Onchocerca volvulus: genetic diversity of parasite isolates from Sudan

Onchocerciasis transmission status in some endemic communities of Cross River State, Nigeria after two decades of mass drug administration with ivermectin

Onchocerciasis is a parasitic disease transmitted by black flies. Human onchocerciasis is a public health and socioeconomic problem in Nigeria. Its prevalence and morbidity have reduced over the years because of control efforts especially, Mass Drug Administration with ivermectin. The current goal is to eliminate the disease transmission by 2030. Understanding the changes in transmission patterns in Cross River State is critical to elimination of onchocerciasis in Nigeria. This study was designed to determine the transmission dynamics of onchocerciasis in Cross River State after over two decades of mass ivermectin distribution in endemic communities. Agbokim, Aningeje, Ekong Anaku and Orimekpang are four endemic communities from three Local Government Areas of the State selected for this study. Transmission indices such as infectivity rates, biting rates and transmission potentials, parity rates and diurnal biting activities were determined. A total of 15,520 adult female flies were caught on human baits, Agbokim (2831), Aningeje (6209), Ekong Anaku (4364) and Orimekpang (2116). A total of 9488 and 5695 flies were collected during the rainy and dry seasons respectively in the four communities studied. The differences in relative abundance among the communities were statistically significant (P < 0.001). Monthly and seasonal fly numbers varied significantly (P < 0.008). There were differences in diurnal biting activities of flies in this study at different hours of the day and different months. The peak monthly biting rates were 5993 (Agbokim, October), 13,134 (Aningeje, October), 8680 (Ekong Anaku, October) and 6120 (Orimekpang, September) bites/person/month while the lowest monthly biting rates were 400 (Agbokim, November), 2862 (Aningeje, August), 1405 (Ekong Anaku, January) and 0.0 (Orimekpang, November and December) bites/person/month. Differences in biting rates among the study communities were significant (P < 0.001). The peak monthly transmission potential in Aningeje was 160 infective bites/person/month in the month of February while the lowest (except for months with no transmission) was 42 infective bites/person/month in the month of April. All other study sites had no ongoing transmission in this study. Transmission studies showed that there is progress toward transmission interruption especially in 3 out of the four studied areas. Molecular O-150 poolscreen studies is required to confirm the true transmission situation in the areas.

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.

Socioeconomic impacts of elimination of onchocerciasis in Abu-Hamed focus, northern Sudan: lessons after elimination

OBJECTIVES

Onchocerciasis is one of the most devastating neglected tropical diseases and it is mostly prevalent in Africa. The disease has important heavy social and economic burdens on the infected populations including low productivity, unemployment, social isolation, and stigma. A cross-sectional study was implemented using a well-established questionnaire to investigate the socio-economic impacts of Onchocerciasis elimination in Abu-Hamed, River Nile State, Sudan in 2015; 512 participants in ten affected communities were interviewed.

RESULTS

Our findings revealed that these communities are recovering from the social and economic burden of the diseases. Ninety percent of the research participants reported general satisfaction about elimination of the disease in their community, 48.3% of them attended secondary school or university. Only 0.6% reported unemployment. Also, 25.3% and 24.7% of the participants were workers and farmers respectively. Except about the vector biting and nuisance, the majority of the respondents (90%) had no complain related to the disease after the elimination. Also, 90.5% of the participants reported either stable or increase in their work performance during the last 12 months. About 93.8% of the respondents were engaged in normal daily life activities and involved in happy events like marriage and giving birth during the last 12 months.

