Journal of Ophthalmology of Eastern Central and Southern Africa

July 2014

Blinding Onchocerciasis in Pader District, Northern Uganda

Watmon B1, Lakwo TL2, Onapa AW3
Consultant Ophthalmologist, Gulu Regional Referral Hospital, Uganda
National Onchocerciasis Control Programme Manager, Ministry of Health, Uganda
3
Programme Manager, ENVISION/RTI NTD Control, Kampala, Uganda
1
2

Corresponding author: Dr B Watmon. Email: watben2002@yahoo.com

ABSTRACT

Background: Onchocerciasis is caused by a filarial nematode Onchocerca volvulus, and is transmitted

by a female black fly of the genus Simulium which breeds in fast flowing rivers. In Uganda, the disease
is endemic in 37 districts with clinical manifestations mainly on the skin. The long-term armed conflict
in northern Uganda made research and control of onchocerciasis in the region and particularly Pader
district receive little attention. There have been no attempts to establish the magnitude of the disease
in the region.
Objective: To establish the magnitude and clinical manifestations of Onchocerciasis in Pader district,
northern Uganda.
Methods: Twenty parishes in sub counties with Rapid Epidemiological Mapping of Onchocerciasis
(REMO) nodule prevalence of 25.0% or more were randomly sampled and 675 persons consecutively
enrolled in 13 parishes. The respondents underwent dermatological, parasitological and ocular
examinations.
Results: A total of 675 persons were examined and of these, 318 had skin snipping and microscopy
done. The prevalence of microfilaria (mf) in skin snip was 29.6% (95% CI: 24.6%-34.6%) while prevalence
of nodules was 30.1% (95% CI: 3.1%-6.5%). The prevalence of microfilaria in the anterior chamber of
the eye (MFAC) was 4.1% (95% CI: 2.6%-5.6%) and that of reversible ocular lesions was 4.0% (95% CI:
2.5%-5.5%). The reversible ocular lesions of onchocerciasis observed were punctate keratitis stage B
(PKB, 0.1%), punctate keratitis stage D (PKD, 0.1%) and punctate keratitis stage E (PKE, 3.7%) while the
irreversible ocular lesions were observed in 16.1% (95% CI: 13.3%-18.9%) of the respondents. The most
important irreversible lesions were optic atrophy 6.4%, (95% CI: 3.7%-9.1%) and sclerosing keratitis,
5.2% (95% CI: 2.8%-7.6%). Visual impairment was detected in 29.2% (95% CI: 25.8%-32.6%) of the
respondents and the main causes were cataracts (27.4%) and optic atrophy (21.8%). The association
between irreversible lesion and visual loss (p< 0.00) and irreversible lesions and nodules (p< 0.00) were
both significant.
Conclusion: This study indicates that the onchocerciasis in Pader district is the blinding type. There is
need to strengthen health education, community social mobilization and start biannual Mass Drug
Administration (MDA) with Ivermectin.
Republic of Congo, Northern Uganda, West Nile and
the Elgon Mountain regions. A study conducted by
Ndyomugyenyi in 1992 indicated that over 3 million
people in Uganda were at risk of infection and 1.4
million were infected2. In the 1990s the National
Onchocerciasis Control Programme of the Ministry of
Health (Uganda) started control projects in most of the
endemic districts using MDA with Ivermectin. Kitgum
and Pader were not included on the control program
because of the prolonged insurgency in northern
Uganda until after the Rapid Epidemiological Mapping
of Onchocerciasis (REMO) in 2008. Information on
ocular manifestations of onchocerciasis in northern
Uganda had been limited to clinical reports from the
Eye Department of Gulu Regional Referral Hospital3.
These results provide baseline data for future evaluation
of any onchocerciasis control program in the district.

