Abstract
The use of alternative (or complementary) treatment strategies (ATSs) i.e. differing from annual community-directed treatment with ivermectin (CDTI) is required in some African foci to eliminate onchocerciasis by 2025. ATSs include vector control, biannual or pluriannual CDTI, better timing of CDTI, community-directed treatment with combinations of currently available anthelminthics or new drugs, and ‘test-and-treat’ (TNT) strategies requiring diagnosis of infection and/or contraindications to treatment for decisions on who to treat with what regimen. Two TNT strategies can be considered. Loa-first TNT, designed for loiasis-endemic areas and currently being evaluated using a rapid test (LoaScope), consists of identifying individuals with levels of Loa microfilaremia associated with a risk of post-ivermectin severe adverse events to exclude them from ivermectin treatment and in treating the rest (usually >97%) of the population safely. Oncho-first TNT consists of testing community members for onchocerciasis before giving treatment (currently ivermectin or doxycycline) to those who are infected. The choice of the ATS depends on the prevalences and intensities of infection with Onchocerca volvulus and Loa loa and on the relative cost-effectiveness of the strategies for the given epidemiological situation. Modelling can help select the optimal strategies, but field evaluations to determine the relative cost-effectiveness are urgently needed.
Highlights
Three international programmes have supported countries to control onchocerciasis as a public health problem or to eliminate onchocerciasis: the Onchocerciasis Elimination Program for the Americas (OEPA), the Onchocerciasis Control Programme (OCP) in West Africa and the African Programme for Onchocerciasis Control (APOC)
The fact that compliance seems to be associated with individual perception of the communitydirected treatment with ivermectin (CDTI) programme (CDD commitment, mass drug administration (MDA) organization and perception of ivermectin effectiveness) needs to be taken into account.[26]
A similar decrease in ocular microfilariae levels after moxidectin and ivermectin treatment contributes to a moxidectin safety profile compatible with community-directed treatment (CDT).[44,45,46]
Summary
Three international programmes have supported countries to control onchocerciasis as a public health problem or to eliminate onchocerciasis: the Onchocerciasis Elimination Program for the Americas (OEPA), the Onchocerciasis Control Programme (OCP) in West Africa and the African Programme for Onchocerciasis Control (APOC). When OCP closed in 2002, it had achieved its objective of eliminating onchocerciasis as a public health and socioeconomic problem,[5,11] except in four river basins in Benin, Ghana, Guinea-Conakry and all of Sierra Leone These special intervention zones (SIZs) received financial and technical support from 2003 to 2007 for ivermectin distribution and aerial or ground larviciding. Where CDTI will not achieve elimination by 2025 for programmatic reasons (reasons under the control of the health system and partners, as opposed to non-programmatic reasons such as hyperendemicity or loiasis co-endemicity), successful ATS implementation cannot be expected In these areas, the first step has to be to optimize annual CDTI to achieve 100% geographic and ≥80% therapeutic coverage. The fact that compliance seems to be associated with individual perception of the CDTI programme (CDD commitment, MDA organization and perception of ivermectin effectiveness) needs to be taken into account.[26]
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