that women are more effective community health workers with resulting improvement in outcomes and new job opportunities for women • Elephantiasis, lymphatic filariasis, can also be treated with invermectin with albendazole with twice yearly medicine donated by Smith-Kline • Pioneered long-term donation model which has been replicated with Smith-Kline and at cost programs for other vaccines and ARV medications for HIV/AIDS • Merck has donated $1. 3 billion of medication since 1987
APOC Successes and Complications • Pioneered team funding model – shared funding by donors and • • national health ministries, donated administrative costs by WHO and WBG, donated medicines and shipping by pharmaceutical firms Demonstrated that targeted health care investments can return 17% or more, as high or higher than traditional economic development projects Loa loa is a parasitic disease that is widespread in areas where river blindness is endemic. People with loa have adverse reactions to invermectin. Makes control efforts more difficult in Cameroon, CAR, Congo, DRC, Nigeria and S. Sudan Conflict zones have made full coverage difficult In 2017, 145 million people received doses of medicine 70% coverage for endemic river blindness
Geography of river blindness
Next Steps in Sub-Saharan Africa • River blindness treatment became part of a new WHO effort – Expanded Special Project for the Elimination of Neglected Tropical Diseases in Africa (ESPEN) • Worked to cover four diseases with 100% coverage • 2015 – 2020 • Strengthen research and information sharing • Better management of the supply chain • Elephantiasis Program • Trachoma • Black fly may be developing resistance to invermectin and new medicines are now under clinical trial • January 2021 WHO announces new NTD program under SDG umbrella
Onchocerciasis Elimination Program for the Americas (OEPA) • Begun in 1993 • Carter Center took over coordination in 1996 • Worked in Brazil, Colombia, Ecuador, Guatemala, Mexico, and Venezuela • Partners include PAHO, CDC, USAID, Merck and other organizations • Identified 13 areas in the Americas with endemic river blindness
Map of river blindness - 2010
OEPA Images
Onchocerciasis Elimination Program for the Americas (OEPA) • Steps in the process • 100% coverage with invermectin in endemic areas • 45 million doses distributed • Once eliminated, medication ceases, three years of surveillance • After three years, declared free of disease • River blindness eliminated in Colombia (2013), Ecuador (2014), Mexico (2015) and Guatemala (2016) • Work continues in the border area of Venezuela and Brazil among Yanomami
Lessons Learned • Pharmaceutical companies can be dependable, long-term, generous partners • Creative approaches to cost-sharing can maximize benefits • Community-based programs can succeed • Women health workers are effective and should be trained and deployed • Community-based health care providers can help prevent multiple diseases. Care should be integrated. • Data collection, mapping, research and surveillance work • Investments in health care can yield very high returns • Economic costs of illness and disability should be documented to demonstrate benefits of investment
Questions and Answers
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