INTRODUCTION
Onchocerciasis is caused by a filarial nematode
Onchocerca volvulus and transmitted by the female
black fly, Simulium, which breeds in fast flowing
rivers, hence the name river blindness. The disease
is endemic in large areas of Africa where favorable
ecology for the black fly that is a determinant of disease
distribution prevails and is known for both ocular and
dermatological effects. In the affected communities
the most devastating ocular complication is blindness.
It has been reported that mortality amongst the blind
people is four times higher than in the sighted persons
of the same age in the community1.
In Uganda the disease is endemic in 37 of the
112 districts which include the areas located in the
western axis of the country bordering the Democratic

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Journal of Ophthalmology

Journal
of Ophthalmology
of Eastern Central and Southern Africa
The aim of the study was to establish the magnitude
and ocular manifestations of onchocerciasis in Pader
district, northern Uganda and objectives were to
determine the prevalence of onchocercal nodules,
microfilaria in the anterior chamber of the eye, the
reversible and irreversible ocular manifestations of
onchocerciasis.

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2014

Data was collected by the Ophthalmologist,

Ophthalmic Clinical and Vector Control Officers using
pre-tested closed ended questionnaires, cleaned and
entered in Excel and exported to SPSS 16.0 for analysis.
Ethical clearance and permission to conduct the
survey was obtained from Uganda National Council
of Science and Technology, the district authority and
community leaders. Informed consent was obtained
from the individual participant or the next of kin of
the children. The procedures of taking skin snip for
examinations and associated complications or pain
were explained to participants in groups and thereafter
individually. Only those adults or children whose
parents or next of kin consented had skin snip done.

MATERIALS AND METHODS

This survey was conducted in Pader district in northern
Uganda during the period January to August 2009. At
the time of the survey Pader had two counties; Aruu and
Agago. This study was done in Aruu County which had
nine sub counties and 35 parishes. The sample size was
calculated using Kish and Frankel formula4. Multistage
cluster sampling method was employed based on the
REMO survey report of 2008 from the Ministry of
Health National Onchocerciasis Control Programme5, 6.
Seven sub counties with nodule prevalence more than
25.0% were sampled. In each sub county, parishes were
randomly sampled basing on probability proportionate
to population. Sixty individuals aged five years or
more were consecutively recruited until the sample
size of sixty per parish was reached. Participants were
examined from a common site which was either a
primary school or health facility.
The study variables included age, sex, intake of
Ivermectin, presence of onchocercal nodules and
skin snip for analysis for microfilaria. The ocular
variables were visual acuity, evidence of microfilaria
in the cornea, onchocercal related keratitis, presence
of microfilaria in the anterior chamber, evidence of the
iritis and lesions in the posterior segment of the eye.
Communities were mobilized through their
leaders, local radio announcements and telephone
calls to Village Health Teams. Prior to enrolment,
health education focusing on onchocerciasis and other
neglected tropical diseases were given to the gathering.
The study purpose and procedures were explained and
consent sought. Parents or next of kin consented for the
minors.
Each participant was given an identification number
prior to examination; visual acuity assessed using the
Snellen chart or appropriate method depending on the
level of visual impairment and age7. Ocular examinations
were done with torch, direct ophthalmoscope and
hand held portable Slit Lamp at x10 magnification.
Dermatological and nodule examinations were done
while skin snip for microscopy was conducted under
standard aseptic procedure. Respondents who had
other significant medical conditions were either treated
or referred for further management in the appropriate
health facility. Skin snip slides were preserved under standard
conditions and analyzed by the Vector Control Officers.

