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Onchocerciasis.

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Clinical review

Science, medicine, and the future

Onchocerciasis
Achim Hoerauf, Dietrich W Büttner, Ohene Adjei, Eric Pearlman

Endosymbiotic Wolbachia bacteria in the worms are targets for a new therapeutic approach

Onchocerciasis, or river blindness, caused by the filaria Bernhard Nocht

Institute for
Onchocerca volvulus, affects more than 17 million Summary points Tropical Medicine,
people in Africa, Latin America, and Yemen. The Department of
microfilaricidal agent ivermectin is the principal means Helminthology,
Onchocerciasis is a major cause of blindness Bernhard-Nocht-Strasse
of controlling the disease, through mass treatment. 74, 20359
Wolbachia endosymbiotic bacteria in filarias have Current strategies rely on mass distribution of Hamburg, Germany
emerged as a new target for treatment with drugs that ivermectin by a community directed distribution
Achim Hoerauf
head of department
lead to long term sterilisation of adult female filarias. system Dietrich W Büttner
Participants at recent international meetings have professor emeritus
agreed that anti-Wolbachia chemotherapy with doxycy- New chemotherapeutic strategies need to be Departments of
cline (currently for six weeks) could be used to treat developed to kill adult worms or sterilise them in Medicine and
infected individuals. This approach holds promise for the long term Ophthalmology,
Case Western
new developments based on registered antibiotics that Reserve University
are affordable in resource poor settings, as extensive Wolbachia symbiotic endobacteria in filarias are SOM W137, 2109
registration processes are not needed. Recent experi- Adelbert Road,
essential for fertility and offer novel targets for Cleveland, OH
mental findings also indicate that endotoxin-like treatment 44106, USA
molecules from Wolbachia have a role in the patho- Eric Pearlman
genesis of the disease and in adverse reactions after Anti-wolbachial treatment with 100 mg/day associate professor
treatment. doxycycline for six weeks can be used to treat Department of
onchocerciasis Microbiology,
School of Medical
Methods Wolbachia have been implicated in the induction
Sciences, University
of Science and
This review is based on information from World of adverse effects of microfilaricidal drugs and Technology,
Kumasi, Ghana
Health Organization publications on onchocerciasis1 2; may have a role in the development of pathology,
Ohene Adjei
on recent conferences, such as the WHO-cosponsored including keratitis professor
Hamburg conference on filariasis in September 2001 Correspondence to:
and the conference on the eradicability of onchocer- A Hoerauf
ciasis organised by the Carter Center and the WHO in hoerauf@bni.
chronic dermatitis and skin atrophy, lymphadenitis
uni-hamburg.de
Atlanta, USA, in January 20023 4; and on our and fibrosis, and ocular inflammation that can lead to
experimental work and human trials in Ghana. We also blindness (fig 1). BMJ 2003;326:207–10
used recent literature on the topic. Major steps have been taken towards control of
onchocerciasis, mainly owing to successful pro-
grammes involving active partnership between the
Current concepts of control and
WHO or Pan American Health Organization and vari-
treatment ous donor organisations (box 1 and fig A on bmj.com).6
Onchocerciasis is the second most common cause of Mass distribution of the microfilaricidal drug ivermec-
preventable blindness in sub-Saharan Africa; it has an tin is the principal intervention in onchocerciasis con-
estimated prevalence of 500 000 with visual impair- trol.7 However, recent endemicity suggests that, at least
ment and 270 000 with blindness.2 The infection is in Africa, this approach may not stop transmission8 9
transmitted by Simulium spp blackflies, which transfer and that in areas where interruption of transmission
infective larvas during a meal of blood. These larvas has been achieved by vector control the infection will
mature to female and male worms within a year and be reimported by (re)migration of people who still
are located in subcutaneous nodules (oncho- carry the infection.4 Ivermectin, although it acts rapidly
cercomas). The females produce millions of micro- to reduce the number of skin microfilarias, depletes
Two extra figures
filarias (first stage larvas) during their lifetime, which them for only a few months, after which microfilarias and additional
lasts up to 14 years.5 The microfilarias induce the reappear at levels of 20% or more of pretreatment references appear
pathology characteristic of the disease, including numbers within a year.10 This microfilarial density on bmj.com

