1. Insight to Future Sight Investing in the Future
Sue Gerber
July 22, 2009
PUBH 6165/8165
Good morning and thank you for asking me to speak today. I think it is very heartening to have such a powerful group in the room today. Our colleagues from the Ministry of Planning have joined the Ministry of Health from – as I look around the room – almost every county in the country. It is with great pleasure that I join my colleagues here with you to discuss a disease that has had a profound impact on the lives of many Liberians. It is impressive when all sectors of government work together to improve the lives of Liberian citizens and today we will have a chance to discuss one of many health problems facing our nation. I believe that everyone in the room knows someone that has been infected with onchocerciasis. This disease has plagued our citizens for the past several decades and in the past several years while other African countries such as Mali and Senegal have had the opportunity to develop model programs that have reduced the disease burden of Onchocerciasis, so significantly scientists could find not substantial disease burden in humans or the black fly, we have been unable do to the civil unrest. We will have the opportunity to discuss their success in greater detail later in the discussion. To control river blindness we must understand the transmission and develop strategies that will work in Liberia. We must develop insight into ensuring future sight for all our citizens and this will require an investment in the future. All pictures and maps in this presentation are courtesy of the World Health Organization and are used with permission.
The maps and pictures I will show today in this presentation have come from the WHO and APOC websites

2. of river blindness in Liberia and the impact within communities
An open discussion
of river blindness in Liberia and
the impact within communities
What are our opportunities?
I would hope this session today would be very interactive. Please feel free to ask questions or comment during the discussions. Today we will talk about opportunities. Now having been through several planning sessions in the development of your county development plans you might be thinking- following our analysis of available resources our county health care services stretched thin, human recourses are at an all time low, tuberculosis, HIV and now the recent polio outbreak are high priority in our communities. Agree on all points which is exactly why we must look for opportunities!

3. Overview Description of Onchocerciasis Impact globally Impact locally
Current activities and opportunities to intervene
Future considerations
References and materials for review
Today I will begin by giving an overview of the disease and how it is transmitted. I will then describe global impact of this devastating disease and how Liberia is being affected- or shall we say infected. I will then discuss the many opportunities we currently have to control the disease and what we might consider for the future. Finally I will present a number of materials and websites that contain information and reference that you could use for future reference. I hope that we have interesting discussions and I also hope we can ensure our children are not affected by this disease.

4. I am sure these pictures represent scenes you are familiar with
I am sure these pictures represent scenes you are familiar with. Villagers in your mothers village that are now blinded crippled or scared from this disease.

5. Onchocerciasis Transmission
Spread by the bites of black flies
Larvae of the Onchocerca volvulus worm enters the body during the bite
Hundreds of bites are usually required to acquire onchocerciasis.
Black flies require fast moving streams/rivers for reproduction
Onchocerciasis is a parasitic disease, which is transmitted through the bite of a black fly. . The parasites are small, threadlike worms, which live under the skin often in aggregated clumps called nodules. Adult worms live for about seven to 15 years. Male and female worms congregate and live for years in these nodules. The female worms produce thousands of offspring called microfilariae. The microfilariae leave the nodules and migrate to the upper layer of the skin, where they can transfer to black flies when the insects bite to take a blood meal. In the fly, the microfilariae develop into infective larvae, which can then be transmitted to the next unknowing victim during the fly's next bite. Over the course of a year, these larvae mature into adult worms, and the cycle continues.
Haymann, D. (Ed.). (2004). Control of Communicable Diseases in Man (18 ed.). Washington: American Public Health Association

6. Symptoms and Complications
Intense itching
Skin discoloration
Blindness
Lymphadenitis
Dermatitis and rash
Adult worm nodules/nests around pelvic area
Infection reduces immunity and resistance to other diseases
When adult worms reach maturity they will begin to reproduce. The microfilarie then cause the most damage as they feed on tissue during the night and migrate to the surface of the skin during the day. It has been said that the itching is so intense it can cause insomnia. The itching can also lead to skin infections
Haymann, D. (Ed.). (2004). Control of Communicable Diseases in Man (18 ed.). Washington: American Public Health Association

7. Transmission cycle
I would now like to to review how this infection and re-infection takes place. The black fly will be take in the microfilarie from a person during the bite- while taking a blood meal the microfilarie will then mature and then will be passed to another person when the fly feeds again- so the cycle repeats itself.
World Health Organization(2009) retrieved July 1, 2009 from