RESULTS
Demographic characteristics: A total of 675 persons
were examined in the 13 surveyed parishes: females
351(52.0%) and males 324 (48.0%). The distribution
of the respondents by age was as follows: 5-14 years
203(30.1%), 15-24 years 96(14.2%), 25-34 years
76 (11.3%), 35-44 years 94 (13.9%), 45-54 years 69
(10.2%), 55-64 years 59(8.7%) and above 64 years
78(11.6%).
Intake of Ivermectin: Sixty one percent of the
respondents had swallowed Ivermectin in the previous
12 months; males 335 (49.6%) and females 340
(50.4%). The majority (83.5%) received Ivermectin
from the VHT in their respective village of stay, 15.7%
from the health facility and remaining 0.7% received
from the District Vector Control Officer. Intake of
Ivermectin was lowest in the age group 25-34 years
(46.0 %).
Nodules: Of the 675 participants 203 (30.1%, 95% CI:
3.1%-6.5%) had palpable onchocercal nodules in the
following sites: Iliac region (50.9%), buttocks/coccyx
(25.5%), chest (12.4%), head (5.0%), knee (4.7%)
and elbow (0.7%). The youngest with nodules were
two nine year old males (Table 1). The youngest with
nodules were two nine year old males.
Table 1: Statistical relationship between nodule site
and visual loss among participants (n=675)
Nodule
site
Head
Chest
Iliac crest
Buttocks
/ coccyx
Knee
Elbow

20

Chisquare
26.101
13.925
49.019

Df

P-value

95% CI

3
3
3

0.00
0.00
0.00

5.0% (2.0%-8%)
12.4%, (8.0-17.5%)
50.9% (44.0-57.8%)

54.592

0.00

25.5 % (20.0-32.0%)

7.921
9.228

3
3

0.05
0.03

4.7 % (1.8%-7.6%)

Journal of Ophthalmology of Eastern Central and Southern Africa

Figure 2: Severe visual impairment and blindness by

age

Skin snip and microfilaria in the anterior chamber:

Of the 318 respondents who had skin snip taken for
microscopic examination for O.vulvulus microfilaria,
94 (29.6%, 95% CI: 24.6%-34.6%) were positive.
Twenty eight (4.1%, 95% CI: 2.6%-5.6%) of the 675
respondents had Microfilaria in the Anterior Chamber
(MFAC) of the eye (Figure 1).

45

14

40
35
30

Blind Bilateral

25

20

10

5 - 14

15 - 24

7
3
5-14

15-24

Pos Snip
8

56

25-34

35-44

3
45-54

2
55-64

35 - 44 45 - 54 55 - 64

>64

Table 2: Distribution of reversible ocular lesions

MFAC

25 -34

5
2

Reversible ocular lesions: Reversible anterior segment

lesions, Puntate Keratitis was observed in 27 (4.0%,
95% CI: 2.5%-5.5%) (Table 2).

20
14

Bilateral SVI
Unilateral SVI

28

Blind Unilateral

10

15

Figure 1: Distribution of positive skin snip and

microfilaria in anterior chamber by age

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July 2014

Reversible lesion

Frequency

(%)

0.1

0.1

25

3.7(CI: 2.3-5.1%)

Punctuate Keratitis
stage F (PKF);
normal cornea

638

94.5(CI: 92.8-96.2)

Active iritis

0.3

Total

668

98.8

Punctuate Keratitis
stage B (PKB)
Punctuate Keratitis
stage D (PKD)
Punctuate Keratitis
stage E (PKE)

3
>65

(years)

The youngest with a positive snip were two five year

olds (male and female). Both positive skin snip and
presence of MFAC were statistically significantly
associated with visual loss [(p< 0.00) and (p<0.00)
respectively]. The presence of MFAC was statistically
significantly associated with presence of nodules (2 =
207.006; df = 82; p< 0.00).
Visual assessment: A total of 1339 eyes were examined;
664 binocular and 11 were monocular. One hundred
and ninety seven (29.1%, (95% CI: 25.7-32.6%)
respondents had visual impairment; 64 (32.5%)
were unilateral while 133(67.5%) were bilateral.
The distribution of impairment on the basis of visual
acuity was as follows: Low Vision (LV) 34.5%, Severe
Visual Impairment (SVI) 20.8% and blindness 44.7%.
Generally visual impairment gradually increased with
age (Figure 2).

