Ocular onchocerciasis. Diagnosis and current clinical approaches

Onchocerciasis (river blindness) - more than a century of research and control

This review summarises more than a century of research on onchocerciasis, also known as river blindness, and its control. River blindness is an infection caused by the tissue filaria Onchocerca volvulus affecting the skin, subcutaneous tissue and eyes and leading to blindness in a minority of infected persons. The parasite is transmitted by its intermediate hosts Simulium spp. which breed in rivers. Featured are history and milestones in onchocerciasis research and control, state-of-the-art data on the parasite, its endobacteria Wolbachia, on the vectors, previous and current prevalence of the infection, its diagnostics, the interaction between the parasite and its host, immune responses and the pathology of onchocerciasis. Detailed information is documented on the time course of control programmes in the afflicted countries in Africa and the Americas, a long road from previous programmes to current successes in control of the transmission of this infectious disease. By development, adjustment and optimization of the control measures, transmission by the vector has been interrupted in foci of countries in the Americas, in Uganda, in Sudan and elsewhere, followed by onchocerciasis eliminations. The current state and future perspectives for control, elimination and eradication within the next 20-30 years are described and discussed. This review contributes to a deeper comprehension of this disease by a tissue-dwelling filaria and it will be helpful in efforts to control and eliminate other filarial infections.

Clinical responses in human onchocerciasis: parasitological and immunological implications

Onchocerciasis can cause severe dermal and ocular disease due, it is thought, to the events surrounding the destruction of the microfilarial stage. The evolution of papular pruritic dermatitis and punctate keratitis is clearly related to the killing of microfilariae. Other more chronic changes such as dermal and epidermal atrophy are probably due to repeated episodes of microfilarial killing. It is common to find that not all patients are, at any one time, mounting clinically obvious destructive host responses against the microfilariae, and such individuals can carry very high loads of parasites without any apparent adverse effects. The immunological basis of the differences between these types of patients forms one of the most important questions in the pathogenesis of onchocerciasis today. Various explanations are now emerging. These include immunosuppressive factors and variation in the form of Onchocerca volvulus antigens presented to the host. Clinical presentations of this disease appear to reflect variations in host responses and can be used to provide information concerning the protective immune responses an individual can mount against this parasite.

Effects of repeated doses of ivermectin on ocular onchocerciasis: community-based trial in Sierra Leone

Ivermectin seems to be a safe and effective treatment for onchocerciasis when given in a single dose, but less is known about the effects of repeated doses. Also, there seem to be differences in its effectiveness in anterior and posterior segment ocular disease. The ocular effects of ivermectin were studied in 586 villagers who were taking part in a double-blind, placebo-controlled, randomised trial in Sierra Leone. Only those who had received four doses, with 6-month intervals, of ivermectin or placebo were eligible. The 296 ivermectin-treated subjects and the 272 who received placebo were comparable with respect to age, sex, Onchocerca infection, blindness, and visual impairment before treatment. After treatment, the ivermectin group had less anterior segment disease than the placebo group, with significantly lower prevalences of microfilariae in the anterior chamber and cornea, and punctate keratitis (all p less than 0.001), and iritis (p less than 0.05). There was no significant difference in the prevalence of sclerosing keratitis, optic atrophy, or chorioretinitis between the groups. Visual acuities tended to be better in the ivermectin group, but the difference was not significant. There was a small but significant (p less than 0.01) excess of vascular sheathing in the ivermectin group. These differences persisted when subjects who were blind or visually impaired at baseline were excluded from analysis. The long-term effects of ivermectin, particularly on posterior segment disease, need further evaluation. In the mean time, the mass distribution of ivermectin should be promoted for all communities with hyperendemic onchocerciasis at risk of anterior segment disease.

Severe onchocercal dermatitis in the Ethiopian border region of Sudan

Onchocerca volvulus infection of the residents of two villages in the Upper Atbara River region of Sudan (63.4% prevalence) was found to be medically and socially significant with a remarkable degree of pruritus and dermal pathology present. The severest skin changes, which were often confined to certain areas of the body, were most common in the teenage group (13-19 years). Quantitation of the clinical changes showed that the most severe alterations were present in patients with the lower levels of microfilariae in the skin (0.1-6 mf mg-1) rather than in those with higher levels. Nodules containing adult O. volvulus were found in many individuals, and often in clusters in older patients. Major losses of vision due to O. volvulus were not found, although microfilariae were frequently seen in the cornea and anterior chamber. The commonest corneal change was punctate keratitis, and this was most frequently seen in the teenage group. Trachomatous changes of eyelids and corneas were also seen. The prevalence values of O. volvulus infection in the two villages were significantly increased when, in addition to microfilarial presence in skin biopsies, onchocercal signs such as punctate keratitis, nodule presence and microfilariae in the anterior chamber were taken into consideration. This illustrates the need to consider factors other than skin snip parasitology in obtaining a diagnosis. This study also emphasizes the degree of severity that onchodermatitis can reach and that low levels of dermal microfilariae can be accompanied by very extensive skin changes without any loss of vision. The necessity of considering the severity of skin changes when defining tolerable levels of onchocerciasis in a community is discussed.

Associations between clinical disease, circulating antibodies and C1q-binding immune complexes in human onchocerciasis

Onchocerciasis is a disease where often there are high levels of serum antibodies and high parasitic loads. The role of immune complexes in the development of the disease is investigated here by studying non-specific and Onchocerca volvulus specific immune complex levels, as well as the antibody concentrations, in the sera of 372 people living in either Southern (199) or Northern (173) Sudan; sera from Sudanese individuals (31) and Caucasians (21) living outside the onchocerciasis endemic area were also tested. The levels of non-specific immune complexes (NS-IC) in these sera were measured by a solid phase radio-immunoassay and those of O. volvulus-specific immune complexes (OV-IC) by an assay measuring antibody-excess complexes using C1q-coated plates. The concentrations of O. volvulus IgG antibodies were measured by ELISA. Immune complex and antibody levels of the serum donors were compared with regard to their clinical status due to onchocerciasis. These clinical changes were classified according to onchocercal lesions related to either the active destruction of microfilariae (acute changes), or the long term tissue alterations (chronic changes). Data was analysed using the Odds Ratio method. A negative association between microfilarial load and immune complex level was found, with the higher levels of OV-IC present in patients with the lower levels of dermal microfilariae (i.e., less than 10 mf/mg). Significant associations between immune complex levels and the severity of onchocercal disease were also found. Levels of OV-IC specific immune complexes were higher in infected individuals carrying dermal onchocercal lesions than in those without such clinical changes; there was no apparent relationship between these levels and the presence of ocular lesions. OV-IC levels varied considerably within each age group and from age to age. A weak positive association was detected between microfilarial load and parasite-specific IgG antibody concentration in the sera. On average younger individuals (less than 25 years) had the higher antibody levels with a gradual reduction in mean concentrations with age. The significance of these serological findings in terms of the pathogenesis of onchocerciasis is discussed.