8. Treatment No effective treatment to kill the worm
Treatment with Mectizan every 6 to 12 months in endemic communities
Reduces Microfilarial load
Kills microfilariae
Blocks release of microfilariae from adult worm
Currently there is no effective treatment to kill the adult worm however Merck- a partner in river blindness control has donated Mectizan for anyone that needs treatment. As we mentioned before the adult worm can live for 15 years inside the human body. Therefore to control river blindness individuals in endemic areas must currently be treated for at least 15 years or longer. Treatment is currently recommended for everyone above the age of five years and the dosage of Mectizan is 150 micrograms per kilogram. While Mectizan does not kill the adult worm it will block release of the microfilarie from the uterus of the adult worm and will kill those that have been released -this will reduce the number of microfilarie that can migrate throughout the body – reducing the amount of itching and ability to reach and affect the eye. Merck has been donating this drug since 1988 and has recently pledged to continue as a partner in River blindness elimination
Haymann, D. (Ed.). (2004). Control of Communicable Diseases in Man (18 ed.). Washington: American Public Health Association

9. River Blindness Global Impact
17.7 million people worldwide are infected
37 endemic countries
500,000 are visually impaired
270,000 are blind due to the disease
The Carter Center, which has been one of the leading partners in the control of river blindness estimates there are 37 countries in which river blindness continues to have an impact on its citizens. Currently there are well over 17 million people infected and this disease has left 500,000 with visual problems and over half have resulted in permanent irreversible blindness
Carter Center (2009) River Blindness, retrieved on July 1, 2009 from

10. Countries affected by River Blindness
It is estimated that 123 million people live in endemic areas worldwide and are therefore at risk of infection and as you can see from the map the greatest number of countries at risk are in Africa. Experts tell us the country most affected in the west African region is Nigeria.
In addition to the impact on health onchocerciasis has an enormous economic impact, preventing people from working, harvesting crops, receiving an education, or taking care of children.
World Health Organization (2009) retrieved July 1, 2009
from

11. Liberia
Over 2 million people in 3500 communities are at risk living in endemic area
Only 3 community-directed treatment projects
As there is currently no surveillance information for Onchocerciasis, a rapid epidemiologic mapping exercise for Onchocerciasis was conducted. In this survey 2-4 % of the villages in a geographic area were surveyed. 50 adults per village were evaluated for the sub-cutaneous worm nodules. The adults are at least 20 years old and have been resident in the community for at least 10 years. If ≥20% of adults have nodules, mass treatment is required and this area is mapped in red. In communities where the nodule rate is less than 20% clinic-based treatment is applied and this area is marked in green. The areas that are marked in yellow must be reevaluated. As you can see a significant area of the county is red requiring mass treatment. The onchocerciasis map is overlapped with a population map to then plan which communities to treat. It also allows us to have a better estimate of the number of people to be treated, and a better estimate of the burden of disease.
In there were 3546 communities that considered to be endemic with over 2 million people at risk. Any projects that were underway before the war were halted due to dangerous conditions for the community volunteer. The program has started again slowly with three community directed treatment projects at the end of These community directed projects rely on community members that are selected and supported by the community to provide treatment either yearly or twice a year to the population under their assignment.
African Programme for Onchocerciasis Control (2009) Liberia Onchocerciasis Status retrieved July 1, 2009 from

12. Progress in Liberia in 2007 4,370 communities were reached
Over 2,400,000 individuals were treated
Currently 16, 987 community-directed distributors have been trained and are actively working in their community
Over 300 health workers trained and providing treatment
In 2007 using health workers and community volunteers we were able to reach 73% of the 5940 identified communities however only 66% of the 3.6 million individuals that were targeted for treatment actually were treated, which means almost half of those identified in need of treatment did not receive it.
It is encouraging that at the end of 2007 there are close to 17,00 trained community directed distributors and over 300 trained health workers. Each community directed distributor is responsible for just over 200 people. But this is not enough to assist our people we need more volunteers willing to support this initiative.
The World Bank reported that the most important aspect of the success of the treatment programs in west africa was the work of the community directed distributors. In many countries these volunteers have expanded their roles and assisted in Guinea Worm eradication, polio eradication and community based surveillance among many other things. This may be a very interesting topic when we have a chance to discuss opportunities. What is clear is the number of volunteers and health workers available for treatment of our communities is not sufficient. The county development plans validate this!
African Programme for Onchocerciasis Control (2009) LiberiaOnchaisris Statis retrieved July 1, 2009 from
Bump, J., Benton, B., Seketeli, A., Liese, B. H. (2004). West Africa: Defeating Riverblindness—Success in Scaling Up and Lessons Learned: World Bank.

