Joseph Kamgno

Serious reactions after mass treatment of onchocerciasis with ivermectin in an area endemic for Loa loa infection

BACKGROUND In 1995, the World Bank launched an African Programme for Onchocerciasis Control to eliminate Onchocerca volvulus disease from 19 African countries by means of community-based ivermectin treatment (CBIT). Several cases of encephalopathy have been reported after ivermectin in people heavily infected with microfilariae of Loa loa (loiasis). We assessed the incidence of serious events in an area where onchocerciasis and loiasis are both endemic. METHODS Ivermectin (at 150 micrograms/kg) was given to 17877 people living in the Lékié area of Cameroon. 50 microL samples of capillary blood were taken during the daytime before treatment from all adults (aged > or = 15 years), and the numbers of L loa and Mansonella perstans microfilariae in them were counted. Patients were monitored for 7 days after treatment. Adverse reactions were classified as mild, marked, or serious. Serious reactions were defined as those associated with a functional impairment that required at least a week of full-time assistance to undertake normal activities. We calculated the relative risk of developing marked or serious reactions for increasing L loa microfilarial loads. Risk factors for serious reactions were identified and assessed with a logistic regression model. FINDINGS 20 patients (0-11%) developed serious reactions without neurological signs but associated with a functional impairment lasting more than a week. Two other patients were in coma for 2-3 days, associated with L loa microfilariae in cerebrospinal fluid. Occurrence of serious reactions was related to the intensity of pretreatment L loa microfilaraemia. The relative risk of developing marked or serious reactions was significantly higher when the L loa load exceeded 8000 microfilariae/mL; for serious reactions, the risk is very high (odds ratio > 1000) for loads above 50000 microfilariae/mL. INTERPRETATION Epidemiological surveys aimed at assessing the intensity of infection with L loa microfilariae should be done before ivermectin is distributed for onchocerciasis control in areas where loiasis is endemic. In communities at risk, monitoring procedures should be established and adhered to during CBIT so that people developing serious reactions may receive appropriate treatment.

Th2 Cytokines Are Associated with Reduced Worm Burdens in a Human Intestinal Helminth Infection

Although T helper 2 (Th2) cytokines are known to be critical in the generation of protective immunity against intestinal helminths in mouse models, it is unclear whether they are important in natural immunity against gut helminthiases in humans. Therefore, we investigated cytokine production in ex vivo whole-blood cultures in response to Ascaris lumbricoides antigen and mitogen in a cross-section of a community where the parasite is hyperendemic. The intensity of A. lumbricoides infection was significantly reduced after age 11 years. Levels of cytokines associated with Th2 lymphocytes (interleukin [IL]-4, IL-9, IL-10, and IL-13) demonstrated an inverse relationship with intensity of A. lumbricoides infection only in individuals aged >11 years. Furthermore, the IL-9, IL-10, and IL-13 produced in response to parasite antigen were of primary importance in this relationship. These findings promote a role for Th2-mediated responses in the age-dependent reduction of intestinal helminth infections in humans.

Effects of standard and high doses of ivermectin on adult worms of Onchocerca volvulus: a randomised controlled trial

BACKGROUND At present, control of onchocerciasis depends almost entirely on yearly treatments with 150 microg/kg ivermectin. We aimed to compare the effect of higher doses, more frequent doses, or both with the standard regimen on adult Onchocerca volvulus. METHODS We randomly allocated 657 patients who had onchocerciasis to 150 microg/kg ivermectin yearly (reference group), 150 microg/kg every 3 months, 400 then 800 microg/kg yearly, or 400 then 800 microg/kg every 3 months. We took skin snip samples from every patient before, and 3 years and 4 years after the first dose, and, at the same time excised one subcutaneous O volvulus nodule, which was examined histologically. The primary outcome was the vital status of the female worms. Analysis was done per protocol. FINDINGS We obtained nodules from 511 patients. After 3 years of treatment, more female worms had died in the groups treated every 3 months than in the reference group (odds ratio=1.84 [95% CI 1.23-2.75], p=0.003 for 150 microg/kg; and 2.17 [1.42-3.31], p<0.001 for high doses). Female worms were also less fertile in these groups than in the reference group (0.24 [0.14-0.43], p<0.0001; and 0.14 [0.06-0.29], p<0.0001, respectively). No difference was recorded between groups treated yearly (p=0.83 for the proportion of dead females). Unexpected side-effects consisted of mild, temporary, subjective visual changes in patients on high-dose regimens. INTERPRETATION Treatment with 3-monthly ivermectin could greatly reduce the number of female worms and acute itching and skin lesions; lower transmission of O volvulus; and change the duration of control programmes.

