Mpox remains endemic in the Democratic Republic of the Congo (DRC), where co-endemic infections and non-communicable comorbidities may influence disease severity and clinical outcomes. However, data on associated factors of adverse outcomes among hospitalised adults with mpox in African settings remain limited. This study aimed to describe the clinical profile of adults hospitalised with mpox in South Kivu Province, eastern DRC, and to explore associations between selected comorbid conditions, including HIV infection, malaria, and hyperglycaemia, and mpox disease severity, mortality, and hospitalisation duration. We conducted a multicentre retrospective observational study among adults admitted to five mpox treatment centres in South Kivu Province, DRC, between January 2024 and December 2025. Demographic, clinical, and laboratory data were extracted from routine hospital registers. Mpox disease severity (available only for a subset of participants) was classified according to WHO criteria. Participants included adults with suspected, probable or laboratory-confirmed mpox according to WHO case definitions in use during the study period. In addition to mpox disease severity, outcomes of interest included in-hospital mortality and duration of hospitalisation. Multivariable regression models were used to explore associations between selected comorbidities and clinical outcomes after adjustment for age and sex. Among 652 hospitalised adults included in the analysis, the median age was 26 years (IQR 21.0-35.0), and 383/652 (58.7%) were female. Among patients with recorded severity data (n = 104), moderate or severe mpox was documented in 88/104 (84.6%) patients. Overall mortality was 14/645 (2.2%). HIV infection was identified in 5 of the 71 participants tested (7.0%). Among participants with available test results, HIV infection appeared to be associated with higher mpox severity and mortality. Increasing age, but not HIV infection, malaria, or glycaemic status, was associated with longer hospitalisation. Because laboratory investigations were performed in only a subset of participants and missing data were substantial, these findings should be interpreted cautiously and considered exploratory. Prospective studies incorporating systematic laboratory testing and standardised clinical data collection are needed to better define factors associated with severe mpox in endemic African settings.

BACKGROUND:The Kakoi-Koda focus in Ituri Province was historically hyperendemic for onchocerciasis, yet screening for a recent trial suggested a marked decline, including in Logo Health Zone, which had never received routine ivermectin. We explored whether this decline extended across the focus and how infection indicators corresponded spatially with ivermectin delivery, entomological observations and deforestation. METHODOLOGY:We conducted a scoping evidence synthesis of epidemiological, programmatic, entomological and geospatial sources. Against a 2003 nodule-mapping baseline, change was assessed from repeated cross-sectional moxidectin trial screenings in 2010-11 and 2021-2023, which applied the same four-skin-snip protocol to community-recruited residents aged ≥12 years. Anti-Ov16 serology (2015-21), two-skin-snip surveys (2015/17), exploratory blackfly observations (2009-18) and remotely sensed tree-cover loss (2001-24) provided further contextual evidence. PRINCIPAL FINDINGS:Between the two trial screenings, microfilarial prevalence significantly declined from 79.0% to 9.0% (Draju) and 68.9% to 8.6% (Kanga) in Logo, similar to declines observed in villages of Nyarambe Health Zone (72.2% to 2.9%), which received routine ivermectin for lymphatic filariasis. Mean infection intensity mirrored this pattern, from 17-26 to 1 microfilariae per milligram of skin in Logo, and 11 to 0.4 in Nyarambe. Seroprevalence in children aged 3-10 years from 2016 onward was low (0-5%), geographically circumscribed and broadly concordant with the skin-snip spatial pattern. Opportunistic blackfly collections and breeding-site prospections detected Simulium dentulosum and S. vorax as the current anthropophagic species, with no evidence of S. neavei after 2009. Extensive dense forest loss (75-90% in historically hyperendemic Logo) and canopy opening are consistent with a shift from crab-associated S. neavei habitats towards more open-habitat vectors, providing a plausible ecological mechanism. SIGNIFICANCE:Parasitological, serological, entomological and geospatial evidence consistently indicates substantial declines in O. volvulus infection indicators across Kakoi-Koda, compatible with reduced transmission. Residual positive indicators were spatially circumscribed, including in Logo where no routine ivermectin was delivered. Whether the current simuliid species can sustain transmission above elimination thresholds remains uncertain. Standardised, representative surveys in the Muda/Kuda and Lebu River basins are warranted to guide decisions on starting and stopping ivermectin delivery.

