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Elimination in Sight
Alumnus Maurcio Sauerbrey leads the effort to end River Blindness in the Americas
What do you do when you have significantly reduced malaria transmission rates in your home country? For Mauricio Sauerbrey, you turn your attention toward another illness that has plagued your region for more than a century.
Sauerbrey began his career in parasitology at the Tulane School of Public Health and Tropical Medicine in the late ’60s, an enthusiastic young man from El Salvador delighted to be studying under the luminaries of his chosen field.
“I had the great opportunity to meet Dr. Ernest Carroll Faust,” he declares with a characteristic gleam in his eye. Faust was an international authority on parasitology who had been with Tulane since the Depression.
Sauerbrey recalls the required weekly Wednesday Seminars, open discussions about public health topics of the day where everyone was expected to comment on recent journal articles in front of the school’s faculty.
“I was so afraid at the first seminar I went to,” he says. He was concerned because “my English was not that good.” Another Tulane luminary and a mentor of Sauerbrey’s, Paul Beaver, urged him not to be afraid. “It’s an opportunity to show off, to show your abilities,” Sauerbrey recalls him saying.
The young Sauerbrey and his growing family (his son was born during his first year at Tulane) enjoyed New Orleans, and after receiving his master’s he wanted to continue on to earn his doctorate. Unfortunately, his arrangement with the University of El Salvador to cover tuition was only for two years, and he had no funds to continue.
“One day, Dr. Beaver came to me and said ‘Mauricio, I want to talk to you. I want to know what your plans are.’” Sauerbrey affection for the celebrated parasitologist is evident. “Dr. Beaver was always in back of everything,” he says.
The Wednesday Seminars were also opportunities to meet some of the other leading figures in parasitology. One presenter was Robert Coatney, a leading figure in the battle against malaria from the Centers for Disease Control and Prevention. After the seminar, Sauerbrey approached him.
“He encouraged me to talk to the boys there [at CDC].” But Sauerbrey was committed to repaying his debt to the School of Medicine at the University of El Salvador, so he returned to his home country and began teaching parasitology.
Before long, Sauerbrey would have another opportunity to connect with the CDC. In the 1970s and 80s, the CDC maintained a research station in El Salvador to monitor malaria. By that time Sauerbrey had become a full professor with the University El Salvador, and the Central American Research Station had expanded beyond malaria, including work on Chagas disease.
“I did my thesis on Chagas disease”, under Robert Yeager’s advisory says Sauerbrey, so a relationship with the station was an ideal fit for the ambitious scientist. Malaria, however, was the bigger challenge in El Salvador at that time and Sauerbrey’s work spanned both.
“My connection with malaria was starting to grow and grow and grow,” he recalls.
In the late ‘80s and early ‘90s the situation in El Salvador was becoming more tense as political unrest increased. While the U.S. professionals working with the CDC were forced to leave the country, it provided an opportunity for Sauerbrey who became director of the Central American Research Station.
“It was a tremendous experience for me,” he says.
Before long, national turmoil forced the CDC to close the station in El Salvador entirely and move to a smaller site in Guatemala.
Robert Kaiser, who was head of parasitology and tropical diseases at the CDC, offered Sauerbrey opportunities to go to Atlanta or Guatemala. Sauerbrey considered both options, but ultimately decided that El Salvador was home. His wife was a passionate teacher with a school of her own; he did not want to interrupt the dedication she had for her students.
He began talking to USAID, the U.S. agency primarily tasked with administering foreign aid, which, due to the magnitude of the problem, had become interested in malaria in El Salvador. At that time, 100,000 cases were diagnosed annually in El Salvador, 18 percent of which were attributed to plasmodium falciparum. They decided to offer Sauerbrey a 6-month intervention to improve the situation.
Those original six months were ultimately extended many times over the course of a dozen years, a direct result of Sauerbrey’s positive track record with the program.
“Success brings success,” Sauerbrey says with a smile.