13. Global Opportunities
New Drug on the horizon and in last phase of clinical trials
Commitment from the development partners for the elimination of River blindness
I mentioned at the beginning of our discussions that I would touch on opportunities. While there has been success in the use of Mecitzan to reduce the burden of disease, treatment lasts the lifetime of the adult worm which can be as long as 15 years. Currently Wyeth announced they have developed a drug, which is undergoing phase three clinical trial in DRC, Ghana and here in Liberia, which they believe will work to reduce the microfilaria burden and kill the adult worm over a period of time. This drug hold great promise as it will then reduce the time needed to stop transmission from humans to the black fly. In addition Merck joined the World Health Association announcing it would extend its assistance through drug and financial contributions to the elimination of river blindness. This is our opportunity .
Diawara, L., Traore´, M. O., Badji, A., Bissan, Y., Doumbia, K., Goita, S. F., Konate´, L., et al. (2009). Feasibility of Onchocerciasis Elimination with
Ivermectin Treatment in Endemic Foci in Africa: First Evidence from Studies in Mali and Senegal. Public Library of Science Neglected Tropical Diseases, 3(7), 15.

14. Opportunities within Liberia
Infrastructure development
Poverty Reduction Plan
Basic Package of Health and Social Welfare Services
County Development Agenda
The Poverty reduction plan calls for expanding peace and security, revitalizing the economy, strengthening governance and the rule of law; and rehabilitating infrastructure and delivering basic services. The Basic package of services call for expanding access to disease prevention and control programs – and the use of community health workers that are supported by the community. This is our opportunity!
In addition provisions will be made to enhance pre service and in-service training for all cadres of health workers. What is needed is the support for these activities from both the Ministries of Health and Planning to ensure these activities happen and that these workers can then make a difference in the health and well being of the underserved communities living in rural area We look to you to use the county development agenda as an agent of change within your county. You are the one that can turn these opportunities into reality.
Republic of Liberia, Ministry of Planning (2009) Poverty Reduction Strategy retrieved July 15, 2009 from
Repubic of Liberia, Ministry of Health and Social Welfare (2009), Basic Package of Health and Social Welfare Services retrieved July 15, 2009 from

15. Opportunities for 2010
Increase awareness among chiefs and elders and the community
Work to meet demand of treatment through supply of community health workers
Use development partners to support training for all levels of staff
Look for other opportunities to partner in field activities related to health and social services
This statue resides at the Carter Center in Atlanta Georgia in the United States. It is my hope that statue will one day be the only symbol of blindness as a result of river blindness. This can be achieved through your work- that of the Ministry of Health and the Ministry of Planning – having a mutual understanding of the diseases that affect Liberians and the strategies for safe guarding the population is everyone's business. We have discussed the transmission of river blindness and the impact it has on the global community. We have also reviewed the survey showing the endemic areas of Liberia in which all individuals over five should be treated with one or two doses a year. We also realize the human capital to complete these exercises is very limited. We know that Liberia is moving forward, improving the infrastructure and I hope we can use ideas put forward today to move our program forward. I believe that everyone in this room has the ability to make change first by understanding the level of treatment needed in their geographic area, second by sharing this information with the leaders of those communities to create demand for treatment- My feeling from our discussions today is that this is happening already, it is the system that is not quite in place to meet the demand. I would like to thank everyone for their questions and for their time today and in the future.

16. Recommended Reading References and Resources
Bump, J., Benton, B., Seketeli, A., Liese, B. H. (2004). West Africa: Defeating Riverblindness-Success in Scaling Up and Lessons Learned: World Bank
Diawara, L., Traore´, M. O., Badji, A., Bissan, Y., Doumbia, K., Goita, S. F., Lassana et al. (2009). Feasibility of Onchocerciasis Elimination with Ivermectin Treatment in Endemic Foci in Africa: First Evidence from Studies in Mali and Senegal. Public Library of Science Neglected Tropical Diseases, 3(7), 15.
Republic of Liberia: Poverty Reduction Strategy
Republic of Liberia: Basic Package of Health and Social Welfare Services
Republic of Liberia: County Development Agenda (Available for all counties)
The first two articles give a very good over view of the problems and success with the river blindness program over the past 15 years. The PRS and BPHS give a very sobering overview of the country at this time with the CDAs provide insight into each county and their public health infrastructure and capacity. Thank you again this has been a very productive session today.

17. Useful Websites
African Programme for Onchocerciasis Control (APOC)
Carter Center
Centers for Disease Control
World Bank
These are websites of four of the development partners which help to support the river blindness program.