BMJ VOLUME 326 25 JANUARY 2003 bmj.com 207

Clinical review

nematode that causes onchocerciasis. They belong to

Box 1: Programmes executed by the WHO for the elimination of the order of Rickettsiales and are found in the body
onchocerciasis as a public health problem wall (the hypodermis), in oocytes, in all embryonic
stages, and in microfilarias (fig 2). Wolbachia spp in
Onchocerciasis control programme in west Africa (1974-2002)
filarias seem to have evolved as symbionts essential for
Approach—Control of the blackfly vectors by application of insecticide in
savannah areas, combined in recent years with annual mass chemotherapy fertility of their nematode hosts and are transmitted
with ivermectin; or, in areas of low transmission and community transovarially to the next worm generation, in a simi-
microfilarial loads, ivermectin treatment up to three times a year lar way to mitochondria. Antibiotics have been used to
Achievements—High level of elimination of transmission in savannah areas deplete the endosymbionts from filarias and show the
African programme for onchocerciasis control (1995-2007) mutualistic symbiosis between filarial Wolbachia and
Approach—Reduction of morbidity and transmission by annual mass their hosts. Depletion of Wolbachia resulted in the dis-
chemotherapy with ivermectin in all hyperendemic and mesoendemic areas ruption of embryogenesis in female worms.13 14 A par-
( > 30% prevalence) tial macrofilaricidal activity has also been reported in
Achievements—Reduction of morbidity in areas where programme has been bovine onchocerciasis (O ochengi).15 These effects were
implemented strictly associated with depletion of the bacteria and
Onchocerciasis elimination program of the Americas (1993-no limit) were not observed in a filarial species that is devoid of
Approach—Reduction of morbidity and interruption of transmission by Wolbachia. So far, tetracyclines, rifampicin, and chlor-
semi-annual mass chemotherapy with ivermectin in all endemic areas amphenicol have shown activity against Wolbachia in
Achievements—Reduction of transmission in areas where programme has vivo,13,w1-3 and azithromycin has shown in vitro
been implemented; interruption of transmission in some areas (possibly in
part due to the lower transmission effectiveness of the New World vectors)
activity.w4
The fact that doxycycline is already registered
allowed for a quick transition to phase IIa studies on
seems to be sufficient for transmission to continue.11 human onchocerciasis, which have been carried out in
The reason for this rather limited effect of ivermectin is Ghana over the past three years. Doxycycline (100
that it does not kill the long lived adult worms and that mg/day) was given to 63 patients for six weeks under
its embryocidal activity seems to be mainly restricted to daily supervision by a physician. Activity of doxycy-
the late stages of microfilarial development, leaving cline against Wolbachia and adult worms was assessed
early embryogenesis intact.5 Studies using albendazole from extirpated onchocercomas. Immunohistology
showed only a very transient effect on early with antibodies to Wolbachia proteins was used to
embryogenesis.10 Thus newly infected people will con- assess the presence or absence of Wolbachia and moni-
tinue to enter the transmission cycle, and worldwide tor changes in embryogenesis (see fig 2). Nodules
elimination of onchocerciasis may remain a distant from 36 patients not treated with doxycycline served
goal not achievable without better drugs. Furthermore, as controls.
should resistance to ivermectin arise in human Administration of 100 mg/day doxycycline for six
onchocerciasis, as seen with intestinal helminths in weeks led to depletion of Wolbachia followed by an
animals,12 control activities would be severely compro- interruption of embryogenesis in worms, which could
mised. be observed for 18 months.16 17 In further trials using
Thus for both individual and community based doxycycline at 200 mg/day for four or six weeks, inter-
treatment a chemotherapeutic approach that has a ruption of embryogenesis was observed for 24 months
more sustained effect than ivermectin on microfilarial (Büttner and Hoerauf, unpublished data). This is the
levels is needed. The ideal agent would have a deleteri- longest period of sterility of female worms ever
ous effect on the adult filarias. achieved by an antifilarial drug without severe side
effects. Consistent with the blockade of embryogenesis,
after additional treatment with ivermectin more than
Wolbachia endobacteria—new targets for 90% of the patients who had received doxycycline
chemotherapy showed an absence of microfilaridermia after 18
Wolbachia are bacterial symbionts of the major human months, and the remaining patients showed very low
filarias, including Onchocerca volvulus, the parasitic numbers of microfilarias. In contrast, patients treated
with ivermectin alone showed an increase in micro-
filarial counts as early as four months after administra-
tion of ivermectin.17
Preliminary results with other doxycycline regi-
mens indicate that
x 100 mg or 200 mg doxycycline per day for two
weeks does not eliminate the endobacteria or interrupt
embryogenesis
x 200 mg doxycycline per day for four weeks may
have the same efficacy as l00 mg for six weeks (Hoerauf
and Büttner, unpublished data).
Wolbachia have emerged as a target for a
chemotherapy that fulfils the priority research
objective of long term sterilising activity. The long
period of treatment (four weeks or more) and the
known contraindications to doxycycline (pregnant or
Fig 1 Major manifestations of onchocerciasis: chronic lichenification with papular dermatitis breastfeeding women, children up to 9 years of age)
(left); sclerosing keratitis (right) preclude its application for mass treatment at the