His results were so favorable, in fact, that they were held up as a success story in congressional hearings. By 1992, the number of cases of malaria had dropped in El Salvador to 3,000 per year, with none related to plasmodium falciparum. Indeed, the decrease has continued to the present day, when there are barely half a dozen cases reported each year, most imported from neighboring countries.
How did Sauerbrey find such success in battling malaria in El Salvador? When he began working to reduce malaria in El Salvador, the standard method to treat the disease was through insecticides. Spraying would begin at one end of the country and continue throughout the year to the other side.
At the same time, the difference between when someone was tested for malaria and results were returned was at least one month. There was only one central laboratory for testing in the entire country.
The first thing that Sauerbrey did was to decentralize the process by establishing small labs scattered throughout the country. His staff enlisted and trained voluntary collaborators in these small communities to conduct finger prick tests and deliver the resulting slides to the decentralized labs via motorcycle. The turnaround time dropped from 30 days to 72 hours. Additionally, they instituted presumptive treatment using both chloroquine and primaquine, a combination first used at the Central American Research Station after a field research study there demonstrated its efficacy.
At the height of the fight against malaria, Sauerbrey and his team had 4,000 collaborators who were not paid, but were provided with everything they needed to test and treat in the field.
At the same time, Sauerbrey and his team created an information system that provided them with a record of all the cases of malaria in all communities. Once this information system was built up, they were able to track the increase or decrease of malaria month to month or year to year and “react much, much faster than in the past.”
They began looking for breeding places and enlisted engineers to design a way to shut off sources of mosquito-breeding (source reduction). Previously, the insecticides used were not specific, but now, when adult carriers were found, they used adulticides to kill off the vectors; when larvae were found, larvicides were used. Over time, they were able to reduce the amount of insecticide used while increasing the source reduction and timely treatment of individual cases. By the end of the program, spraying of insecticides was completely eliminated and the strategy was completely transformed from eradication to control.
Sauerbrey recalls that it was difficult, at first, to gain the trust of his country’s malaria program director, whom he directly advised. The director would hear anecdotal reports of increased malaria in various parts of the country. But as Sauerbrey’s information systems developed more and more data, they were able to demonstrate specifically where malaria cases were on the rise or falling. Eventually the director got on board and became Sauerbrey’s biggest supporter.
A new task: Eliminating river blindness
The success of the program ultimately put Sauerbrey out of a job, although by this time he had his own private medical lab. It was around this time that upon the recommendation by his good friend at Tulane and afterwards at CDC, Richard Collins, he received a call asking him to sit on the coordinating committee for the Onchocerciasis Elimination Program for the Americas (OEPA), a regional initiative coordinated by The Carter Center to eliminate the transmission of river blindness throughout the Americas.
Both Frank Richards, director of the Carter Center’s River Blindness Program, and Donald Hopkins, Carter Center vice president of health programs, were there at the time of the IACO meeting in Cali, Colombia. Sauerbrey had barely become a committee member when the director of OEPA surprisingly resigned, and Hopkins suggested him as a candidate for the position. Hopkins and Richards had suggested that he present his experience with malaria in El Salvador and, at the conclusion of the three day meeting, he was asked to consider becoming the new director of the OEPA program.
OEPA is based in Guatemala and Sauerbrey’s immediate response was “no”. He still wanted to stay in El Salvador. Hopkins and Richards, sensing that they had the opportunity to hire someone who could make a big difference, asked him again. Richards proposed Sauerbrey to develop a plan where he could direct the program while remaining in El Salvador.
Sauerbrey developed such a plan, presented it, and they accepted it on a conditional six months, reminiscent of his initial work with USAID. He started in February 1998 as acting director. “Acting” was soon removed from the title he retains to this day.
“He is one of those folks, if you are lucky enough to get them you just let them fly,” says Richards. He considers Sauerbrey the complete package, a director with the technical know-how to combat the disease but also the political sense, which Richards considers just as essential as the scientific knowledge.
