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Mectizan Program Notes No. 23 text only
The Onchocerciasis Control Programme Celebrates its 25 Year Anniversary: 1974-1999
Over the past 25 years, OCP has made countless contributions to onchocerciasis prevention and control in West Africa, setting exemplary standards for research and programme development. The multi-country attack on blackfly vectors of the disease pioneered by OCP successfully avoided ecological damage that might have accompanied the intense larviciding needed for meaningful vector control. In combination with mass treatment with Mectizan, the Programme virtually eliminated the disease from its participating countries.
No such control program in the region had been implemented previously because of the difficulties working in a multi-country programme. Because of the serious health problems the disease causes and its impact on socioeconomic stability, OCP was established in 1974 following a meeting in Tunis between the United States Agency for International Development (USAID), the Organization for Coordination and Cooperation in the Control of Major Endemic Diseases (OCCGE), and the World Health Organization (WHO). A pilot study in 1966 had shown that vector control by larvaciding was feasible, persuading the participating countries to support the establishment of OCP. The Programme began operation after funding by the United Nations Development Program, the Food and Agriculture Organization, The World Bank, the World Health Organization, private donors, and the support necessary from the participating countries.
Operations began in a seven-country zone, in an area of approximately 1,235,000 sq km. Of a population of 10 million in the programme area, approximately one million suffered from onchocerciasis, of whom 100,000 had serious eye manifestations, including 35,000 blinded by disease. In some cases, entire villages and thousands of acres of fertile riverine land were abandoned simply from the fear of contracting the disease.
In the beginning of the Programme, the only means of controlling the disease was reducing the black fly population to a level where transmission of O. volvulus microfilariae to humans could be eliminated. That level then had to be maintained until the macrofilariae already present in the humans died. This was done by regular aerial application of insecticides to breeding sites of the black fly larvae in rivers for at least 14 years. With expert care and surveillance by national hydrobiology teams, damage of the rivers by larvicide pollution was avoided.
This system worked efficiently and had satisfactory results; however it was soon realized that limiting the project to the seven-country zone permitted re-invasion of the fly from other nearby countries posing a threat to the success of the programme. It was for this reason that OCP expanded from seven countries to eleven in 1986 including: Benin, Burkina Faso, Cote d'Ivoire, Ghana, Guinea, Guinea Bissau, Mali, Niger, Senegal, Sierra Leone, Togo.
Prior to 1987 the only practical means OCP had of suppressing the disease was vector control, since the drugs available for treatment caused too many side-effects. Although new cases were being prevented with the use of larvacides, millions of people with clinical manifestations of the disease could not be helped. In 1987, Merck & Co., Inc. announced plans to make safe treatment of the disease possible by donating Mectizanä (ivermectin, MSD) to all who needed it, free of charge, for as long as necessary.
Merck's generosity had profound effects on the work of OCP, helping it achieve its objective of disease control. By 1998, close to six million people had been treated with Mectizanä in OCP countries through the Community Directed Treatment with Ivermectin (CDTI) approach, whereby communities themselves carry out planning for and the distribution of the drug; a concept which enables the continuation of the work even after OCP concludes in 2002.
With such dedicated programme workers and willing communities eager to learn how to combat the disease, it is not surprising that OCP has attained so much in the last twenty-five years. Onchocerciasis is no longer a severe threat to public health, given the low prevalence of infections in the programme area. And there is a great deal of gratitude in the communities who have successfully fought the disease. The facts show clearly why: 11 million children born in the area since the programme started have been spared the risk of onchoceral blindness, 35 million people are protected from infection, 500,000 have been prevented from going blind or becoming having their vision severely impaired, and 1.5 million have become free of infection.
The long term benefits of OCP's 25 years of operation are far reaching. For many of the people in the area, the future is bright. By eliminating the threat of blindness, OCP has paved the way for resettlement and agricultural development in fertile areas along the riverbanks- up to 25,000 square km. Roads are being built, bore holes drilled and health centers established in the areas where onchocerciasis is under control. OCP has also contributed to the overall development of its member countries by training health workers, including more than 1000 local health professionals, scientists, physicians and technicians.
The Mectizan Donation Program looks forward to continuing work with OCP and to ensuring that West Africa remains free of the threat of onchocerciasis.
Alleviation and Prevention of Lymphoedema and Elephantiasis with Hygiene: Second in a series of articles on lymphatic filariasis
Secondary bacterial infections which can be treated and prevented by intensive local hygiene, are important contributions to elephantiasis -- one of the most common and debilitating clinical signs of lymphatic filariasis.
Bacteria enter the body through small wounds, often on the feet or between the toes, or through the characteristic skin folds, cracks, and crevices characteristic of elephantiasis. Because the lymph vessels are damaged by the parasite. Wuchereria bancrofti, they become dysfunctional, and the normal flow of lymph fluid through the lymphatic vessels is interrupted. This allows bacteria to proliferate in the body and cause infections ("acute attacks") resulting in swelling of the limbs (lymphoedema) and ultimately elephantiasis. Disfiguring elephantiasis is characterized by hyper-pigmentation, hardening of the tissues, wart-like growths.