Mpox-associated ocular disease, including keratitis, is an emerging, vision-threatening complication. Management is challenging because no anti-viral therapy has yet been approved to prevent permanent corneal scaring or blindness. We describe a 43-year-old female Ugandan health worker who acquired a Clade Ib mpox infection following occupational exposure during clinical examination of a patient with confirmed mpox attending a health facility in Kampala, Uganda. She developed severe ulcerative keratitis, with persistent epithelial defects and progressive stromal involvement despite standard-of-care treatment, including topical trifluridine and supportive therapy. Diagnostic confirmation of mpox was made by real-time polymerase chain reaction (PCR) from lesion swabs, and Clade Ib was identified. The keratitis remained active and vision-threatening for more than four months after symptom onset. Because of ongoing deterioration and high risk of irreversible vision loss, the treating team initiated topical cidofovir 0.5

BACKGROUND:Despite over two decades of Community-Directed Treatment with Ivermectin (CDTI), onchocerciasis transmission persists in localized pockets in Ghana, particularly in the Kwanware-Ottou community within the Wenchi Health District. This study trialled a scalable approach to identifying context-specific barriers and solutions for improving CDTI effectiveness. METHODOLOGY/PRINCIPAL FINDINGS:A mixed-methods approach was employed, including Geographical Information System mapping, community consultation, census and treatment coverage evaluation, and qualitative assessments. These informed the participatory development of an Action Plan, which was implemented and evaluated across three sub-districts. Key challenges identified and addressed included poor data quality, high population mobility, remote settlements with accessibility issues, limited awareness, and inadequate number and deployment of community drug distributors. As a result, therapeutic coverage increased from 70.8% to 88.2. Seven out of eight communities with pre-intervention coverage below the recommended 65% threshold not only achieved but exceeded this target. Ultimately, all communities met the coverage goal. The intervention also improved data accuracy and quality, community engagement, and adherence to directly observed treatment, while addressing systemic gaps in CDTI delivery. CONCLUSIONS/SIGNIFICANCE:This study demonstrates that a coordinated, locally adapted stimulus package can significantly enhance CDTI performance in areas of persistent onchocerciasis transmission. The approach presents a scalable model for similar endemic settings and aligns with the World Health Organization's 2021-2030 Roadmap for the elimination of Neglected Tropical Diseases.

Background Despite more than 27 years of ivermectin mass drug administration (MDA), onchocerciasis transmission persists in the Kwanware-Ottou focus within the Wenchi Health District of Ghana. This study examined participation in ivermectin MDA over time in this transmission focus.Methods In March 2024, two months after MDA using the community-directed treatment with ivermectin (CDTI) approach, settlements within Kwanware-Ottou focus were identified through community consultations and satellite imagery. A census was then conducted integrating an ivermectin treatment coverage evaluation survey (CES) to evaluate community participation in CDTI. Data were cleaned using STATA and analysed in R. Descriptive statistics, multiple logistic regression, and ordinal logistic regression were conducted to examine factors associated with point and effective participation in CDTI. Point participation is the percentage of individuals aged 15 + who took ivermectin during the last CDTI, while effective participation refers to those who have taken it at least ten times in past rounds. Pearson correlation was used to assess the relationship between participation and infection prevalence.Results Nineteen settlements were identified, with an overall point participation of 80.3% (n = 1461 participants; 95% Confidence Interval, CI:78.6 - 82) for the preceding CDTI. However, 10 settlements had coverage below 80%. Effective participation was only 53.5% (n = 974; CI: 51.2 -55.9), well below the recommended 80%. Participation was influenced by factors such as age, occupation, ethnicity, remoteness, length of stay in the settlement, and mobility (migration). Effective participation was correlated with infection levels, with correlation coefficients of -0.74 for microfilariae prevalence and -0.79 for anti-Ov16 seroprevalence, indicating a strong inverse relationship.Conclusion High point participation masks low effective participation and insufficient subdistrict geographical coverage. Conducting exhaustive CES in delineated foci is essential for evaluating CDTI performance, tailoring and strengthening CDTI, and informing alternative strategies to interrupt onchocerciasis transmission. This approach has contributed to effective, context-specific strategies to interrupt transmission in Wenchi and beyond.

