The distribution of the Simulium damnosum complex in Sierra Leone and its relation to onchocerciasis

Neglected tropical disease control in post-war Sierra Leone using the Onchocerciasis Control Programme as a platform

Strategic investments in the control of neglected tropical diseases (NTD) spearheaded by the US Government, the British Government and other bilateral donors such as foundations and key pharmaceutical partners have enabled the treatment of millions of people for the five targeted debilitating diseases (lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis and trachoma), paving the way for the potential elimination as public health problems of some of these diseases. Like many other countries, Sierra Leone has a high burden of these major NTDs. Despite the fragile infrastructure of a health system emerging from a devastating 10-year civil war, the country has successfully implemented the National NTD Control Programme, reaching national coverage in 2010. The NTD Control Programme uses the existing Onchocerciasis Control Programme as a platform and involves primary health workers. The programme has provided extensive training opportunities to health workers at national, district and community levels. The country currently has 31 161 trained community volunteers treating a population of five million people. It is shown that the investments in NTD control are not only to control NTDs but also to strengthen health systems, particularly at the primary level, through extensive capacity building of frontline health workers and community-directed distributors.

Impact of three rounds of mass drug administration on lymphatic filariasis in areas previously treated for onchocerciasis in Sierra Leone

Background

1974–2005 studies across Sierra Leone showed onchocerciasis endemicity in 12 of 14 health districts (HDs) and baseline studies 2005–2008 showed lymphatic filariasis (LF) endemicity in all 14 HDs. Three integrated annual mass drug administration (MDA) were conducted in the 12 co-endemic districts 2008–2010 with good geographic, programme and drug coverage. Midterm assessment was conducted 2011 to determine impact of these MDAs on LF in these districts.

Methodology/Principal Findings

The mf prevalence and intensity in the 12 districts were determined using the thick blood film method and results compared with baseline data from 2007–2008. Overall mf prevalence fell from 2.6% (95% CI: 2.3%–3.0%) to 0.3% (95% CI: 0.19%–0.47%), a decrease of 88.5% (p = 0.000); prevalence was 0.0% (100.0% decrease) in four districts: Bo, Moyamba, Kenema and Kono (p = 0.001, 0.025, 0.085 and 0.000 respectively); and seven districts had reductions in mf prevalence of between 70.0% and 95.0% (p = 0.000, 0.060, 0.001, 0.014, 0.000, 0.000 and 0.002 for Bombali, Bonthe, Kailahun, Kambia, Koinadugu, Port Loko and Tonkolili districts respectively). Pujehun had baseline mf prevalence of 0.0%, which was maintained. Only Bombali still had an mf prevalence ≥1.0% (1.58%, 95% CI: 0.80%–3.09%)), and this is the district that had the highest baseline mf prevalence: 6.9% (95% CI: 5.3%–8.8%). Overall arithmetic mean mf density after three MDAs was 17.59 mf/ml (95% CI: 15.64 mf/ml–19.55 mf/ml) among mf positive individuals (65.4% decrease from baseline of 50.9 mf/ml (95% CI: 40.25 mf/ml–61.62 mf/ml; p = 0.001) and 0.05 mf/ml (95% CI: 0.03 mf/ml–0.08 mf/ml) for the entire population examined (96.2% decrease from baseline of 1.32 mf/ml (95% CI: 1.00 mf/ml–1.65 mf/ml; p = 0.000)).

Conclusions/Significance

The results show that mf prevalence decreased to <1.0% in all but one of the 12 districts after three MDAs. Overall mf density reduced by 65.0% among mf-positive individuals, and 95.8% for the entire population.

Onchocerciasis studies across Sierra Leone between 1974 and 2005 showed that 12 of the 14 health districts (HDs) are endemic for onchocerciasis. Baseline lymphatic filariasis (LF) studies 2005–2008 showed that all 14 HDs of Sierra Leone are LF endemic. Three annual rounds of integrated mass drug administration (MDA) with ivermectin and albendazole 2008–2010 were conducted in the 12 HDs that are co-endemic for onchocerciasis and LF with good geographic, epidemiological drug (or programme) and drug coverage. A midterm evaluation study of mf prevalence and density was conducted in the 12 HDs in 2011. The hypothesis proposed for this study is that areas previously exposed to ivermectin treatment for onchocerciasis control may require less rounds of annual MDA to eliminate LF (i.e. reduce microfilaremia (mf) prevalence to <1%). Results of the midterm evaluation study showed very significant and rapid reduction of mf prevalence and density with 11 out of the 12 districts having mf prevalence <1%. Relatively low LF baseline prevalence and effective integrated MDA for onchocerciasis and LF have led to rapid reduction in LF prevalence.