In eight cases (1.2%) there were corneal scars

and hence the anterior segment could not be well
evaluated. Presence of live microfilaria coiled in the
cornea [PKA] and inflammatory reactions around
the dead microfilariae in the cornea [PKC] were not
observed.
Irreversible ocular lesions: A total of 109 (16.1%,
95% CI: 13.3%-18.9%)) respondents had irreversible
ocular lesions (Table 3).

Table 3: Distribution of irreversible ocular lesions (n=109)

Age
Sclerosing
Iris
Optic
group
Keratitis(SK)
atrophy
Atrophy(OA)
5 - 14
3(33.3%)
0(0.0%)
5(55.6%)
15 - 24
5(26.3%)
2(10.5%)
8(42.1%)
25 - 34
4(36.4%)
3(27.3%)
4(36.4%)
35 - 44
1(7.1%)
4(28.6%)
5(35.7%)
45 - 54
11(50.0%)
3(13.6%)
6(27.3%)
55 - 64
4(23.5%)
4(23.5%)
8(47.1%)
> 64
7(36.8%)
5(26.3%)
7(36.8%)
Total
35(32.1%)
21(19.3%)
43(39.4)

21

Optic
Neuritis
0(0.0%)
1(5.9%)
0(0.0%)
2(14.3%)
0(0.0%)
0(0.0%)
0(0.0%)
3(2.8%)

Chorioretinitis
1(11.1%)
1(5.9%)
0(0.0%)
2(14.3%)
2(9.1%)
1(5.9%)
0(0.0%)
7(6.4%)

Total
9(8.3%)
17(15.6%)
11(10.1%)
14(12.8%)
22(20.2%)
17(17.6%)
19(17.4%)
109(100%)

East
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Journal of Ophthalmology

Journal
of Ophthalmology
of Eastern Central and Southern Africa

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Journal of Ophthalmology of Eastern Central and Southern Africa

CONTACT DETAILS
MS Aparna Patel
Territory Manager-East Africa Alcon Labs
Cell No: 0722 514 044
Email: aparna.patel@alcon.com
23

July 2014

East
African
Journal of Ophthalmology

Journal
of Ophthalmology
of Eastern Central and Southern Africa
The overall prevalence of optic atrophy and sclerosing
keratitis in the surveyed group was 6.4% (95% CI: 3.7%9.1%) and 5.2% (95% CI: 2.8%-7.6%) respectively. Of
the 43 respondents with optic atrophy, 24 (55.8%) had
positive skin snips. Occurrence of irreversible lesions
was significantly associated with positive skin snip, (x2
= 400.982; df = 205, p = 0.00) (Figure 3).
Figure 3: Distribution of sclerosing keratitis and optic
atrophy by age

Frequency

Distribution of Sclerosing Keratitis and Optic Atrophy

12

S.K

10

O.A

8
6
4
2
0
5 - 14

15 - 24

25 - 34

35 - 44

45 - 54

55 - 64

> 65

Age group

A total of 85 eyes had optic atrophy, three were unilateral

and forty cases were bilateral and 54.0% were blind in
terms of visual acuity. There was significant association
between occurrence of these irreversible ocular lesions
with visual loss (x2 = 188.454, df=15, p-value 0.00).
Causes of visual impairment: Of the 675 respondents
197 (29.2%, 95% CI: 25.8%-32.6%) had visual
impairment in one or both eyes with the main causes
being cataract (27.4%), optic atrophy (21.8%), corneal
scars (18.3%) and maculopathy (12.7%).
Table 4: Causes of visual impairment amongst the
respondents
Disorder
Corneal opacities
Cataract
Optic atrophy
Maculopathy
Chorioretinopathy
Others
Total

Monocular
(n=64)
16 (8.1%)
23(11.7%)
3(1.5%)
5(2.5%)
2(1.0%)
15(7.6%)
64(32.5%)

Binocular
(n=133)
20(10.2%)
31(15.7%)
40(20.3%)
20(10.2%)
13(6.6%)
9(4.6%)
133(67.5%)

Total
(n=197)
36(18.3%)
54(27.4%)
43(21.8%)
25(12.7%)
15(7.6%)
24(12.2%)
197(100%)

The most affected age group were those aged above

55 years. The majority of the respondents with optic
atrophy were below 45 years and 24 of them had
positive skin snip.

