Ecuador: Second Country to Eliminate River Blindness

Blogger’s Note: The article below originally appeared on October 8, 2014 on the Reach Beyond homepage. You may look at that story by placing the cursor over the words “Reach Beyond” above and clicking. It will take you to Reach Beyond (formerly HCJB Global.) Or you may read the same story below. More recently, Hannah Notess of Seattle Pacific University published a feature , Adios River Blindness,  on this same topic. (Photos are by Bear Guerra.) You may look at that story by using the mouse to click on the words “Adios River Blindness” above. Thanks for visiting Call of the Andes. -Ralph

Ecuador: Second Country to Eliminate River Blindness

by Ruth Pike, Ralph Kurtenbach and Harold Goerzen

Nearly four decades after the discovery of onchocerciasis (river blindness) in Ecuador, the South American country ranks second in the world after Colombia to be recognized by the World Health Organization (WHO) for eliminating this tropical eye and skin disease.

This momentous achievement was declared by Ecuadorian Health Minister Carina Vance during the opening session of the 53rd Pan American Health Organization (PAHO) Directing Council in Washington, D.C., on Monday, Sept. 29. This is in addition to an official notification from WHO Director-General Dr. Margaret Chan released a week earlier.

“Together with The Carter Center and international partners, Rosalynn and I want to congratulate Ecuador for wiping out river blindness and showing that eliminating this disease from the Americas is possible,” said former U.S. President Jimmy Carter, founder of the center that works with partners throughout Latin America to eradicate the disease.

“The elimination of onchocerciasis is another step toward reducing poverty in Ecuador, and is a significant improvement in Ecuadorians’ quality of life,” The Carter Center quoted Vance as saying. “Ecuador will continue its fight to eliminate so-called diseases of poverty to achieve a good life for all.”

River blindness is a debilitating disease caused by a parasitic worm and transmitted through bites from infected Simulium blackflies. It causes symptoms such as severe itching, disfiguring skin conditions and visual impairment, including permanent blindness.

It is rated as the second-leading infectious cause of blindness globally. More than 99 percent of those infected with the disease live in Africa, but it’s also found in tropical areas of South and Central America as well as in Yemen.

River Blindness Discovered in Ecuador

Ron Guderian

The disease was first discovered to be in Ecuador in 1976 by Dr. Ron Guderian, a clinical pathologist and missionary who had arrived in Ecuador two years earlier with his wife, Eleanor, to serve with Reach Beyond (formerly HCJB Global).

It was while seeing indigenous patients at Zapallo Grande, a Chachi village along the Cayapas River in northwestern Ecuador’s Esmeraldas province, that Guderian came across a woman with a noticeable lump on her back.

When he and his colleagues opened up the nodule, they found a long, curled threadlike worm inside that measured about 50 cm (20 inches) long. He immediately noted the similarity with a worm called Onchocerca volvulus that causes river blindness. However, the worm was believed to be found primarily in Africa.

The first evidence he found of River Blindness in Ecuador was about 20 inches long, according to Dr. Guderian.

“After the first case of river blindness was discovered, we did a small study in three Chachi villages and found that more than 60 percent of all adults were infected with Onchocerca volvulus,” Guderian related. “A meeting was called with the chief of the tribe, Pedro Tapuyo, and his council to relate what we had found.”

“After hearing the results of the study, he looked at me and said that he and his people greatly appreciated our coming to this area to help with their health problems. However, he was very saddened by the finding of this new disease—of which there was no known cure—that could, and was, causing blindness.”

The chief then challenged Guderian: “Are you going to let us die with this ‘curse,’ or are you going to seek a remedy for this disease so my children and grandchildren won’t die or go blind?”

“Because of Pedro, I took up the challenge and hence the results we have today,” Guderian recounted. “If he had not challenged us, I am not sure where we would be today.”

The discovery of the disease in Ecuador opened a new chapter of research. “First of all, we had to prove that it really was Onchocerca… and then we started searching for who had the disease and how it got to Ecuador,” Guderian said.

After being on the river for 10 months, two volunteers from Europe tested positive for onchocerciasis.

“In our discussion as to determine why they become infected so quickly, it was noted that the resident missionary, after being in the area for some 15 years, still tested negative,” he continued. “The only difference between the two groups was that the volunteers from Europe did not take chloroquine as prophylaxis against malaria.”

Preliminary studies showed that concentrations of chloroquine comparable to those found in the skin of those taking the drug as a prophylaxis was toxic to the infective form of the microfilariae (microscopic worms) that were deposited by a blackfly bite.

“This suggested that chloroquine probably played a role in protecting the resident missionary from becoming infected with river blindness,” Guderian explained.

Medical Community Acknowledges Findings

Initially encountering strong skepticism from the medical community, it wasn’t until the 1980s that Guderian’s findings were finally accepted in Ecuador and internationally. Consequently, the first confirmed case of river blindness is generally cited as that of a black male from the province of Esmeraldas. This was documented by Carvajal and Zerega in 1980 in the Revista Ecuatoriana de Higiene y Medicina Tropical (Ecuadorian Journal of Hygiene and Tropical Medicine).

In the next decade, Reach Beyond received financial and technical support from the Christian Blind Mission (CBM) in Germany for documenting and treating those with eye disease. Epidemiological research was undertaken to determine who had river blindness, how it was spread and where it was endemic.