T Helper Cell Type 2 Responsiveness Predicts Future Susceptibility to Gastrointestinal Nematodes in Humans

Some humans are persistently more susceptible to gastrointestinal nematodes than others. Here, for the first time, susceptibility to reinfection has been linked to host cytokine responses. Ascaris lumbricoides and Trichuris trichiura abundance was assessed immediately before and 8-9 months after deworming in a Cameroonian population (starting n=191). Profiles of whole-blood cytokine responses to parasite antigens (for interleukin [IL]-5, IL-13, IL-10, IL-12p40, tumor necrosis factor- alpha , and interferon- gamma), assayed before treatment, were significantly related both to an overall measure of host susceptibility and to susceptibility to reinfection. Significant effects were primarily due to a negative association between IL-13 and IL-5 responses and infection. Persistently susceptible individuals were, therefore, characterized by a weak T helper cell type 2 response. The apparent plasticity of age-specific cytokine response-worm abundance relationships between different populations is also discussed.

Genetic Selection of Low Fertile Onchocerca volvulus by Ivermectin Treatment

Background Onchocerca volvulus is the causative agent of onchocerciasis, or “river blindness”. Ivermectin has been used for mass treatment of onchocerciasis for up to 18 years, and recently there have been reports of poor parasitological responses to the drug. Should ivermectin resistance be developing, it would have a genetic basis. We monitored genetic changes in parasites obtained from the same patients before use of ivermectin and following different levels of ivermectin exposure. Methods and Findings O. volvulus adult worms were obtained from 73 patients before exposure to ivermectin and in the same patients following three years of annual or three-monthly treatment at 150 µg/kg or 800 µg/kg. Genotype frequencies were determined in β-tubulin, a gene previously found to be linked to ivermectin selection and resistance in parasitic nematodes. Such frequencies were also determined in two other genes, heat shock protein 60 and acidic ribosomal protein, not known to be linked to ivermectin effects. In addition, we investigated the relationship between β-tubulin genotype and female parasite fertility. We found a significant selection for β-tubulin heterozygotes in female worms. There was no significant selection for the two other genes. Quarterly ivermectin treatment over three years reduced the frequency of the β-tubulin “aa” homozygotes from 68.6% to 25.6%, while the “ab” heterozygotes increased from 20.9% to 69.2% in the female parasites. The female worms that were homozygous at the β-tubulin locus were more fertile than the heterozygous female worms before treatment (67% versus 37%; p = 0.003) and twelve months after the last dose of ivermectin in the groups treated annually (60% versus 17%; p<0.001). Differences in fertility between heterozygous and homozygous worms were less apparent three months after the last treatment in the groups treated three-monthly. Conclusions The results indicate that ivermectin is causing genetic selection on O. volvulus. This genetic selection is associated with a lower reproductive rate in the female parasites. We hypothesize that this genetic selection indicates that a population of O. volvulus, which is more tolerant to ivermectin, is being selected. This selection could have implications for the development of ivermectin resistance in O. volvulus and for the ongoing onchocerciasis control programmes.

Age- and Infection Intensity-Dependent Cytokine and Antibody Production in Human Trichuriasis: The Importance of IgE

The cytokine and antibody response to Trichuris trichiura infection was determined for 96 persons living in an area where the parasite is highly endemic and infection exhibits a convex age intensity profile. In response to stimulation with T. trichiura antigen, a small proportion of the study group produced interleukin (IL)-4 (7%), IL-9 (5%), and IL-13 (17%). A larger proportion produced IL-10 (97%), tumor necrosis factor (TNF)-alpha (93%), and interferon (IFN)-gamma (32%). The levels of TNF-alpha (P =.016) and IFN-gamma (P =.012) significantly increased with age, suggesting a switch to a more chronic infection phenotype. The predominant parasite-specific antibodies produced were IgG1, IgG4, IgA, and IgE. Unlike the IgG subclasses and IgA, parasite-specific IgE correlated negatively with infection intensity, as defined by egg output (P =.008), and positively with host age (P =.010). These findings suggest a mixed cytokine response in trichuriasis and an IgE-associated level of protection.

Intensity of Intestinal Infection with Multiple Worm Species Is Related to Regulatory Cytokine Output and Immune Hyporesponsiveness

Increasing immunological dysfunction (atopy and autoimmunity) in western society may be linked to changes in undetermined environmental agents. We hypothesize that increased exposure to multiple gut worm species promotes stronger immunological regulation. We report here that African children constitutively secrete more immunoregulatory cytokines (interleukin [IL]-10 and transforming growth factor [TGF]- beta1) under conditions of hyperendemic exposure to the intestinal nematodes Ascaris lumbricoides and Trichuris trichiura, compared with conditions of mesoendemic exposure. Under conditions of hyperendemic exposure, estimators of combined intestinal nematode infection level relate positively to combined constitutive IL-10 and TGF-beta1 production and negatively to total immune reactivity (determined as IL-4, interferon-gamma, and cellular proliferative responses to Ascaris or Trichuris helminth antigens, Streptococcus pneumoniae bacterial antigen, or the mitogen phytohemaglutinin). Total immune reactivity and anti-inflammatory cytokine production relate inversely. Our data suggest that gut nematodes are important mediators of immunoregulation.