DISCUSSION
The results of clinical, parasitological and ocular
examinations in this study reveal the presence of
onchocerciasis in the district.
Intake of Ivermectin: The 61.0% intake of Ivermectin
was lower than WHO recommended annual coverage
of 65% 1. Katabarwa et al8 reported treatment coverage

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2014

in the following places: Bangange (Cameroon) 99.5%;

Kasese (Uganda) 88%; Nebbi (Uganda) 91%. This
low coverage could be due to the fact that community
distribution of Ivermectin in Pader was still a new
program which was not yet fully established since it
started one year prior to this study.
Nodules: The distribution of onchoceral nodules at the
different sites nearly doubles that reported by Fischer
et al9 amongst the community in Kabarole district
in Uganda which was as follows: Iliac crest 27.9%,
buttocks 11.3% and chest 5.3%. Lakwo et al 6 reported
nodule prevalence of 24% in Pader district while Krupp
and Chatton10 reported that nodules are mostly seen
over bony prominences like the iliac crest, coccyx,
trochanter, chest wall and limps. In this survey nodules
located in the head, chest, iliac region and buttocks
were all separately statistically significantly associated
with visual loss [(x2 = 26.101 df= 3; p-value 0.000),
(x2 =13.925; df= 3 p-value 0.003), x2 = 49.019; df= 3;
p-value 0.000) and (x2 = 54.592; df= 3; p-value 0.000)
respectively].
We observed that children with nodules in the
head tend to develop visual impairment earlier than
their counter parts with nodules elsewhere. There was
no significant association of nodules in the knees and
elbows with visual loss.
Skin snip: Positive skin snip confirmed the presence
of onchocerciasis in Pader and a prevalence of 29.6%
shows high endemicity. In the younger age groups
5-24 years positive snip was higher in males compared
to females while in the age groups 25-64 years more
females than males had positive snips. This could
probably be due to young males (5-24 years) being
more involved in outdoor activities such as swimming,
fishing charcoal burning and farming compared to their
counterparts in the same age bracket. In the groups
above 24 years females tend to be more involved in
outdoor activities such as gardening, gathering fire
woods and fetching water hence increasing exposure
to the fly bites. In this community, weeding of crops
is essentially the work of women. Majority of the men
dig/ plough in the morning and retire home by midday
while women may continue up to late afternoon or
evening hours.
Reversible ocular lesions: The occurrence of reversible
lesions of 4% was low compared to the findings of
Newland et al11 where live and dead microfilariae
was 13.6% while punctuate corneal opacities was
19.1%. Abiose12 reported that a single treatment with
Ivermectin reduced the microfilaria in the cornea to
2% and 9% of pretreatment count after four months.
In the surveyed communities two cases (0.2%) had
dead microfilaria in the cornea. These communities
had received one course of Ivermectin in the past three
to six months prior to this study. The pre treatment
microfilaria load was however, not established.