Genomic Epidemiology in Filarial Nematodes: Transforming the Basis for Elimination Program Decisions

Onchocerciasis and lymphatic filariasis are targeted for elimination, primarily using mass drug administration at the country and community levels. Elimination of transmission is the onchocerciasis target and global elimination as a public health problem is the end point for lymphatic filariasis. Where program duration, treatment coverage, and compliance are sufficiently high, elimination is achievable for both parasites within defined geographic areas. However, transmission has re-emerged after apparent elimination in some areas, and in others has continued despite years of mass drug treatment. A critical question is whether this re-emergence and/or persistence of transmission is due to persistence of local parasites-i.e., the result of insufficient duration or drug coverage, poor parasite response to the drugs, or inadequate methods of assessment and/or criteria for determining when to stop treatment-or due to re-introduction of parasites via human or vector movement from another endemic area. We review recent genetics-based research exploring these questions in Onchocerca volvulus, the filarial nematode that causes onchocerciasis, and Wuchereria bancrofti, the major pathogen for lymphatic filariasis. We focus in particular on the combination of genomic epidemiology and genome-wide associations to delineate transmission zones and distinguish between local and introduced parasites as the source of resurgence or continuing transmission, and to identify genetic markers associated with parasite response to chemotherapy. Our ultimate goal is to assist elimination efforts by developing easy-to-use tools that incorporate genetic information about transmission and drug response for more effective mass drug distribution, surveillance strategies, and decisions on when to stop interventions to improve sustainability of elimination.

Insights Into Onchocerca volvulus Population Biology Through Multilocus Immunophenotyping

We have developed a serologically based immunophenotyping approach to study Onchocerca volvulus (Ov) population diversity. Using genomic sequence data and polymerase chain reaction-based genotyping, we identified nonsynonymous single-nucleotide polymorphisms (SNPs) in the genes of 16 major immunogenic Ov proteins: Ov-CHI-1/Ov-CHI-2, Ov16, Ov-FAR-1, Ov-CPI-1, Ov-B20, Ov-ASP-1, Ov-TMY-1, OvSOD1, OvGST1, Ov-CAL-1, M3/M4, Ov-RAL-1, Ov-RAL-2, Ov-ALT-1, Ov-FBA-1, and Ov-B8. We assessed the immunoreactivity of onchocerciasis patient sera (n = 152) from the Americas, West Africa, Central Africa, and East Africa against peptides derived from 10 of these proteins containing SNPs. Statistically significant variation in immunoreactivity among the regions was seen in SNP-containing peptides derived from 8 of 10 proteins tested: OVOC1192(1-15), OVOC9988(28-42), OVOC9225(320-334), OVOC7453(22-36), OVOC11517(14-28), OVOC3177(283-297), OVOC7911(594-608), and OVOC12628(174-188). Our data show that differences in immunoreactivity to variant antigenic peptides may be used to characterize Ov populations, thereby elucidating features of Ov population biology previously inaccessible because of the limited availability of parasite material.

Significant heterogeneity in Wolbachia copy number within and between populations of Onchocerca volvulus

BACKGROUND

Wolbachia are intracellular bacteria found in arthropods and several filarial nematode species. The filarial Wolbachia have been proposed to be involved in the immunopathology associated with onchocerciasis. Higher Wolbachia-to-nematode ratios have been reported in the savannah-ecotype compared to the forest-ecotype, and have been interpreted as consistent with a correlation between Wolbachia density and disease severity. However, factors such as geographic stratification and ivermectin drug exposure can lead to significant genetic heterogeneity in the nematode host populations, so we investigated whether Wolbachia copy number variation is also associated with these underlying factors.

METHODS

Genomic DNA was prepared from single adult nematodes representing forest and savannah ecotypes sampled from Togo, Ghana, Côte d'Ivoire and Mali. A qPCR assay was developed to measure the number of Wolbachia genome(s) per nematode genome. Next-generation sequencing (NGS) was also used to measure relative Wolbachia copy number, and independently verify the qPCR assay.

RESULTS

Significant variation was observed within the forest (range: 0.02 to 452.99; median: 10.58) and savannah (range: 0.01 to 1106.25; median: 9.10) ecotypes, however, no significant difference between ecotypes (P = 0.645) was observed; rather, strongly significant Wolbachia variation was observed within and between the nine study communities analysed (P = 0.021), independent of ecotype. Analysis of ivermectin-treated and untreated nematodes by qPCR showed no correlation (P = 0.869); however, an additional analysis of a subset of the nematodes by qPCR and NGS revealed a correlation between response to ivermectin treatment and Wolbachia copy number (P = 0.020).