With several international outbreaks ongoing, mpox-related eye disease is increasingly detected, yet data on its prevalence remain limited. We conducted a descriptive cross-sectional study in four health zones in South-Kivu Province, Democratic Republic of the Congo, between November 1, 2024 and January 31, 2025, to describe the clinical features of mpox-related ophthalmic disease in hospitalized patients during the ongoing clade Ib outbreak. Routine ophthalmic examination was performed in laboratory-confirmed hospitalized mpox patients. The assessment included visual acuity measurement, inspection of eyelids and ocular surface with a magnifying glass, portable slit lamp biomicroscopy of the anterior segment, and ophthalmoscopy. We examined a total of 366 patients, of whom 210 (57.4%) were male. The median (IQR) age was 8 (4-16) years, 260 (71%) of the patients were younger than 15, and 168 (45.8%) were under 5. Ocular symptoms and disease were recorded in 190 (51.9%) patients. The most common ocular symptom was redness (51.9%), followed by pain (20.0%), itching (18.3%), and conjunctival discharge (16.7%). Conjunctivitis was observed in 113 (30.9%) patients. Other manifestations included blepharoconjunctivitis (7.4%), blepharitis (5.2%), and keratoconjunctivitis (3.3%). Ulcerative and non-ulcerative keratitis were present in 2.5% and 2.2% of the patients, respectively. Two (0.6%) HIV-positive patients had herpes zoster ophthalmicus. Visual impairment was recorded in 5.7% and blindness in 2.5% of the patients. Ophthalmologic manifestations were common during hospitalization in this group of patients. The early occurrence of ophthalmic manifestations requires early ophthalmic assessment for timely diagnosis and treatment to achieve better outcomes. Outbreak frontline healthcare workers should be alert of ocular symptoms such as redness, pain, sensitivity to light, and tearing in both suspected and laboratory-confirmed cases and promptly initiate an ophthalmic evaluation.

BACKGROUND:Despite more than 27 years of ivermectin mass drug administration (MDA), onchocerciasis transmission persists in the Kwanware-Ottou focus within the Wenchi Health District of Ghana. This study examined participation in ivermectin MDA over time in this transmission focus. METHODS:In March 2024, two months after MDA using the community-directed treatment with ivermectin (CDTI) approach, settlements within Kwanware-Ottou focus were identified through community consultations and satellite imagery. A census was then conducted integrating an ivermectin treatment coverage evaluation survey (CES) to evaluate community participation in CDTI. Data were cleaned using STATA and analysed in R. Descriptive statistics, multiple logistic regression, and ordinal logistic regression were conducted to examine factors associated with point and effective participation in CDTI. Point participation is the percentage of individuals aged 15 + who took ivermectin during the last CDTI, while effective participation refers to those who have taken it at least ten times in past rounds. Pearson correlation was used to assess the relationship between participation and infection prevalence. RESULTS:Nineteen settlements were identified, with an overall point participation of 80.3% (n = 1461 participants; 95% Confidence Interval, CI:78.6 - 82) for the preceding CDTI. However, 10 settlements had coverage below 80%. Effective participation was only 53.5% (n = 974; CI: 51.2 -55.9), well below the recommended 80%. Participation was influenced by factors such as age, occupation, ethnicity, remoteness, length of stay in the settlement, and mobility (migration). Effective participation was correlated with infection levels, with correlation coefficients of -0.74 for microfilariae prevalence and -0.79 for anti-Ov16 seroprevalence, indicating a strong inverse relationship. CONCLUSION:High point participation masks low effective participation and insufficient subdistrict geographical coverage. Conducting exhaustive CES in delineated foci is essential for evaluating CDTI performance, tailoring and strengthening CDTI, and informing alternative strategies to interrupt onchocerciasis transmission. This approach has contributed to effective, context-specific strategies to interrupt transmission in Wenchi and beyond.

