1. Onchocerciasis (River Blindness) Presented by Elizabeth Ndubisi-Ukandu, Ph.D Student In partial fulfillment of PUBH-8165-3-Environmental Health Walden University Instructor: Dr. Jeff Wu Summer Term, 2009

2. Outline of topic presentation This presentation is aimed at indirect education primary victims of River Blindness through primary healthcare providers, volunteers, local health agencies in the endemic areas. There is review of the etiology, mode of transmission of this disease, as well as examining why the situation persists, cultural barriers and prevention measures. There is a look at the successes of prevention strategies; and continuing efforts in other areas. Lastly there is a provision of a list of resources for further reading.

3. Presentation Topic Onchocerciasis (River Blindness) Health education campaign for primary care providers and health agencies in endemic regions. Self-prevention measures by primary victims through health education by public health educators.

4. Presentation Objective Educate rural inhabitants of endemic regions, travelers in the region on River Blindness. Educate rural inhabitants of endemic regions, travelers in the region on River Blindness. Educate on Cultural, ethnic and religious values Educate on Cultural, ethnic and religious values Campaign for the elimination and eradication of River Blindness. Campaign for the elimination and eradication of River Blindness. Encourage victims to seek professional healthcare services. Encourage victims to seek professional healthcare services.

5. Who are the target audience?  Healthcare providers for the targeted community  Rural inhabitants of endemic regions particularly in Africa’s remote villages, the traveler in these regions. Departments of Public Health Departments of Public Health Policy makers and interested public Policy makers and interested public (WHO, 2001; CDC, 2008)

6. Why are they the target audience? The healthcare providers because they are the primary providers of care for the victims The healthcare providers because they are the primary providers of care for the victims The rural village inhabitants who are the primary victims of the disease The rural village inhabitants who are the primary victims of the disease Health care agencies who are responsible for the public health of the community Health care agencies who are responsible for the public health of the community Global agencies interested in eradicating the disease. Global agencies interested in eradicating the disease. (Levine, 2007; WHO, 2007)

7. Etiology of Onchocerciasis (River Blindness) Onchocerciasis is caused by a parasitic worm and is spread by the bite of an infected blackfly Onchocerciasis is caused by a parasitic worm and is spread by the bite of an infected blackfly It is also called River Blindness because infections are most intense in remote African rural agricultural villages, located near rapidly flowing streams. It is also called River Blindness because infections are most intense in remote African rural agricultural villages, located near rapidly flowing streams. (WHO,2001; CDC, 2008; Levine, 2007)

8. Host and Mode of Transmission The parasitic worm lives in the Blackfly where it develops The parasitic worm lives in the Blackfly where it develops Once a blackfly is infected, it infects the human victim by bites. The severity of the resulting disease depends on the intensity of the bites (CDC, Fact sheet:2008) Once a blackfly is infected, it infects the human victim by bites. The severity of the resulting disease depends on the intensity of the bites (CDC, Fact sheet:2008)

9. Cycle of Onchocerciasis Transmission Source: Basáñez M-G et al: River Blindness, A Success story under threat?

10. Significance of Onchocerciasis (River Blindness) Global Onchocerciasis prevalence is 17.7 million Global Onchocerciasis prevalence is 17.7 million 270,000 are blind and another 500,000 have visual impairment 270,000 are blind and another 500,000 have visual impairment 99% of infected persons are in Africa; the remainder is in Yemen and six countries in the Americas 99% of infected persons are in Africa; the remainder is in Yemen and six countries in the Americas world's second leading infectious cause of blindness (CDC, 2008; WHO, 2001). world's second leading infectious cause of blindness (CDC, 2008; WHO, 2001).

11. Chart of Onchocerciasis Infection Source: Basáñez M-G et al: River Blindness, A Success story under threat?

12. How enduring is it? It is the world's second leading infectious cause of blindness It is the world's second leading infectious cause of blindness Millions of people are being handicapped from a preventable disease. Millions of people are being handicapped from a preventable disease. (CDC, 2008; WHO, 2001).

13. Why does it continue to persist? Lack of education on the dangers of fast flowing rivers. Lack of education on the dangers of fast flowing rivers. Rural communities and their cultural and spiritual connections and interpretations of water, its natural source and the “correct way” of using it (WHO, 2001; Rinne, 2006). Rural communities and their cultural and spiritual connections and interpretations of water, its natural source and the “correct way” of using it (WHO, 2001; Rinne, 2006).