CONCLUSIONS

This study demonstrates that extensive within and between population variation exists in the Wolbachia content of individual adult O. volvulus. The origin and functional significance of such variation (up to ~ 100,000-fold between worms; ~10 to 100-fold between communities) in the context of the proposed mutualistic relationship between the worms and the bacteria, and between the presence of Wolbachia and clinical outcome of infection, remains unclear. These data do not support a correlation between Wolbachia copy number and forest or savannah ecotype, and may have implications for the development of anti-Wolbachia drugs as a macrofilaricidal treatment of onchocerciasis. The biological significance of a correlation between variation in Wolbachia copy number and ivermectin response remains unexplained.

Genomic diversity in Onchocerca volvulus and its Wolbachia endosymbiont

Ongoing elimination efforts have altered the global distribution of Onchocerca volvulus, the agent of river blindness, and further population restructuring is expected as efforts continue. Therefore, a better understanding of population genetic processes and their effect on biogeography is needed to support elimination goals. We describe O. volvulus genome variation in 27 isolates from the early 1990s (before widespread mass treatment) from four distinct locales: Ecuador, Uganda, the West African forest and the West African savanna. We observed genetic substructuring between Ecuador and West Africa and between the West African forest and savanna bioclimes, with evidence of unidirectional gene flow from savanna to forest strains. We identified forest:savanna-discriminatory genomic regions and report a set of ancestry informative loci that can be used to differentiate between forest, savanna and admixed isolates, which has not previously been possible. We observed mito-nuclear discordance possibly stemming from incomplete lineage sorting. The catalogue of the nuclear, mitochondrial and endosymbiont DNA variants generated in this study will support future basic and translational onchocerciasis research, with particular relevance for ongoing control programmes, and boost efforts to characterize drug, vaccine and diagnostic targets.

The First Confirmed Elimination of an Onchocerciasis Focus in Africa: Abu Hamed, Sudan

Mass treatment with ivermectin for onchocerciasis was stopped in 2012 in Abu Hamed, an isolated focus on the River Nile in northern Sudan. A 3-year posttreatment surveillance (PTS) ensued, at the end of which an evaluation was conducted in 2015 following the current World Health Organization guidelines for verification of onchocerciasis elimination. Vector black flies were collected from sentinel breeding sites and finger-prick bloodspots were collected from children ≤ 10 years of age resident in 35 communities within the focus. Polymerase chain reaction (PCR) screening of 19,191 flies from four sites for the O-150 parasite-specific marker found no flies carrying Onchocerca volvulus larvae (0%, 95% upper confidence limit [UCL] = 0.16), and serological testing of 5,266 children identified only one Ov16 seropositive child (0.019%, 95% UCL = 0.074); whose skin snips were negative when tested by O-150 PCR assay. These results indicate that for the first time in Africa, onchocerciasis elimination has been verified after a successful PTS in Abu Hamed.

Onchocerciasis in Yemen: Time to take action against a neglected tropical parasitic disease

Onchocerciasis is a neglected parasitic disease affecting the poorest underserved people in Yemen. A national control programme with goals to eliminate onchocerciasis has yet to be launched due to the current upheaval and social unrest in the country. The disease, locally termed as sowda, is unique in its clinicopathologic pattern, being of the localized, non-blinding, hyperreactive onchocercal skin disease. Although early reports identified endemic foci along seasonal watercourses, there is a need to redefine its epidemiologic patterns as well as health and socioeconomic impacts. Laboratory diagnosis of sowda among Yemeni patients is difficult due to the low load of microfilariae in skin snips and the presence of asymptomatic itching-free microfilaria carriers. Adoption of ivermectin use at three-month intervals as a control strategy has not been evaluated because the drug is mostly used in clinics and distributed to only a few affected communities. This paper addresses key aspects of onchocerciasis in Yemen and highlights the need for screening at-risk populations using highly sensitive techniques and mapping the distributions of the parasite in human and vector populations of blackflies. The new research should be integrated with the launch of a national onchocerciasis control programme to achieve onchocerciasis elimination.

