How to eliminate river blindness: lessons from Colombia

From an article published in The Guardian written by OEPA’s Alba Lucia Morales

Colombia recently eliminated this neglected disease through health education and drugs. Sound easy? Here’s how other countries can follow suit.

My homeland of Colombia recently became the first country in the Americas to wipe out onchocerciasis (river blindness) and the first in the world to be granted ‘verification of elimination’ status by the World Health Organisation. Colombia rid itself of the neglected tropical disease, that affects millions across 35 countries worldwide, through health education and use of the drug ivermectin.

Eliminating a disease from a nation is complex. It requires community-based health education and sustained, heightened interventions including, increased drug treatments and enhanced monitoring and surveillance. Elimination means that the disease’s transmission has been interrupted permanently and health resources can be used for other issues.

For nearly two decades, the Carter Centre’s Onchocerciasis elimination programme for the Americas has led the regional campaign and provided technical and financial assistance to each of the six river blindness-endemic countries in Latin America. As a health educator and community organiser for the centre’s OEPA, I have worked since 1997 with the ministries of health to stop transmission of river blindness in Brazil, Colombia, Ecuador, Guatemala, Mexico and Venezuela.

When Colombia’s President Juan Manuel Santos made the historic announcement, many river blindness elimination programme partners, including former US president Jimmy Carter and former first lady Rosalynn Carter, travelled to Bogota to recognise the country’s political commitment, praise health workers, and congratulate the nation for purging this so-called neglected disease from their borders.

Using medicine to treat the disease

River blindness is a parasitic disease spread by the bites of tiny black flies that breed near fast-flowing streams. It causes unbearable itching, skin lesions, and can ultimately lead to diminished vision and blindness.

That’s where the oral drug ivermectin comes in. In the late 1980s, research proved that ivermectin is a safe and effective drug that kills the microfilariae, causes symptoms to diminish, and helps control the spread of the disease. We now know that in heavily endemic areas semi-annual or quarterly doses help accelerate the interruption of the disease’s transmission. In 1987, the pharmaceutical company Merck pledged to donate ivermectin, packaged as Mectizan, as much as needed for as long as necessary to fight the disease worldwide.

Getting Mectizan to people in at-risk communities required the dedication and hard work of many health promoters. In Colombia, throughout the year these workers travelled thousands of miles to reach isolated, formerly endemic area Lopez Micay first sailing by sea and then navigating rough, fast flowing rivers to supervise the distribution of Mectizan and encourage community participation. Political insecurity and armed conflict in the region further complicated the mission as health workers took personal risks to successfully accomplish an already difficult job. Colombia, together with its partners OEPA and Pan American Health Organisation, a regional body of the WHO, eliminated river blindness using a strategy of biannual community-wide administration of ivermectin to people in the affected area.

Community role

While Mectizan has been crucial, a major contributor to elimination strategy has been the marshalling of large networks of health workers and community volunteers to teach their neighbours how to prevent the disease. With the support of community leaders, artistic troupes, schools, and women’s groups, each of the national river blindness elimination programmes integrated various creative activities: staging plays for the community, crafting fly puppets in primary school classes, displaying posters and murals in public spaces. These activities inspired, engaged, and educated people to take charge of their health.

In Colombia, one of the challenges was to reach an at-risk population with limited literacy skills. We found that visual teaching tools such as slideshows, image flashcards, table games, memory exercises, and flipcharts called ‘Naicionito’ proved to be particularly effective ways to educate various segments of the population at small community gatherings.

Health education remained a critical intervention even after Mectizan treatments were stopped in 2008. Continued community-based communications ensured people understood that they had been successful in wiping out the disease and that their community had begun three years of post-treatment surveillance to confirm if transmission of the parasite has stopped and elimination could be declared.

Colombia also has shown us that education doesn’t have to stop at the door of this one disease, but can contribute to a community’s overall health and wellbeing. We were fortunate in our Colombia campaign to have devoted experts staying in Lopez Micay for long periods of time who motivated an enthusiastic response from the community. Together, the staff and the residents devised innovative strategies to enhance the quality of life such as creating community vegetable gardens and embracing local food to improve nutrition;,devising ways to filter and obtain safe drinking water, and building a healthcentre, a school, and a school cafeteria.

Success in the Americas

The Carter Centre’s OEPA, with support from generous donors and partners, works closely with health ministries in each of the river blindness endemic countries in the Americas, and that bond has yielded success. Transmission has stopped in Ecuador, Mexico, and Guatemala, and each country is working to get official elimination verification by the WHO. Only one location — a hard-to-reach area in the Amazon rainforest on the Venezuela-Brazil border — has active disease. The programme coalition expects to halt transmission there in the next few years, and when that happens river blindness will be gone from two continents: North and South America.

OEPA’s lessons and successes have also served as an inspiration for a new Carter Centre goal: to eliminate river blindness in the areas we assist in Africa, where nearly all of the world’s river blindness remains. Sudan and Uganda have recently reported transmission interruption in key endemic areas, overturning decades of scientific belief that elimination in Africa was impossible.

Alba Lucia Morales Castro is health education adviser with the Carter Centre’s Onchocerciasis Elimination Programme for the Americas

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