A molecular marker for the identification of Simulium squamosum (Diptera: Simuliidae)

All except one of the important groups of West African vectors of Onchocerca volvulus that lie within the Simulium damnosum complex can be distinguished from each other using morphological characteristics. The exception is S. squamosum, which overlaps with other species, and this results in significant levels of misidentification. Variation in the untranscribed H3-H4 histone intergenic spacer region of flies of the S. damnosum complex has now been investigated. Although a CAA/CAG microsatellite was found to be hyper-variable and unsuitable for species diagnosis, a 10-bp indel seemed to vary in a species-specific manner. This indel was apparently absent from S. squamosum but present in all of the other species tested (S. damnosum s.s., S. sirbanum, S yahense, S. sanctipauli and S. leonense/konkourense). It should now be possible to identify individual, adult, female S. squamosum from the absence of the indel, using a PCR-based amplification and agarose- or polyacrylamide-gel electrophoresis, thus removing the major barrier to the routine identification of unknown samples.

Filariasis in the Kaiyamba Chiefdom, Moyamba District Sierra Leone: an epidemiological and clinical study

In a cross-sectional epidemiological and clinical study of human filariasis, 630 individuals were examined for Onchocerca volvulus, Wuchereria bancrofti and Mansonella perstans infections in five communities in the Kaiyamba Chiefdom, Moyamba District, Sierra Leone. The overall prevalence of O. volvulus infection in males 144(39.1%) and females 94(35.9%) was not significantly different and the sex prevalence rate between communities was also not significant (G = 3, d.f. = 4, P > 0.05). Prevalence of O. volvulus was significantly lower (G = 42.331, d.f. = 5, P < 0.001) in the 5-9 age group (13.3%) compared to the 40-49 age group (61.9%). Sixty-four (10.2%) and 38(6.0%) of individuals examined were positive for W. bancrofti and M. perstans infections respectively and prevalence of both infections in the five communities was not significant. Mixed infections with the all three filaria parasites were recorded in 10(3.2%) of the individuals. One hundred and sixty-four (71.3%) clinical cases due to W. bancrofti were inflammatory in nature; 36.5% were chronic, of which, 26.6% were hydroceles and 9.4% involved elephantiasis of both the scrotum and the lower legs. All 19(3.0%) of M. perstans-related clinical cases were inflammatory. Ninety-three(63.3%) of O. volvulus positive individuals that presented symptoms were inflammatory in nature, 14(9.5%) had ocular symptoms and 57(38.8%) had subcutaneous nodules. These data indicate that infections due to O. volvulus, W. bancrofti and M. perstans may be of public health importance in Sierra Leone.

Drastic reduction of populations of Simulium sirbanum (Diptera: Simuliidae) in central Sierra Leone after 5 years of larviciding operations by the Onchocerciasis Control Programme

The major vectors of the blinding form of human onchocerciasis in West Africa are two blackfly species, Simulium sirbanum and Simulium damnosum s.s. (Diptera: Simuliidae), identified at the adult stage as the 'savanna group' of the Simulium damnosum complex. In 1988, in the central part of Sierra Leone, the average daily biting rate (females/man/day) by savanna blackflies (mostly S. sirbanum) during the peak of the dry season (April-May) was 59.9, making up 69.1% of total captures on average. There was evidence of a strong long-range immigration of adult females of S. sirbanum through eastern Guinea in the dry season, with a reverse movement towards Guinea in the rainy season. Therefore, in 1989, the World Health Organization's Onchocerciasis Control Programme (OCP) extended its vector control operations from central West Africa to rivers of central and northern Sierra Leone, and to rivers of eastern Guinea. Four years of efficient larviciding drastically reduced adult populations of S. sirbanum in Sierra Leone. In the peak of the dry seasons of 1993 and 1994, the average biting rate by savanna blackflies in central Sierra Leone had dropped to 1.0, making up only 4.3% of total captures on average. Yearly biting rates by S. sirbanum in central Sierra Leone were therefore reduced to 2% of their pre-intervention levels. Based on larval samples, the S. sirbanum has been replaced by two forest species, S. leonense in the south and S. squamosum in the north. Since 1992, it has been possible to calculate accurate transmission rates for blinding onchocerciasis, based on DNA-probe identifications. From 1993, the risk of transmission has not only been reduced by vector control but also by mass distribution of ivermectin to rural communities. In terms of control strategy, the authors conclude that larviciding operations could be alleviated in central Sierra Leone without increasing the risk of blinding onchocerciasis transmission, as long as the migration of S. sirbanum through eastern Guinea and northern Sierra Leone is prevented.