Seasonal Variation in Biting Rates of Simulium damnosum sensu lato, Vector of Onchocerca volvulus, in Two Sudanese Foci

Background

The abundance of onchocerciasis vectors affects the epidemiology of disease in Sudan, therefore, studies of vector dynamics are crucial for onchocerciasis control/elimination programs. This study aims to compare the relative abundance, monthly biting-rates (MBR) and hourly-based distribution of onchocerciasis vectors in Abu-Hamed and Galabat foci. These seasonally-based factors can be used to structure vector control efforts to reduce fly-biting rates as a component of onchocerciasis elimination programs.

Methods

A cross-sectional study was conducted in four endemic villages in Abu-Hamed and Galabat foci during two non-consecutive years (2007–2008 and 2009–2010). Both adults and aquatic stages of the potential onchocerciasis vector Simulium damnosum sensu lato were collected following standard procedures during wet and dry seasons. Adult flies were collected using human landing capture for 5 days/month. The data was recorded on handheld data collection sheets to calculate the relative abundance, MBR, and hourly-based distribution associated with climatic factors. The data analysis was carried out using ANOVA and Spearman rank correlation tests.

Results

Data on vector surveillance revealed higher relative abundance of S. damnosum s.l. in Abu- Hamed (39,934 flies) than Galabat (8,202 flies). In Abu-Hamed, vector populations increased in January-April then declined in June-July until they disappeared in August-October. Highest black fly density and MBR were found in March 2007 (N = 9,444, MBR = 58,552.8 bites/person/month), and March 2010 (N = 2,603, MBR = 16,138.6 bites/person/month) while none of flies were collected in August-October (MBR = 0 bites/person/month). In Galabat, vectors increased in September-December, then decreased in February-June. The highest vector density and MBR were recorded in September 2007 (N = 1,138, MBR = 6,828 bites/person/month) and September 2010 (N = 1,163, MBR = 6,978 bites/person/month), whereas, none appeared in collection from April to June. There was a significant difference in mean monthly density of S. damnosum s.l. across the two foci in 2007–2008 (df = 3, F = 3.91, P = 0.011). Minimum temperature showed significant correlation with adult flies counts in four areas sampled; the adult counts were increased in Nady village (r_s = 0.799) and were decreased in Kalasecal (r_s = - 0.676), Gumaiza (r_s = - 0.585), and Hilat Khateir (r_s = - 0.496). Maximum temperature showed positive correlation with black fly counts only in Galabat focus. Precipitation was significantly correlated with adult flies counts in Nady village, Abu-Hamed, but no significance was found in the rest of the sampled villages in both foci. Hourly-based distribution of black flies showed a unimodal pattern in Abu-Hamed with one peak (10:00–18:00), while a bimodal pattern with two peaks (07:00–10:00) and (14:00–18:00) was exhibited in Galabat.

Conclusion

Transmission of onchocerciasis in both foci showed marked differences in seasonality, which may be attributed to ecology, microclimate and proximity of breeding sites to collection sites. The seasonal shifts between the two foci might be related to variations in climate zones. This information on black fly vector seasonality, ecology, distribution and biting activity has obvious implications in monitoring transmission levels to guide the national and regional onchocerciasis elimination programs in Sudan.

The impact of Merowe Dam on Simulium hamedense vector of onchocerciasis in Abu Hamed focus - Northern Sudan

Background

Abu Hamed, the northernmost onchocerciasis focus in the world, is located along the River Nile banks in the Nubian Desert. Hydroelectric dams can alter activity of black flies and may provide breeding sites for black fly. Merowe Dam, the largest hydropower project in Africa, was built west of Abu Hamed focus in 2009. The impact of the Dam on onchocerciasis and its black fly vectors in Abu Hamed focus was measured in this study.