14. Where are the endemic regions? The endemic regions are primarily the rural villages of Africa, which are close to bodies of flowing waters. The endemic regions are primarily the rural villages of Africa, which are close to bodies of flowing waters. Yemen Yemen 6 other countries in the Americas 6 other countries in the Americas (CDC, 2008; WHO, 2001).

15. Endemic Areas for Onchocerciasis Disease Source: Basáñez M-G et al: River Blindness, A Success story under threat?

16. Is the disease treatable? Disease is highly preventable Disease is highly preventable Once a victim has been infected, there is no cure for the disease, its progress can be delayed with oral medication (CDC: River Blindness fact sheet, 2008). Once a victim has been infected, there is no cure for the disease, its progress can be delayed with oral medication (CDC: River Blindness fact sheet, 2008).

17. Prevention measures - Personal Oral dose of 150 micrograms per kilogram (maximum 12 mg) every 6-12 months of the highly effective Mectizan (invermectin) – (WHO, 2008). Oral dose of 150 micrograms per kilogram (maximum 12 mg) every 6-12 months of the highly effective Mectizan (invermectin) – (WHO, 2008). This medication will not cure the disease but it will slow down its progress, killing off almost 95% of the tiny worms (Levin, 2007). This medication will not cure the disease but it will slow down its progress, killing off almost 95% of the tiny worms (Levin, 2007).

18. Prevention measures – health agencies Controlling insect breeding sites in rivers is one of the pillars of prevention– by spraying the aerial spaces and rivers (WHO, 2001). Controlling insect breeding sites in rivers is one of the pillars of prevention– by spraying the aerial spaces and rivers (WHO, 2001). Free distribution of the highly effective medicine – Mectizan (ivermectin), this medication provides a yearly protection from a single dose (Levine, 2007). Free distribution of the highly effective medicine – Mectizan (ivermectin), this medication provides a yearly protection from a single dose (Levine, 2007). Sustaining a comprehensive regional prevention effort and collaborations (Levine, 2007). Sustaining a comprehensive regional prevention effort and collaborations (Levine, 2007).

19. Prevention measures – Global efforts Onchocerciasis Control Program in West Africa (OCP), which is being sponsored by the WHO, World Bank, UNDP and UN Food and Agriculture Organization Onchocerciasis Control Program in West Africa (OCP), which is being sponsored by the WHO, World Bank, UNDP and UN Food and Agriculture Organization Onchocerciasis Control Program Onchocerciasis Control Program In 1992, the Onchocerciasis Elimination Program in the Americas (OEPA) was launched in 6 countries In 1992, the Onchocerciasis Elimination Program in the Americas (OEPA) was launched in 6 countries

20. Barriers to prevention Cultural, spiritual and religious symbolism of water in endemic regions Cultural, spiritual and religious symbolism of water in endemic regions Lack of education on the health issues and risks associated with the transmission of River Blindness disease Lack of education on the health issues and risks associated with the transmission of River Blindness disease Lack of adequate funding to implement a sustained intervening campaign. Lack of adequate funding to implement a sustained intervening campaign. (Rinne, 2006; Gary-Felder et al: 1999; Parker et al, 2003).

21. Communication goals Intimate knowledge of the etiology and mode of transmission of River Blindness and of the cultural and ethnic values of its victims; in this instance – the rural inhabitants of African villages and possible travelers through the region (Schiavo, 2007; cancer.gov/pinkbook) Intimate knowledge of the etiology and mode of transmission of River Blindness and of the cultural and ethnic values of its victims; in this instance – the rural inhabitants of African villages and possible travelers through the region (Schiavo, 2007; cancer.gov/pinkbook) A sustained education campaign; developed to be sensitive to the cultural, religious, ethnic values of the target groups (Katzen, et al; 2005) A sustained education campaign; developed to be sensitive to the cultural, religious, ethnic values of the target groups (Katzen, et al; 2005)

22. Message of this presentation River Blindness is a health risk with reported and documented incidences of mortality River Blindness is a health risk with reported and documented incidences of mortality River Blindness is preventable and controllable. River Blindness is preventable and controllable. River Blindness can be eradicated through a concerted effort by all stakeholders. River Blindness can be eradicated through a concerted effort by all stakeholders.