Onchocerciasis, also known as river blindness, is the second leading infectious cause of preventable blindness in the world and affects approximately 18 million people worldwide, with about 270,000 permanently blinded1 .While the vast majority of onchocerciasis cases occur in Africa, the areas impacted by the disease in Latin America represented significant burden for the small, isolated communities where it had taken hold. The parasite that carries the disease is transmitted to humans through the bite of black flies that breed near river beds.
Sauerbrey has used the same systematic approach he employed with malaria in El Salvador to address river blindness throughout the region. OEPA’S efforts have been assisted through the donation of Mectizan, a brand-name for ivermectin, an antiparisitic medication produced by the pharmaceutical firm Merck.
Treatment with Mectizan is given to those in the majority of affected areas of Latin America twice a year. Mectizan is a microfilaricide drug, Sauerbrey explains. Although it has some effect on adult parasites over the long term, it’s not a complete solution and after six months the adults resume the production of microfilaria. Another dose knocks the microfilaria back down and ensures that the black flies transmitting the disease do not become infected again. Treatments continue every six months until the adult parasites disappear from natural causes or from the prolonged effect of the drug, and transmission becomes permanently interrupted.
OEPA is a public/private partnership convened to address the disease. On the public side, the six governments of the Latin American countries impacted by river blindness are responsible for distributing the treatment. They pay for the personnel to distribute Mectizan.
Success breeds success
The results of the program have been nothing short of extraordinary. This year, OEPA is celebrating the first country to have completely eliminated the disease. It is expected that the World Health Organization will certify Colombia as free of the disease later this year. “Colombia is proof of the concept, proof that this strategy is the right one,” says Sauerbrey.
Ecuador is expected to be the second country to be eligible for certification, with evaluation wrapping up in 2012. Ecuador, he says, had one of the worst regional scenarios with a very efficient vector, making that country’s success all the sweeter.
Mexico and Guatemala, which represent the two largest endemic countries in the region, are scheduled to follow suit, with both countries ending the intervention phase and starting the three year period of post treatment surveillance (PTS) this year.
Small, nomadic, Yanomami indigenous tribes in northern Brazil and southern Venezuela remain the most difficult populations to treat and represent the last challenge to achieve regional elimination. They are located in a border area in very remote sylvatic sites, accessible only by boat and/or helicopter and many day’s travel.
According to Richards, at the start of the program there were as many as three million people at risk in the Americas for river blindness. “Now, in Brazil and Venezuela, there are about 100,000 people at risk,” he says, marking the significant change the OEPA program has made.
He cautions that that effort is not over. “This final mile is just as difficult as the initial mile,” he says. We need people to get down to these most affected areas and to maintain the political will to get it done. With countries like Brazil and Venezuela, Sauerbrey’s unique combination of talents will help see the job through. It’s the “intangible skills that Mauricio has to get people on the team,” Richards says, that will make it happen.
While Sauerbrey is understandably proud of their accomplishments in eliminating river blindness, he is perhaps even more gratified by the way they have been instrumental in helping what are often forgotten regions. In many cases, the areas they assist see not only treatment for a disease that once crippled their communities, but they also end up benefited by new schools, health facilities, and efficient water systems due to the public attention generated by the onchocerciasis program’s success. “We’ve not only eliminated a disease in these areas, we’ve provided people with a voice, because otherwise no one will care about them.”
When the team is finally able to say they are done, that they have eliminated ochocerciasis in the Americas, “there’s going to be shockwaves,” says Hopkins. “The fact that Latin America has eliminated that disease will reverberate in Africa.”
It’s long been assumed that Africa could never eliminate river blindness which is so prevalent in that continent, but the success in Latin America is leading some to consider the possibility that it can be done one day.
The obvious question for Sauerbrey, now that the dream of eliminating ochoceriasis in the Americas is being realized, is “What’s next?”
“I never tend to think what is next,” he laughs. “God is the one who guides me and He is the one who gives me my next mission.”
With an obvious passion for solving problems, a passion encouraged during his early days at the Tulane School of Public Health and Tropical Medicine, it’s easy to believe he will soon take up a new battle and begin a new effort to help people in need in Latin America.