Findings

Entomological surveys for aquatic stages and adult Simulium hamedense were conducted before and after the inception of Merowe Dam in 2007/2008 and 2010/2011. There was no black fly breeding or adult activity in the previously known breeding sites upstream of the Merowe Dam with the western most breeding site found in AlSarsaf village near the center of the focus. No adult or aquatic stages of black flies were found downstream of the Dam.

Conclusions

The artificial lake of the Dam flooded all the breeding sites in the western region of the focus and no aquatic stages and/or adult black fly activity were established in the study area upstream of the Dam. The Dam seems to have positive impact on onchocerciasis and its black fly vectors in Abu Hamed focus. These outcomes of the Merowe Dam might have contributed to the recently declared interruption of onchocerciasis transmission in Abu Hamed focus. Continuous entomological surveys are needed to monitor presence of black fly vectors and its impact on the disease.

Interruption of Onchocerca volvulus transmission in the Abu Hamed focus, Sudan

Abu Hamed, Sudan, the northernmost location of onchocerciasis in the world, began community-directed treatment with ivermectin (CDTI) in 1998, with annual treatments enhanced to semiannual in 2007. We assessed the status of the parasite transmission in 2011 entomologically, parasitologically, and serologically. O-150 pool screening showed no parasite DNA in 17,537 black flies collected in 2011 (95% confidence interval upper limit [95% CI UL] = 0.023). Skin microfilariae, nodules, and signs of skin disease were absent in 536 individuals in seven local communities. Similarly, no evidence of Onchocerca volvulus Ov16 antibodies was found in 6,756 school children ≤ 10 years (95% CI UL = 0.03%). Because this assessment of the focus meets the 2001 World Health Organization (WHO) criteria for interrupted transmission, treatment was halted in 2012, and a post-treatment surveillance period was initiated in anticipation of declaration of disease elimination in this area. We provide the first evidence in East Africa that long-term CDTI alone can interrupt transmission of onchocerciasis.

Indices of onchocerciasis transmission by different members of the Simulium damnosum complex conflict with the paradigm of forest and savanna parasite strains

Onchocerciasis in savanna zones is generally more severe than in the forest and pathologies also differ geographically, differences often ascribed to the existence of two or more strains and incompatibilities between vectors and strains. However, flies in the forest transmit more infective larvae than their savanna counterparts, even in sympatry, contradicting expectations based on the forest and savanna strains paradigm. We analysed data on the numbers of Onchocerca volvulus larvae of different stages found in 10 different taxonomic categories of the Simulium damnosum complex derived from more than 48,800 dissections of flies from Sierra Leone in the west of Africa to Uganda in the east. The samples were collected before widespread ivermectin distribution and thus provide a baseline for evaluating control measures. Savanna species contained fewer larvae per infected or per infective fly than the forest species, even when biting and parous rates were accounted for. The highest transmission indices were found in the forest-dwelling Pra form of Simulium sanctipauli (616 L3/1000 parous flies) and the lowest in the savanna-inhabiting species S. damnosum/S. sirbanum (135) and S. kilibanum (65). Frequency distributions of numbers of L1-2 and L3 larvae found in parous S. damnosum/S. sirbanum, S. kilibanum, S. squamosum, S. yahense, S. sanctipauli, S. leonense and S. soubrense all conformed to the negative binomial distribution, with the mainly savanna-dwelling species (S. damnosum/S. sirbanum) having less overdispersed distributions than the mainly forest-dwelling species. These infection patterns were maintained even when forest and savanna forms were sympatric and biting the same human population. Furthermore, for the first time, levels of blindness were positively correlated with infection intensities of the forest vector S. yahense, consistent with relations previously reported for savanna zones. Another novel result was that conversion rates of L1-2 larvae to L3s were equivalent for both forest and savanna vectors. We suggest that either a multiplicity of factors are contributing to the observed disease patterns or that many parasite strains exist within a continuum.