Aggregated oviposition in the Simulium damnosum complex is mediated by eggs in a laboratory bioassay

The phenomenon of aggregated oviposition in blackflies (Diptera: Simuliidae) was investigated under controlled laboratory conditions, using wild-caught females of the Simulium damnosum complex in Sierra Leone. A method was developed for inducing Simulium females to lay eggs, and used as a bioassay to measure the responses of gravid S. damnosum s.l. to freshly laid eggs of the same species complex. In a series of two-choice tests, significantly more ovipositing flies chose substrates already containing eggs over control substrates (P = 0.004). The time from introduction of flies into the oviposition system to the onset of egg-laying was significantly less when eggs were already present (P = 0.049). Flies responded more quickly when more eggs were present and the relationship between egg-batch number and the time of this response was curvilinear (P = 0.012). Ecological advantages and disadvantages of such aggregation behaviour and the possible role of semiochemicals in its mediation are discussed.

Deforestation: effects on vector-borne disease

This review addresses changes in the ecology of vectors and epidemiology of vector-borne diseases which result from deforestation. Selected examples are considered from viral and parasitic infections (arboviruses, malaria, the leishmaniases, filariases, Chagas Disease and schistosomiasis) where disease patterns have been directly or indirectly influenced by loss of natural tropical forests. A wide range of activities have resulted in deforestation. These include colonisation and settlement, transmigrant programmes, logging, agricultural activities to provide for cash crops, mining, hydropower development and fuelwood collection. Each activity influences the prevalence, incidence and distribution of vector-borne disease. Three main regions are considered--South America, West & Central Africa and South-East Asia. In each, documented changes in vector ecology and behaviour and disease pattern have occurred. Such changes result from human activity at the forest interface and within the forest. They include both deforestation and reafforestation programmes. Deforestation, or activities associated with it, have produced new habitats for Anopheles darlingi mosquitoes and have caused malaria epidemics in South America. The different species complexes in South-East Asia (A. dirus, A. minimus, A. balabacensis) have been affected in different ways by forest clearance with different impacts on malaria incidence. The ability of zoophilic vectors to adapt to human blood as an alternative source of food and to become associated with human dwellings (peridomestic behaviour) have influenced the distribution of the leishmaniases in South America. Certain species of sandflies (Lutzomyia intermedia, Lu. longipalpis, Lu. whitmani), which were originally zoophilic and sylvatic, have adapted to feeding on humans in peridomestic and even periurban situations. The changes in behaviour of reservoir hosts and the ability of pathogens to adapt to new reservoir hosts in the newly-created habitats also influence the patterns of disease. In anthroponotic infections, such as Plasmodium, Onchocerca and Wuchereria, changes in disease patterns and vector ecology may be more difficult to detect. Detailed knowledge of vector species and species complexes is needed in relation to changing climate associated with deforestation. The distributions of the Anopheles gambiae and Simulium damnosum species complexes in West Africa are examples. There have been detailed longitudinal studies of Anopheles gambiae populations in different ecological zones of West Africa. Studies on Simulium damnosum cytoforms (using chromosome identification methods) in the Onchocerciasis Control Programme were necessary to detect changes in distribution of species in relation to changed habitats. These examples underline the need for studies on the taxonomy of medically-important insects in parallel with long-term observations on changing habitats.(ABSTRACT TRUNCATED AT 400 WORDS)

Visual loss in an onchocerciasis endemic community in Sierra Leone

The visual acuities of 1625 individuals recruited to a community-based clinical trial of ivermectin in southern Sierra Leone were measured, and the prevalence of visual loss in this rural population where onchocerciasis is hyperendemic was determined. Ocular examination was performed before treatment to establish the cause of visual loss. Using WHO definitions, 1.3% were blind (less than 3/60 in both eyes), 4.3% were visually impaired (between 6/24 and 3/60 in the better eye), and a further 3.4% were uniocularly blind (less than 3/60 in one eye and better than 6/24 in the other). Cataract and onchocerciasis were the major causes of visual loss in this population. More than half of the ocular morbidity was preventable or treatable by public health measures or basic curative medicine. These findings are discussed in the light of the available health and eye care services.

A community trial of ivermectin for onchocerciasis in Sierra Leone: clinical and parasitological responses to the initial dose

A double-blind placebo-controlled trial of ivermectin was started in 1987 in 6 villages in southern Sierra Leone. 1625 villagers, 93% of the total population, were surveyed before treatment and allocated at random to the trial. Onchocerciasis was hyperendemic and of moderate intensity in the area. Typical onchocerciasis skin lesions were seen in most cases; the blindness rate was 1.5% and a further 4.3% had visual impairment. Six months after treatment 988 subjects (80%) were reassessed and microfilarial loads in the ivermectin group were found to be 10% of control levels. Additionally, blood eosinophil concentrations were reduced by one-quarter. The severity, but not the prevalence, of skin lesions was significantly reduced in the ivermectin group, with a particularly marked effect on papular eruptions. There had been no reduction in the prevalence of itching, nor had markers of general health shown improvement after ivermectin. Ivermectin is an effective microfilaricidal agent and may improve Onchocerca-related skin lesions after a single dose. However, the lack of obvious benefit to a target population after the first dose of ivermectin may reduce compliance with subsequent doses. This has implications for planned mass treatment initiatives in onchocerciasis endemic regions.

