BIO3207

PARASITOLOGY AND IMMUNOLOGY

Lecture 4
Parasitic helminthes and diseases
River blindness

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Helminth parasites
4.4.4. Onchocerca volvulus

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 Helminth parasites
Onchocerca volvulus
 The host fly

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 Helminth parasites
 Onchocerca volvulus (River Blindness)

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 Helminth parasites
Onchocerca volvulus
•River blindness is one of the most serious helminth diseases in Africa with
possibly 200 million people infected
•It is distributed across the continent from Senegal in the north west to
Tanzania in the East occurring on and around rivers with fast flowing white
water rapids where the vector breeds.
•It is recorded from Rwanda, Burundi, Uganda and Kenya. It is a chronic disease
(not usually fatal) with a high endeminicity and renders some areas of Africa
uninhabitable to humans.
•In parts of Ghana and Upper Volta whole villages are found where the majority
of adults are blind and have to be led around by the children.
•Apart from blindness, which does not occur in every case, it causes extreme
skin irritation and makes people’s lives a misery.
•The life cycle was first discovered in Sierra Leone (where 45 % of the rural
population is infected) by Blacklock from the Liverpool School of Tropical 5
Medicine in the early years of the 20th century.
 Helminth parasites
Onchocerca volvulus
• The disease also occurs in S. America where it is believed to have been carried
by the slave trade.
• This disease has been given a high priority by the World Health Organisation
who in 1983 began the Onchocerciasis Control Programme (OCP) in Ghana and
Upper Volta.
• The OCP is the largest vector control programme ever undertaken and has
cost hundreds of millions of dollars to date.
• The adult worms live in connective tissues below the skin or deeper in the
body and they become surrounded by a fibrous capsule or nodule secreted by
the body as part of a general inflammatory reaction designed to isolate their
intruders.
• The worms are usually in pairs inside the nodule wrapped together like a ball
of string.
• The male is 2-4 cm long and 0.2 mm in diameter, the female 60-70 cm long
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and 0.4 mm in diameter
• The life cycle (see next slide)
The life cycle

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 Helminth parasites
Onchocerca volvulus
• Throughout her life, which may last for 20 years or more, the female
produces daily thousands of microfilariae larvae which migrate out of the
nodule and into tissues.
• Many come to rest in the skin where they cause serious pathological
changes and where they are ideally placed to be picked up by the vector for
onward transmission.
• A proportion of microfilariae can enter the eye causing the blindness for
which the disease is named.
• The vector is the blackfly, Simulium damnosum, which feeds on man and
other mammals.
• The mouth parts of the blackfly are not like those of a mosquito, they are
equipped with teeth which are used to rasp a small hole in the skin of about
0.5 mm in diameter.
• A pool of blood forms in the wound from ruptured capillaries and the fly8
feeds by sucking up this blood together with any microfilariae present in
the skin.
 Helminth parasites
Onchocerca volvulus
• In the fly, the larvae leave the intestine and migrate to the muscle of the
thorax where they metamorphose over a period of 6-9 days to infective L3
larvae.
• The L3 larvae accumulate in the head of the fly and enter the proboscis ready
for onward transmission.
• Once inside another human the L3 larvae moult to L4 forms which migrate
around the body and undergo their final moult to the adult stage after a period
of 6-10 weeks.
• It takes 15-18 months for the adults to become sexually mature
• Onchocerciasis is a disease that builds up slowly over the years as a result of
repeated biting by blackflies and blindness normally occurs in adults who have
infections of many years 'standing.
 Pathology
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• Nodules containing the adult worms may be seen on the elbows, knees and
scalps but others may be more deep-seated and invisible.
 Helminth parasites
Onchocerca volvulus
• The presence of microfilariae in the skin causes severe pruritis (itching),
depigmentation in people with black skin and lichenification.
• The microfilariae, in contrast to the adults, are not very long lived and the
body reacts to dead ones with a general inflammatory reaction which is
responsible for the skin changes.
• The skin may loose its elasticity resulting in the condition known as ‘hanging
groin’ which is seen in heavily infected people in Africa.
• Enlargement of the lymph glands, scrotum and testicles also occurs giving
an appearance similar to that of elephantiasis though not as exagerated.
• Presence of microfilaria in the anterior chamber of the eye can lead to
conjunctivitis, iritis, glaucoma and corneal degeneration which may
themselves result in blindness.
• Microfilariae in the posterior part of the eye can destroy the retina and
choroid. 10
 Helminth parasites
Onchocerca volvulus
• Most of the destructive actions in the eye are due to the body’s inflammatory
reaction to dead microfilariae.
• Forest and Savannah Onchocerciasis
• There are two forms of onchocerciasis, the forest form and the savannah
form. These are both spread by Simulium damnosum, but it is believed that
the forest flies constitute a different species to the savannah flies, although
they are morphologically identical.
• For some reason blindness rates are much higher in the savanna form of the
disease and 35 % of the population in parts of Upper Volta may be blind.
 Diagnosis
• The disease can be diagnosed by taking a bloodless snip of skin and teasing it
in saline.
• Under the microscope the microfilariae are easily seen.
• A special punch has been designed to take a standard skin snip of 1 mm 11