Good hygiene is very important in stopping the progression of lymphoedema and elephantiasis and preventing acute attacks. Practicing good skin care by keeping the areas clean and dry and preventing wounds from occurring can help prevent bacterial infections. When practiced regularly and diligently, good hygiene can reverse the signs of elephantiasis and can prevent them from occurring.
Some of the major hygienic measures are:
1. Frequent washing and drying the affected area using soap and water
* Plain soap is recommended since perfumed soaps may irritate the skin
* The skin should not be vigorously scrubbed as this may cause further irritation
2. Application of topical anti-bacterial and anti-fungal creams, as needed
* For those with advanced elephantiasis, systemic antibiotics may reduce the acute attacks more effectively than topical antibiotics
3. Elevating the swollen limb to reduce swelling
* Elevate the affected limb as often as possible throughout day and at night
4. Exercising the swollen limb to encourage circulation of the lymphatic fluid
* Exercise as much as possible by flexing and extending the ankle and working muscles of the lower leg, except during acute attacks
5. Wearing clean, comfortable shoes that do not bind the foot, such as sandals
6. Keeping toenails trim and clean
7. In some patients, bandaging the affected area during the day
* Bandages should be removed at night to allow the skin to breathe, and should not be used during acute attacks
8. If assistance is needed to wash and dry the affected limb, this can be done without concern that the bacteria will harm the assistants
9. Pain in the limb associated with acute attacks can be alleviated by cooling with water
10. Avoid herbal and other folk remedies
The Centers for Disease Control and Prevention, in collaboration with Dr. Gerusa Dreyer, has produced a health education document entitled "New Hope for People with Lymphedema." This document not only outlines the measures described herein, but also encourages the establishment of "Hope Clubs" to spread the word on the effects of good hygiene and to help communities empower each other to help fight this socially ostracizing disease. Dr. Gerusa Dreyer, of the Federal University of Pernambuco in Recife, Brazil, is largely responsible for the creation of the Hope Club concept. Dr. Dreyer has conducted extensive research on the treatment and prevention of lymphatic filariasis; and her discovery that elephantiasis can be controlled through hygiene has greatly strengthened the fight against the disease.
ACRONYMS
The First in a Series of Commonly Used Acronyms
ADB African Development Bank
AFRO African Regional Office (WHO Regional Office for Africa, WHO-AFRO)
AL Albendazole (SmithKline Beecham antihelminthic)
APOC African Program for Onchocerciasis Control
ATO annual treatment objective
CBD community-based distributor
CBM Christoffel-Blindenmission (German NGO)
CBW community-based worker
CC The Carter Center
CCC Collaboration Coordinating Committee (SmithKline Beecham/World Health Organization program group)
CDC Centers for Disease Control and Prevention (US Public Health Service)
CDD Community-directed distributor
CDS Communicable Diseases (World Health Organization cluster)
Two New Mectizan® Expert Committee Members
Replacing former Mectizan Expert Committee members Drs. Mauricio Espinel and Dominique Richard-Lenoble, who completed 3-year terms on the Committee in 1998, new appointees Drs. Christine Godin and Paul Simonsen attended the Spring meeting of the Committee in Amsterdam in late May.
Dr. Godin is Deputy Programs Manager at Organisation pour la PrJvention de la CJcitJ (OPC) and Coordinator of the Health Ocular Network in Africa for the French Cooperation in Paris. Prior to her position with OPC, Dr. Godin was Country Director for the River Blindness Foundation/Global 2000 River Blindness Program in Cameroon, and before that she worked for MJdecins Sans FrontiJres.
Dr. Paul Simonsen is a Senior Scientists at the Danish Bilharziasis Laboratory in Denmark and is a lecturer in human helminthology at the Institute of Zoology for the University of Copenhagen. He has extensive research experience in the epidemiology, immunology and chemotherapy of helminth infections and is currently conducting two field studies in Africa and Asia with regard to chemotherapy of Wuchereria bancrofti infection.
Dr. Godin's experience in onchocerciasis and other tropical diseases will be an asset to the Committee as will Dr. Simonsen's extensive knowledge of helminthic infections. We look forward to working with each of them.
Profile: There are many people involved in the global distribution of Mectizan. In this issue, we introduce Merck & Co., Inc.'s Global Supply Chain Analyst Mr. Dolf Kroep
Dolf Kroep is a global supply chain analyst in the Merck Manufacturing Division, based in Whitehouse Station, NJ. He oversees the avermectin/ivermectin supply chain, from the manufacturing of the bulk chemical compound to the packaging and distribution of the pharmaceutical products, such as Mectizanä. Prior to taking on the role of global supply chain analyst in 1997 at Merck's headquarters in New Jersey, Mr. Kroep worked in Merck's production facility in Haarlem, The Netherlands for three years. He still works closely with his colleagues in Haarlem.
"I find it a privilege to work on the team that coordinates production and supply of MECTIZAN, knowing that the donation program has such a positive impact on the lives of many people in Africa, Latin America and the Middle East," Dolf says. "I hope the expansion of the program to include treatment of lymphatic filariasis will be as big a success as the current onchocerciasis program."