The team discovered that Ecuador’s coastal river systems (Cayapas, Santiago and Onzole rivers) provided ideal conditions for the blackfly to breed—fast-flowing water at an altitude of 50 to 2,000 meters (160 to 6,500 feet). Consequently, it was found that 119 communities on 33 different river systems in the northern part of Esmeraldas province were affected by the disease.

The vector (insect that transmits a disease or parasite) in Ecuador, known as Simulium exiguum, is one of the most efficient onchocerciasis vectors in the Americas, presenting a particular challenge to eliminating the disease in the nation.

Guderian also identified another major obstacle to addressing river blindness—the lack of a healthcare system or hospital in the affected areas. With the help of the Vicariato Apostólico de Esmeraldas (Apostolic Vicariate of Esmeraldas), a healthcare system was set up throughout the region with the aim that “not only river blindness is addressed, but every physical need.” The healthcare system was handed over to the Ecuadorian government in 2000.

Treatment Program Begins

In 1987 the pharmaceutical company, Merck & Co., announced the massive donation of its groundbreaking medicine, ivermectin (Mectizan^®), for the treatment of onchocerciasis “to all who needed it, for as long as needed.”

The therapeutic drug, developed by Merck in the 1970s and hitting the market in 1981, proved to be effective in killing the parasitic worms that cause river blindness, shortening the lifespan of adult worms and destroying their larvae. The medication also had the secondary benefits such as getting rid of scabies, head lice and gastrointestinal roundworms.

In 1990 Ecuador received its first donation of ivermectin and initiated the National Program for Control of Onchocerciasis as a cooperative effort between Reach Beyond’s community development team and Ecuador’s Ministry of Public Health.

Three years later the Onchocerciasis Elimination Program for the Americas (OEPA) was established, a regional initiative based in Guatemala to provide technical and financial support to Latin American countries working to eradicate river blindness.

This program is sponsored by The Carter Center (which absorbed the River Blindness Foundation in 1996) and supported by a number of partners, including the U.S. Centers for Disease Control and Prevention (CDC), the Lion’s Club International Foundation and PAHO. OEPA supported national efforts to fight against river blindness in Ecuador, in line with PAHO’s goal for the region of using a strategy of mass drug administration.

Local health workers strategically chosen and trained across northwestern Ecuador were responsible for ensuring that everyone in their communities received the drug twice a year. This “horizontal-driven” approach, involving primary healthcare workers rather than outsiders to administer the medication, was key to the success of the program, explained Guderian.

He and other Reach Beyond missionaries who took part in the program also sought to share their Christian faith as they treated patients. “Our purpose obviously was not just medical,” underlined Guderian. “Our purpose was to use medicine as a tool to reach people [with the gospel].”

River Blindness Eliminated in Ecuador

By 2010, after health workers had spent thousands of hours doing research, poring over scientific data and compiling reports, it was shown that the incidence of river blindness had been eliminated across the region and transmission of the parasite had stopped.

The next step was to undergo a three-year pre-verification period during which no treatment was administered. After this period, the entire area was re-evaluated to test for reoccurrence of the disease. Based on the negative results, in July 2013 Guderian and his team applied to WHO for verification of their findings.

In May 2014 the WHO International Verification Team (IVT) undertook an assessment in Ecuador. Team members reviewed records since 1990 and interviewed those who had been involved in the treatment program.

The team also traveled three to four hours by canoe to interview and clinically examine members of the communities of El Tigre and Zapallo Grande on the Cayapas River as well as the communities of Playa del Oro and Colón Eloy on the Santiago River. At the end of their visit, the IVT presented a report of their findings, awarding official verification of elimination of river blindness to Ecuador last month.

“This is an important success story for Ecuador and for other countries that are working to eliminate onchocerciasis,” The Carter Center quoted PAHO Director Dr. Carissa Etienne as saying. “It shows what can be accomplished when countries undertake the sustained action that is needed with strong support from their governments and committed international partners.”

Global Fight Continues

Mexico and Guatemala are expected to be the next countries to attain WHO verification for elimination of river blindness followed by Brazil and Venezuela with the goal of eradicating onchocerciasis from the Americas by 2019.

For Guderian, the greatest need in the global fight against river blindness is the need for a new medication that kills not only the larvae but also the adult worms. He hopes that the success of the model used in Ecuador to eliminate river blindness may provide inspiration for other programs to eliminate dozens of other neglected tropical diseases.

Since leaving Ecuador in 1999 and moving to Washington state, Guderian has served with Medical Teams International and acts as a consultant to the Ministry of Health in Ecuador for the National Program of Elimination of Onchocerciasis in Ecuador (PNEO-E).

“When I stumbled across the first case in 1976, whoever would have thought that by the year 2014 the country would be eligible to receive verification that the disease has been eliminated,” he said.

Sources: Reach Beyond, World Health Organization, The Carter Center, Pan American Health Organization, Onchocerciasis Elimination Program for the Americas, Centers for Disease Control and Prevention, Christian Blind Mission, BMC Medicine, National Program for Control of Onchocerciasis in Ecuador, Revista Ecuatoriana de Higiene y Medicina Tropical 33

VIDEO: “Meet Raquel Lovato: Ending Onchocerciasis in Ecuador (Carter Center)” is at this Internet address: http://www.cartercenter.org/video/Default.aspx?youtube_id=4VBToapJ_5M&category=&filter=River%20blindness