23. Message strategy Use of the Theory of Reasoned Action (TRA) model (Schiavo, 2007). Use of the Theory of Reasoned Action (TRA) model (Schiavo, 2007). Use of the Communication for Social Change (CFSC) model (Gary-Felder and Dean, 1999, p.15) Use of the Communication for Social Change (CFSC) model (Gary-Felder and Dean, 1999, p.15) Interpersonal channels such as a) peer-to-peer discussions b) theater presentations c) use community role models with positive influence on the audience (www.campaignstrategy.org). Interpersonal channels such as a) peer-to-peer discussions b) theater presentations c) use community role models with positive influence on the audience (www.campaignstrategy.org).

24. Successes of Prevention measures The Onchocerciasis Control Program (OCP) launched in 1974 and African Programme for Onchocerciasis Control (APOC) in 11 Countries have: The Onchocerciasis Control Program (OCP) launched in 1974 and African Programme for Onchocerciasis Control (APOC) in 11 Countries have: - Prevented over 600,000 cases of River Blindness - 22 million children in endemic areas born free of risk of river blindness - Annual cost of treatment under $0.60 per person - Non-interrupted commitment from 4 original sponsors and 27 donors over 28 years of program

25. Conclusions Although Controlling Onchocerciasis (River Blindness) has been lauded as one of the global public health successes, there are still endemic areas where it still accounts for the leading cause of blindness (Levine, 2007). Although Controlling Onchocerciasis (River Blindness) has been lauded as one of the global public health successes, there are still endemic areas where it still accounts for the leading cause of blindness (Levine, 2007). WHO has just collaborated with a pharmaceutical company to launch the testing of a new promising drug in Africa for River Blindness (WHO, 2009). WHO has just collaborated with a pharmaceutical company to launch the testing of a new promising drug in Africa for River Blindness (WHO, 2009).

26. References: Campaign Strategy Tools http://www.campaignstrategy.org/ http://www.campaignstrategy.org/ http://www.campaignstrategy.org/ CDC: River Blindness – fact Sheet (2008) http://www.cdc.gov/ncidod/dpd/parasites/onchocerciasis/factsht_onchocerciasis.ht m http://www.cdc.gov/ncidod/dpd/parasites/onchocerciasis/factsht_onchocerciasis.ht m http://www.cdc.gov/ncidod/dpd/parasites/onchocerciasis/factsht_onchocerciasis.ht m http://www.cdc.gov/ncidod/dpd/parasites/onchocerciasis/factsht_onchocerciasis.ht m Making Health Communication Programs Work http://www.cancer.gov/pinkbook http://www.cancer.gov/pinkbook http://www.cancer.gov/pinkbook Gray-Felder, D., and Dean, J. Communication for Social Change: A Position Paper and Conference Report. 1999 Conference Report. 1999 Culled from Renata Schiavo: Health Communication: From Theory to Practice Culled from Renata Schiavo: Health Communication: From Theory to Practice Katzen, C., Solan, M., & Dicker, A. (2005). E-mail and oncology: A survey of radiation oncology patience and their attitudes to a new generation of health communication. oncology patience and their attitudes to a new generation of health communication. Levin, Ruth., (2007). Case Studies in Global Health: Millions Saved. Making Health Communication Programs Work http://www.cancer.gov/pinkbook http://www.cancer.gov/pinkbook http://www.cancer.gov/pinkbook

27. References: Parker, M., & Gazmararian, J. (2003). Health Literacy: Essentials for Health Communication. Communication. Rinne, E. M: Seeing is Believing': Perceptions of Safe Water in Rural Yoruba Seeing is Believing': Perceptions of Safe Water in Rural YorubaSeeing is Believing': Perceptions of Safe Water in Rural Yoruba A History of Water, 2006 A History of Water, 2006 Schiavo, Renata: Health Communication: From Theory to Practice (2007) Schiavo, R., & Freimuth, Vicki: "Evaluation of a Public Health Campaign" WHO: Global Plan to combat Neglected Tropical Diseases 2008-2015 http://whqlibdoc.who.int/hq/2007/WHO_CDS_NTD_2007.3_eng.pdf http://whqlibdoc.who.int/hq/2007/WHO_CDS_NTD_2007.3_eng.pdf http://whqlibdoc.who.int/hq/2007/WHO_CDS_NTD_2007.3_eng.pdf WHO: Water-related Diseases (2001) http://www.who.int/water_sanitation_health/diseases/oncho/en/ http://www.who.int/water_sanitation_health/diseases/oncho/en/ http://www.who.int/water_sanitation_health/diseases/oncho/en/ WHO: New Drug being tested in Africa for River Blindness http://www.who.int/mediacentre/news/releases/2009/river_blindness_2009 0701/en/ http://www.who.int/mediacentre/news/releases/2009/river_blindness_2009 0701/en/ http://www.who.int/mediacentre/news/releases/2009/river_blindness_2009 0701/en/ http://www.who.int/mediacentre/news/releases/2009/river_blindness_2009 0701/en/