diameter.
 Helminth parasites
Onchocerca volvulus
• The presence of more than 50 microfilariae per snip is considered to be a
heavy infection.
Treatment
• Until recently treatment of onchocerciasis was a major problem. Two
approaches were taken:
• Nodulectomy: Surgical removal of nodules containing adult worms.
Only those visible on the body surface can be removed and deeper
seated nodules still remain to carry on the infection
• Drug treatment with diethylcarbamazine (Banocide): Banocide kills
microfilariae in the skin but unfortunately leads to severe side effect
as the body reacts to the deade microfilariae and severe itching
results. Many patients refuse to take the drug for this reason
• Fortunately a new drug, Ivermectin, has been found that kills microfilariae
in the skin in a single dose and does not have these adverse side effects. 12
 Helminth parasites
Onchocerca volvulus
• Neither Ivermectin nor Banocide kill adult worms but very recently it has
been found that certain antibiotics can do so. It is thought they act by
destroying the gut flora of the adults.

 Vector Biology
• Only female Simulium damnosum feed on blood and their eggs cannot
successfully mature until they have taken a blood meal.
• The males do not live long after mating and probably never feed.
• The flies bite only in the open, they do not enter houses. Biting intensity is
greatest on cloudy days and in the early morning and evening.
• The flies shun direct sunlight and prefer to bite in the shade.
• In Africa blackflies usually bite below the waist, principally on the legs.
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• The blackfly species in South America which carry onchocerciasis bite above
the waist on the arms and head
 Helminth parasites
Onchocerca volvulus
• The number of L3 larvae in the flies can be counted and an annual
transmission potential calculated.
• This indicates the severity of transmission in any particular area and allows
a decision to be made whether expensive control operations are justified.
• The females lay their eggs under water in batches of 3-500 attached to
rocks, grass etc in fast flowing water.
• The eggs hatch in 4-12 hours and the larvae attach themselves to stones
where they feed by filtration of minute organisms from the water which
flows over the fan-shaped brushes near their mouthparts.
• It is this method of feeding that restricts blackfly breeding to rapidly
flowing water.
• The larvae can move from one feeding site to another by secreting a silken
thread attached to the rock on which they are located and drifting
downstream until hey locate another feeding site. 14

• There are five larval instars followed by pupation after 13 days.

 Helminth parasites
Onchocerca volvulus
• The adult emerge from the pupa after 2-10 days, leave the water and mate
immediately on the wing.
• The males then die or disappear (little is known of the biology of the males
but they are believed not to feed).
Control Methods
• Until mass treatment with Ivermectin became a possibility, all control effort
was directed to eradication of the vector.
• Control effort of the vector fly is directed against the larva which is
susceptible to particulate insecticide poured into the rivers in which they
breed
• The larvae filter the particle of insecticide as they would filter their natural
food and die.
• DDT was used successfully in this way to eliminate blackflies in the Nile in 15
Uganda and in streams on Mt Elgon in Kenya
 Helminth parasites
Onchocerca volvulus
Control Methods
•Temophos (Abate) a less toxic and persistent organophosphorous insecticide
was used initially.
•After some years of the programme the blackflies developed resistance to
Temophos.
•It was replaced by a toxin derived from Bacillus thuringiensis spores
•Because of the remoteness of many of the areas infested with blackflies in
West Africa the insecticide had to be delivered from helicopters which
increased the expense enormously.
•Calculating the amount of insecticide that kill the larvae in a river is a very
complicated business requiring a detailed knowledge of river flow rates and
flow volume.

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 Helminth parasites
Onchocerca volvulus
Control Methods
•Insecticides are expensive so it is essential to use the minimum amount that
will be effective.
•The OCP(onchocerciasis Control programme) programme has had
considerable success and has opened up large areas of land which were
previously abandoned for agriculture.
•Some 80, 000 km of rivers have been treated in the process.
•The original area in Ghana and Upper Volta has had to be expanded
northwards because of the problem of re-invasion by flies from areas outside
the control area. Blackflies, although small, are powerful fliers and with wind
assistance can travel distances of at least 400 km.

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Thanks for your attention
Any questions
Helminthes and Helminthiases?

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