Polymerase chain reaction pool screening used to compare prevalence of infective black flies in two onchocerciasis foci in northern Sudan

Onchocerciasis remains an important debilitating disease in many areas of Africa, including Sudan. The status of infection transmission in 2007 was assessed in the vectors of two disease foci in Sudan: Abu Hamed in northern Sudan, which has received at least 10 years of annual treatment and Galabat focus in eastern Sudan, where only minor, largely undocumented treatment activity has occurred. Assessment of more than 30,000 black flies for Onchocerca volvulus infectious stage L3 larvae by using an O-150 polymerase chain reaction protocol showed that black fly infectivity rates were 0.84 (95% confidence interval = 0.0497-1.88) per 10,000 flies for Abu Hamed and 6.9 (95% confidence interval = 1.1-16.4) infective flies per 10,000 for Galabat. These results provide entomologic evidence for suppressed Onchocerca volvulus transmission in the Abu Hamed focus and a moderate transmission rate of the parasite in the Galabat focus.

Molecular phylogeny of the filaria genus Onchocerca with special emphasis on Afrotropical human and bovine parasites

Filarial parasites of the genus Onchocerca are found in a broad spectrum of ungulate hosts. One species, O. volvulus, is a human parasite that can cause severe disease (onchocerciasis or 'river blindness'). The phylogenetic relationships and the bionomics of many of the nearly 30 known species remain dubious. Here, the phylogeny of 11 species representing most major lineages of the genus is investigated by analysing DNA sequences from three mitochondrial genes (ND5, 12S and 16S rRNA) and portions of the intergenic spacer of the nuclear 5s rRNA. Special emphasis is given to a clade containing a yet unassigned specimen from Uganda (O. sp. 'Siisa'), which appears to be intermediate between O. volvulus and O. ochengi. While the latter can be differentiated by the O-150 tandem repeat commonly used for molecular diagnostics, O. volvulus and O. sp.'Siisa' cannot be differentiated by this marker. In addition, a worm specimen from an African bushbuck appears to be closely related to the bovine O. dukei and represents the basal taxon of the human/bovine clade. At the base of the genus, our data suggest O. flexuosa (red deer), O. ramachandrini (warthog) and O. armillata (cow) to be the representatives of ancient lineages. The results provide better insight into the evolution and zoogeography of Onchocerca. They also have epidemiological and taxonomic implications by providing a framework for more accurate molecular diagnosis of filarial larvae in vectors.

River blindness: a success story under threat?

The success of the Onchocerciasis Control Programme is undeniable and exemplary, say the authors, but it is too early to claim victory against river blindness.

Onchocerciasis-related epilepsy? Prospects at a time of uncertainty

Epilepsy and onchocerciasis (river blindness) constitute serious public health problems in several tropical countries. There are four main mechanisms that might explain a relationship between these two diseases: (i) the presence of Onchocerca volvulus in the central nervous system; (ii) the pathogenicity of various O. volvulus strains; (iii) immunological mechanisms involving cross-reactive immunization or cytokine production during infection; and (iv) the triggering role of insomnia due to itching.

Genetic heterogeneity in Loa loa parasites from southern Cameroon: A preliminary study

Ivermectin (or Mectizan™) is widely used by onchocerciasis and lymphatic filariasis control programs worldwide. Generally, Mectizan™ is both safe and well tolerated. An exception to this general pattern is in some areas co-endemic for Onchocerca volvulus and Loa loa, where a number of severe adverse reactions to Mectizan™ have been noted in L. loa infected individuals. The vast majority of these severe adverse events have occurred in Southern Cameroon. This suggested the hypothesis that the parasites endemic to Southern Cameroon might form a distinct population that exhibited a phenotype of eliciting severe adverse reactions in Loa-infected individuals upon Mectizan™ exposure. To test this hypothesis, the DNA sequences of three potentially polymorphic loci were compared among L. loa parasites from Southern Cameroon and other endemic foci in Sub-Saharan Africa. Analysis of these data suggested that parasites from Southern Cameroon were at least as genetically diverse as those from other foci. Furthermore, no polymorphisms were noted that were unique to and shared among the parasite isolates from Southern Cameroon. Although a limited number of parasite isolates were tested, these results do not appear to support the hypothesis that L. loa parasites from Southern Cameroon represent a unique, genetically isolated population.