Journal of Ophthalmology of Eastern Central and Southern Africa

Microfilaria in the anterior chamber: The prevalence of
microfilaria in the anterior chamber was 4%. Fischer et
al9 reported an average prevalence of 44% in Kabarole
district of Uganda while Dadzie et al13 reported a
reduction of 20%, four months after a single treatment
with Ivermectin. Newland et al11 found microfilaria
in the anterior chamber in 23.9% among 782 subjects
in a survey of ocular onchocerciasis in a rain forest
area of West Africa. The relatively low level of
microfilaria in the anterior chamber of the eyes among
the surveyed communities could have been because the
communities had received Ivermectin in the previous
three to six months prior to the study. However, there
was no statistically significant relationship between the
presence of microfilaria in the anterior chamber and
the intake of Ivermectin. Cases have been observed in
which microfilariae could be demonstrated in the eye
over a period of time without any pathological changes
resulting14.
Iritis / iris atrophy: In this study the prevalence of both
active and inactive iritis (anterior uveitis) of 3.4% was
similar to that reported by Fischer et al9, 5.8%. Abiose12
reported that with the death of microfilaria, a torpid iritis/
uveitis develops. Uveitis is a non specific intra-ocular
inflammation associated with ocular onchocerciasis
due to toxins released by dead microfilaria or their
motility. A more severe anterior uveitis may develop
with the formation of inferior, posterior and peripheral
anterior synerchiae which may be complicated by
secondary cataract and glaucoma. The study findings
are consistent with those of Fischer et al 9 and Abiose12.
In Sudan keratitis, iritis, iridocyclitis synechiae and
associated iris atrophy were reported14. The death of
microfilaria provokes uveitis and repeated uveitis may
result in complications such as iris atrophy, glaucoma,
cataract, hypotony, chorioretinal degeneration and
phthisis bulbi with resultant visual loss.
Distribution of irreversible lesions: The prevalence of
optic atrophy (6.4%) and sclerosing keratitis (5.2%)
was highest in the age groups 45-54 years. The corneal
opacities in sclerosing keratitis tend to be peripheral
with a slightly clear central cornea hence lesser effects
on the visual acuity. The findings in Pader showed
cases with severe posterior segment pathology but little
or absent anterior segment pathology.
A study by Newland et al11 in the rain forest
area of West Africa revealed sclerosing keratitis
prevalence of 5% among 800 respondents and was
more common in older subjects. The prevalence of
optic atrophy in hyperendemic rain forest varied
from 1% - 4% in savanna communities of Cameroon
to 6% - 9% in Guinea savanna of northern Nigeria15.
Atrophy of choriocapillaries, choroido-retinal scaring
and sub-retinal fibrosis and pigment disturbance at
the disc margin with or without primary optic atrophy
are advanced lesions which are sometimes seen.
Berghout16 reported that patients with palpable nodules
present with serious pathology of posterior segment

July 2014

of the eye twice frequently as in non-onchocerciasis

patients. A survey in Adjumani and Moyo districts
(Uganda) by Ukety et al17 revealed that 2.8% of the
respondents had irreversible eye lesions which included
sclerosing keratitis, chorioretinitis and optic atrophy.
In Pader the most significant blinding lesion was
optic atrophy which usually results from repeated
optic neuritis. There was notably a higher affinity
for the optic nerve than other ocular structures. The
relationship between the presence of nodules and
irreversible ocular lesions (x2 = 91.416, p-value 0.000),
and the occurrence of irreversible lesions with positive
skin snip (x2 = 400.982; df = 205, p-value 0.000) was
statistically significant.
The development of ocular lesions correlates
with the degree and duration of infection18. The
pathogenesis of posterior segment pathology, which
mainly includes optic atrophy and chorioretinital,
degeneration has been attributed to a number of factors
such as the role of microvascular occlusion of retinal
vessels by dead microfilaria, effects of toxins released
by the adult worms and dead MF, combined effects
of toxins and avitaminosis A, genetic factors, toxic
products of disintegrating microfilaria in the retina and
choroid and the role of immune complexes11. Kirk 14
reported that hereditary factors, nutritional deficiencies
and intercurrent infections have been regarded as
contributory factors. Ogunrinade et al19 reported two
strains of onchocerca volvulus in Nigeria; the blinding
type which predominates the savannah biochime of
West Africa and the non blinding found in the rain forest.
Infestation by the former is associated with blinding
ocular lesions which are rare in the latter. Studies have
shown that the difference between blinding and non
blinding onchocerciasis may be due to the differences
in endemic parasite populations.
The high prevalence of optic atrophy in Pader
district could be attributed to onchocerciasis. This is
consistent with the findings of Abiose12 that there is
a high prevalence of optic atrophy in onchocerciasis
hyperendemic areas. In western and other parts of
Uganda the onchocercaisis infestation is not blinding
like in Northern Uganda and this has been attributed
to the vector difference, Simulium Naevi. This
study demonstrated co-relationship between visual
impairment with the following variables: irreversible
lesions, optic atrophy, nodules and positive skin snip
hence suggesting that the onchocerca volvulus could be
the responsible agent.
Visual impairment: The study revealed that cataract
was the leading cause of blindness in the surveyed
community. Age related cataract globally accounts
for 50% world blindness while the remaining 50%
is distributed amongst the other diseases such as
glaucomas 12.3%, age related macular degeneration
8.7%, corneal opacities (including trachoma) 8.7% and