Point-of-care quantification of blood-borne filarial parasites with a mobile phone microscope

Loa loa microfilariae load in blood can be automatically quantified at the point of care using a mobile phone video microscope. Dial “L” for Loa: Answering the call for mass drug administration Filarial nematodes—tiny, parasitic worms that get into the bloodstream and use humans as hosts—are common in certain regions in Africa. One of these filarial nematodes, Loa loa, the causative agent of loiasis, is not compatible with current ivermectin-based mass drug administration (MDA) programs in the region, which are aimed to eliminate other worms that cause onchocerciasis and lymphatic filariasis. MDA causes severe and often fatal neurological side effects for patients co-infected with L. loa; thus, many MDA programs have been suspended. To resume these ivermectin-based campaigns, D’Ambrosio et al. devised a mobile phone–based strategy for quantifying Loa microfilariae in whole blood and, in turn, excluding those individuals from MDA. The authors’ Loa-counting device comprised a mobile phone camera (as the video microscope) and a custom algorithm for tracking the “wriggling” motion of the microfilaria by quantifying the displacement of red blood cells surrounding the Loa. The entire device was packaged for point-of-care use, including its own “app” for smartphones. When tested on samples from 33 potentially Loa-infected subjects in Cameroon, Africa, the device was 94% specific (compared with microscopy results from thick blood smears) and 100% sensitive for patients about the threshold for severe adverse events (30,000 microfilaria per milliliter of blood). With its ease of use and only a fingerprick of blood, this mobile analytical device could be integrated into MDA programs, answering the call for safe and effective programs in Loa-endemic regions. Parasitic helminths cause debilitating diseases that affect millions of people in primarily low-resource settings. Efforts to eliminate onchocerciasis and lymphatic filariasis in Central Africa through mass drug administration have been suspended because of ivermectin-associated serious adverse events, including death, in patients infected with the filarial parasite Loa loa. To safely administer ivermectin for onchocerciasis or lymphatic filariasis in regions co-endemic with L. loa, a strategy termed “test and (not) treat” has been proposed whereby those with high levels of L. loa microfilariae (>30,000/ml) that put them at risk for life-threatening serious adverse events are identified and excluded from mass drug administration. To enable this, we developed a mobile phone–based video microscope that automatically quantifies L. loa microfilariae in whole blood loaded directly into a small glass capillary from a fingerprick without the need for conventional sample preparation or staining. This point-of-care device automatically captures and analyzes videos of microfilarial motion in whole blood using motorized sample scanning and onboard motion detection, minimizing input from health care workers and providing a quantification of microfilariae per milliliter of whole blood in under 2 min. To validate performance and usability of the mobile phone microscope, we tested 33 potentially Loa-infected patients in Cameroon and confirmed that automated counts correlated with manual thick smear counts (94% specificity; 100% sensitivity). Use of this technology to exclude patients from ivermectin-based treatment at the point of care in Loa-endemic regions would allow resumption/expansion of mass drug administration programs for onchocerciasis and lymphatic filariasis in Central Africa.

Spatial modelling and the prediction of Loa loa risk: decision making under uncertainty.

Abstract Health decision-makers working in Africa often need to act for millions of people over large geographical areas on little and uncertain information. Spatial statistical modelling and Bayesian inference have now been used to quantify the uncertainty in the predictions of a regional, environmental risk map for Loa loa (a map that is currently being used as an essential decision tool by the African Programme for Onchocerciasis Control). The methodology allows the expression of the probability that, given the data, a particular location does or does not exceed a predefined high-risk threshold for which a change in strategy for the delivery of the antihelmintic ivermectin is required.

Relationship between onchocerciasis and epilepsy: a matched case-control study in the Mbam Valley, Republic of Cameroon.

Studies conducted during the past 10 years to investigate the possible relationship between onchocerciasis and epilepsy have led to contradictory results. In 1991-92 and 2001 we investigated 14 villages in central Cameroon to evaluate the relationship, at the community level, between the prevalence of epilepsy and the endemicity level of onchocerciasis. A case-control study compared the microfilarial loads of 72 epileptic and 72 non-epileptic individuals, matched according to sex, age, and village of residence. The prevalence of epilepsy and the community microfilarial load (CMFL) were closely related (P < 0.02), and the case-control study demonstrated that the microfilarial loads (microfilariae per snip) in the epileptic group (arithmetic mean = 288, median = 216) were significantly higher (P < 10(-4)) than in the control group (arithmetic mean = 141, median = 63). The results strongly support the existence of a link between onchocerciasis and epilepsy. The fact that such a relationship has not been found recently in some other West and Central African areas is probably due to the lowered endemicity of onchocerciasis following vector- and ivermectin-related control measures applied over the past 5-25 years. The socio-economic and demographic impact of onchocerciasis-related epilepsy should be evaluated, and taken into account as part of all onchocerciasis control programmes.