208 BMJ VOLUME 326 25 JANUARY 2003 bmj.com

 Clinical review

inflammatory response. However, a recent study

showed a significant association between adverse reac-
tions after microfilaricidal treatment and elevated
concentrations of Wolbachia DNA.19 Neutrophil
recruitment to onchocercomas seems to depend
almost exclusively on the presence of Wolbachia in the
worms, as few neutrophils are detected at these sites in
people treated with doxycycline.20 In addition, in vitro
and in vivo studies have shown that neutrophils
participate in the attack on microfilarias in concert
with eosinophils and macrophages (fig B on bmj.com).
Whereas the accumulation and activation of eosi-
nophils seem to be triggered by filarial products, the
role of neutrophil recruitment is again dependent on
Wolbachia, and the activity of macrophages seems to
depend on molecules derived from both filarias and
Wolbachia.
A recent study clearly showed that endotoxin-like
products of Wolbachia constitute a major proinflamma-
tory stimulus in the eye. The study used a well
established mouse model, in which parasite antigens
are injected directly into the corneal stroma, and
measured the effect on corneal inflammation (keratitis)
by in vivo scanning confocal microscopy, which meas-
ures corneal thickness and haze, and by infiltration of
neutrophils to the corneal stroma.21 Keratitis was
Fig 2 Transverse sections of female Onchocerca volvulus worms
showing the effect of doxycycline treatment on Wolbachia
induced by extracts of O volvulus worms recovered
endobacteria (visualised by staining with antibodies against bacterial from untreated patients but not by worms from
heat shock protein-60) and on worm embryogenesis. (Top) patients after depletion of Wolbachia with doxycycline.
Onchocercoma from an untreated patient with worms containing Further molecular analysis implicated bacterial
numerous endobacteria (red, arrow) and intact embryogenesis lipopolysaccharide-like molecules in this process,
(o=oocytes; m=morulae; cm=coiled microfilarias; sm=stretched
microfilarias) (x90). (Bottom) Onchocercoma from a patient 11 mediated through its receptor on mammalian cells,
months after treatment for six weeks with doxycycline (100 mg/day); Toll-like receptor 4.22 The authors concluded that the
worms without bacteria; embryos (e) are degenerated. The physical presence of neutrophils in the corneal stroma,
arrowhead depicts staining of mitochondria (smaller than the
bacteria, different location) by anti-hsp-60 antibodies (x55)

moment. Further research is needed to shorten the

length of the current regimen (potentially with other
antibiotics or combinations). However, individual
treatment of people with imported infection or those
leaving an endemic area for a long time constitutes an
indication for doxycycline (six weeks at 100 mg/day),
as agreed at the conferences in Hamburg and
Atlanta.3 4 Other indications could be in formerly
endemic areas where a high level of control has
already been achieved and re-emergence should be
prevented.