28. List of Sources for further reading: Basáñez M-G, Pion SDS, Churcher TS, Breitling LP, Little MP, et al: River Blindness – Basáñez M-G, Pion SDS, Churcher TS, Breitling LP, Little MP, et al: River Blindness – A Success Story under Threat?. PLoS Med 3(9): e371. doi:10.1371/journal.pmed.0030371 Basáñez, María-Gloria; Pion, Sébastien DS; Boakes, Eve; Filipe, João AN; Churcher, Thomas S; Boussinesq, Michel, : Effect of single-dose ivermectin on Onchocerca volvulus: a systematic review and meta-analysis. Lancet Infectious Diseases, May2008, Vol. 8 Issue 5 DOI: 10.1016/S1473-3 Retrieved from Academic Search Premier Basáñez, María-Gloria; Pion, Sébastien DS; Boakes, Eve; Filipe, João AN; Churcher, Thomas S; Boussinesq, Michel, : Effect of single-dose ivermectin on Onchocerca volvulus: a systematic review and meta-analysis. Lancet Infectious Diseases, May2008, Vol. 8 Issue 5 DOI: 10.1016/S1473-3 Retrieved from Academic Search PremierEffect of single-dose ivermectin on Onchocerca volvulus: a systematic review and meta-analysis.Effect of single-dose ivermectin on Onchocerca volvulus: a systematic review and meta-analysis. Duke, B.O.: Onchocerciasis (river blindness)-can it be eradicated? Duke, B.O.: Onchocerciasis (river blindness)-can it be eradicated?Onchocerciasis (river blindness)-can it be eradicated?Onchocerciasis (river blindness)-can it be eradicated? Parasitology today, 1990 - ncbi.nlm.nih.gov

29. List of Sources for further reading: cont. Otubanjo, O. A.; Adeoye, G. O.; Ibidapo, C. A.; Akinsanya, B.; Okeke, P.; Atalabi, T.; Adverse reactions from community directed treatment with ivermectin (CDTI ) for onchocerciasis and loiasis in Ondo State, Nigeria. Revista de Biologia Tropical, dic2008, Vol. 56 Issue 4. Retrieved from Academic Search Premier Otubanjo, O. A.; Adeoye, G. O.; Ibidapo, C. A.; Akinsanya, B.; Okeke, P.; Atalabi, T.; Adverse reactions from community directed treatment with ivermectin (CDTI ) for onchocerciasis and loiasis in Ondo State, Nigeria. Revista de Biologia Tropical, dic2008, Vol. 56 Issue 4. Retrieved from Academic Search PremierAdverse reactions from community directed treatment with ivermectin (CDTI ) for onchocerciasis and loiasis in Ondo State, Nigeria.Adverse reactions from community directed treatment with ivermectin (CDTI ) for onchocerciasis and loiasis in Ondo State, Nigeria. Stingl, Peter.: Onchocerciasis: developments in diagnosis, treatment and control. International Journal of Dermatology, Apr2009, Vol. 48 Issue 4 DOI: 10.1111. Retrieved from Academic Search Premier Stingl, Peter.: Onchocerciasis: developments in diagnosis, treatment and control. International Journal of Dermatology, Apr2009, Vol. 48 Issue 4 DOI: 10.1111. Retrieved from Academic Search PremierOnchocerciasis: developments in diagnosis, treatment and control.Onchocerciasis: developments in diagnosis, treatment and control. Thylefors, B.; Alleman, M. M.; Twum-Danso, N. A. Y.: Operational lessons from 20 years of the Mectizan Donation Program for the control of onchocerciasis. Tropical Medicine & International Health, May2008, Vol. 13 Issue 5 DOI: 10.1111 AN 31678526 Retrieved from Academic Search Premier Thylefors, B.; Alleman, M. M.; Twum-Danso, N. A. Y.: Operational lessons from 20 years of the Mectizan Donation Program for the control of onchocerciasis. Tropical Medicine & International Health, May2008, Vol. 13 Issue 5 DOI: 10.1111 AN 31678526 Retrieved from Academic Search Premier