The transmission of onchocerciasis at a forest village in Sierra Leone. I. Simulium damnosum s.l. biting densities and infection with Onchocerca volvulus at five representative sites

Previous studies in the forest area of Sierra Leone have shown that transmission of Onchocerca volvulus takes place many kilometers away from large breeding rivers and sometimes in open farmland. To determine where and when people in a forest village were most likely to be infected, catches of Simulium damnosum s.l. were carried out every week for 12 months, at five sites in and near a village where onchocerciasis was mesoendemic. The number of flies caught per man a day at open farm sites was significantly higher than the number caught at riverside sites. Infective flies were caught only in farmland and only during the early rainy season. The combined Annual Transmission Potential for the five sites was 129 larvae per man per year. Isoenzyme electrophoresis and morphology of biting flies identified the S. sanctipauli/soubrense subcomplex as the most common vector species. Simulium yahense and S. squamosum were sometimes present. It was concluded that the classical riverside monitoring sites do not represent high risk areas for the transmission of onchocerciasis in a forest village sited well away from the main S. damnosum s.l. breeding sites. The highest risk areas are in open farmland.

Filariasis in the Igwun River Basin, Nigeria: an epidemiological and clinical study with a note on the vectors

In a cross-sectional, epidemiological and parasitological study of human filariasis, 845 individuals were examined in settlements along the Igwun Basin, Imo State, Nigeria. Four different filarial nematode species were identified. Two hundred and fifty-six (30.3%) of the individuals examined were positive for Onchocerca volvulus, 113 (13.4%) for Mansonella perstans, 76 (9.6%) for Wuchereria bancrofti and 77 (9.1%) for Loa loa. Microfilarial rates increased with age of individuals and showed a tendency towards higher prevalence rates in males than in females. The intensity of O. volvulus infection was high, with the highest microfilarial density of 44 mf mg-1 snip which occurred in the 40-49-year-old individuals. In W. bancrofti and L. loa infections, infections of over 1000 mf 20 ml-1 blood were recorded in 15.8% and 19.5% of individuals, respectively. Observed clinical signs were associated with inflammatory, lympho-obstructive and ocular manifestations. In M. perstans infections all clinical cases were inflammatory. In W. bancrofti, 44.4% of clinical cases were inflammatory, and lympho-obstructive manifestations consisted of 23.8% chyluria, 12.7% hydrocele and 19.1% elephantiasis. In L. loa infections all clinical cases were inflammatory with indications of Calabar swellings. In O. volvulus infections 23.5% of clinical cases were inflammatory, while 76.5% showed ocular manifestations. The absence of blindness despite high O. volvulus infection rates was remarkable. The presence of potential insect vectors and the occurrence of clinical signs are indications of active transmissions.

A taxa summary for the Simulium damnosum complex, with special reference to distribution outside the control areas of West Africa

A synoptic list is provided of currently recognized taxa in the Simulium damnosum complex, with an indication of their geographical distributions. Outline maps are given for the distribution of S. damnosum sensu lato, and for the West African cytospecies of the complex. Short reports on the identities and distributions of member taxa are given for countries other than those of the Onchocerciasis Control Programme in the Volta River Basin (OCP) and its Senegambia Extension; these are mainly based on collation of published and unpublished data for the post-1976 period (since the last WHO Expert Committee Report on Onchocerciasis).

Onchocerciasis in Sierra Leone. I. Studies on the prevalence and transmission at Gbaiima village

A longitudinal survey--parasitological, clinical, immunological and entomological--of onchocerciasis is being conducted in Gbaiima village in Sierra Leone. The estimated Annual Transmission Potential (ATP) is 5863. More than 80% of the annual transmission occurs between October and December. Four species of the Simulium damnosum complex are known to breed in a nearby river. The relative role of these species as vectors has yet to be determined. The total population (598 persons) aged one year and over were examined. Based on microfilarial and nodular rates the prevalence of onchocerciasis was 68.6%. In persons above 15 years of age this prevalence was 88.9%. Microfilarial and nodular rates were related to age. Severe skin lesions occurred in 1.0% of persons. 24 adults (7.5%) were blind (but the cause of the blindness was not determined).