Wolbachia as inducers of pathology

Clinical disease of the skin and the eye is associated Fig 3 The role of Wolbachia in the pathogenesis of river blindness
with microfilarias. The presence of live microfilarias at (murine model). Subcutaneous immunisation with Onchocerca
either site does not seem to be associated with the volvulus antigens, which is a model for chronic infection, stimulates
development of much pathology. However, when the the adaptive arm of the immune system, resulting in a predominant
Th2 response, with elevated interleukin-4, interleukin-5, eosinophilia,
microfilarias die, especially after chemotherapy, the and parasite-specific antibodies. After injection of parasite antigens
host response to degenerating worms can result in into the cornea, production of neutrophil and eosinophil chemokines
severe inflammatory responses that lead to progressive is upregulated in the cornea, and expression of vascular adhesion
loss of vision and ultimately blindness. This was seen molecules (PECAM-1 and ICAM-1) on limbal vessels is elevated.
Neutrophils and eosinophils are then recruited to the corneal stroma
when patients were treated systemically with diethyl-
in a biphasic manner, with neutrophils infiltrating within 24 hours
carbamazine, when the side effects, termed the Mazzo- and eosinophils predominating after 72 hours. The physical presence
tti reaction, could be especially severe.2 In contrast, of these cells, combined with degranulation and release of cytotoxic
after treatment with ivermectin microfilarias migrate to mediators, leads to disruption of normal corneal function, loss of
the lymph nodes and limited clinical pathology corneal clarity, and visual impairment. Lipopolysaccharide-like
molecules from Wolbachia endobacteria seem to induce expression
occurs.18 of chemotactic cytokines and vascular adhesion molecules that
Until recently filarial products themselves were mediate neutrophil recruitment to the corneal stroma. Adapted from
thought to be the major stimulus for the underlying Kaifi et al23

BMJ VOLUME 326 25 JANUARY 2003 bmj.com 209

 Clinical review

cline, the advantages of the approach targeting

Box 2: Wolbachia derived immunopathological Wolbachia could outweigh its inherent problems. This
mechanisms of onchocerciasis novel development is in the early stages, and several
• Eosinophils, macrophages, and neutrophils are compounds and regimens await testing in the field,
involved in the killing of microfilarias either for treatment or for mediating pathology.
• Accumulation and activation of neutrophils depend Further research may provide better regimens, not
on Wolbachia endobacteria only for onchocerciasis but also for lymphatic filariasis,
• Wolbachia may be associated with severity of adverse where Wolbachia may also have a role in adverse
reactions after chemotherapy of onchocerciasis reactions after chemotherapy.24,w5
• Wolbachia are major triggers of keratitis in a mouse
model Funding: European Commission (grants ICA4-CT-1999-10002
• Wolbachia, in addition to being targets for and ICA4-CT 2002-10051), German Research Foundation
chemotherapy of onchocerciasis, could evolve into (DFG, grants Ho 2009/1-3 and 2009/5-1), Wellcome Trust
targets for mediating disease and adverse reactions (grant 062680), and Caritas Charity. Keratitis studies were
funded by NIH grant EY10320 (EP).
Competing interests: None declared.

together with release of neutrophil granular products

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and the presence of eosinophils, will disrupt normal sis. World Health Organ Tech Rep Ser 1987;752:1-167.
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reactions to filarial chemotherapy are associated with the release of Wol-
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210 BMJ VOLUME 326 25 JANUARY 2003 bmj.com

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