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Journal
of Ophthalmology
of Eastern Central and Southern Africa
onchocerciasis 0.8%20. Pader district is hyperendemic
for trachoma and hence the high prevalence of
corneal scars and optic atrophy has been linked to
onchocerciasis. The high number of blindness and
severe visual impairment could be attributed to the
sampling methodology.

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2014

7. Gilbert C, Foster A, Negrel AD, Thylefors B.

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11. Newland HS, White AT, Greene BM, Murphy RP,
Taylor HR. Ocular manifestations of onchocerciasis
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13. Dadzie KY, Remme J, Alley ES, De Sole G,
Changes in ocular onchocerciasis four and twelve
months after community-based treatment with
ivermectin in a holoendemic onchocerciasis focus.
Trans. Roy. Soc. Trop. Med. Hyg. 1990a; 84: 103-108.
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onchocerciasis. Bull. WHO. 1957; 16: 485-493.
15. Abiose A, Jones BR, Cousens SN, Murdoch I,
Cassels-Brown A, et al. Reduction in the incidence
of optic nerve disease with annual ivermectin to
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16. Berghout, E. Onchocerciasis and optic atrophy
in the savannah area of Ghana. Trop Geog. Med.
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17. Ukety T, Nyathirombo A, Watmon B, Habomugisha P
(2007). Evaluation of Onchocerciasis treatment
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18. Fuglsang H, Anderson J. In: WHO (1987) Expert
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Organisation. Technical Report series. 752, pp. 66.
19. Ogunrinade A, Boakye D, Merriweather A, TR.
Unnasch. Distribution of blinding and non blinding
onchocerca volvulus in Nigeria. http://www.jstor.org
20. Kocur Ivo. What is new at the back of the eye?
Comm Eye Health. 2006; 19; (57); 1-3.

CONCLUSIONS AND RECOMMENDATION

The results of this study indicate that the onchocerciasis
in Pader district is a blinding type. Semi-annual
Community Directed Treatment with Ivermectin
(CDTI) by the Ministry of Health is recommended.

ACKNOWLEDGMENTS
We extend our sincere appreciations to ENVISION/RTI
Neglected Tropical Disease Control Programme for the
financial support for the field investigations, the African
Programme for Onchocerciasis Control and the WHO
country office (Uganda) for supporting the REMO
survey, Pader district leadership and the communities
in the surveyed parishes. We are also indebted to the
following team members whose extraordinary efforts
made the study a success: E Tukesiga, B.V Abwang,
S.W Oyet, J. Luciyamoi, P. Odonga and Buyinza.
Further appreciation to the following institutions and
Officers for releasing their staffs to participate in
the survey: District Health Offices (Pader, Lamwo,
Mbarara and Kabarole) and Gulu Regional Referral
Hospital.

REFERENCES
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Kitgum and Pader districts, Northern Uganda.
(Unpublished document).

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