Background Mpox-associated ocular disease, including keratitis, is an emerging, vision-threatening complication. Management is challenging because no anti-viral therapy has yet been approved to prevent permanent corneal scaring or blindness. Case presentation We describe a 43-year-old female Ugandan health worker who acquired a Clade Ib mpox infection following occupational exposure during clinical examination of a patient with confirmed mpox attending a health facility in Kampala, Uganda. She developed severe ulcerative keratitis, with persistent epithelial defects and progressive stromal involvement despite standard-of-care treatment, including topical trifluridine and supportive therapy. Diagnostic confirmation of mpox was made by real-time polymerase chain reaction (PCR) from lesion swabs, and Clade Ib was identified. The keratitis remained active and vision-threatening for more than four months after symptom onset. Because of ongoing deterioration and high risk of irreversible vision loss, the treating team initiated topical cidofovir 0.5% ophthalmic drops under emergency compassionate use. Subsequent improvement included epithelial closure, decreased stromal inflammation, and visual recovery after 8 weeks of treatment and has since remained stable for to date. Conclusions Topical cidofovir 0.5% may provide therapeutic benefit in severe, refractory mpox keratitis when trifluridine fails, and when no other effective, approved alternative exists. Controlled clinical evaluation and structured compassionate-use frameworks for cidofovir are urgently warranted given the risk of permanent blindness in mpox keratitis.

INTRODUCTION:Onchocerciasis, commonly known as river blindness, is a parasitic disease caused by Onchocerca volvulus affecting millions predominantly in sub-Saharan Africa. Robust epidemiological evidence points to a clinical relationship between onchocerciasis and epilepsy, a condition termed onchocerciasis-associated epilepsy (OAE). Despite extensive research and various successful elimination programmes over the past decades, the pathogenesis of OAE is still unknown. Current hypotheses propose that O. volvulus microfilaria, their excretory-secretory products or the newly discovered filarial O. volvulus RNA virus 1 (OVRV1) virus may traverse the blood-brain barrier, triggering seizures or immune responses that result in neurological damage. However, direct evidence of microfilaria or their DNA in cerebrospinal fluid (CSF) or brain tissue remains elusive, likely due to immune-mediated parasite clearance. Additionally, investigations into the potential neurotoxicity of these novel filarial viruses have yet to be pioneered. METHODS AND ANALYSIS:This prospective cohort study will involve 100 ivermectin-naïve children aged 2-5 years, recruited from rural communities in the Aketi health zone, located in the Democratic Republic of Congo. This region is known to be an onchocerciasis-endemic area with a high prevalence and transmission of OAE, despite years of community-directed treatment with ivermectin. Lumbar punctures (LP) will be performed in children presenting with complex febrile seizures according to WHO's paediatric guidelines. CSF samples will be examined for white blood cells, protein levels, glycorrhachia, microfilaria, OVRV1 and O. volvulus biomarkers. Children will be followed annually, monitoring the development of epilepsy and O. volvulus infection. This approach aims to elucidate the presence of O. volvulus and OVRV1 in the brain and their role in the pathogenesis of epileptic seizures and the myriad of clinical symptoms observed in OAE. ETHICS AND DISSEMINATION:The protocol has been approved by the Ethics Committee of the University of Kisangani (UNIKIS/CE/KGB/001/2025) and the University of Antwerp (project ID 7323-Edge n/a-BUN B3002025000078). Written informed consent will be obtained from all parents and/or legal guardians of children for whom an LP is considered. Findings will be disseminated at national and international levels via meetings and peer-reviewed open-source publications. Study data will be stored in an open repository. TRIAL REGISTRATION NUMBER:Pan African Clinical Trials Registry (PACTR202507670131109).

Background Severe mpox is increasingly reported in people living with HIV (PLHIV). While immune reconstitution inflammatory syndrome (IRIS) is well-characterised in other opportunistic infections, its role in the acute clinical course of mpox remains poorly understood. Case presentation A 42-year-old man from eastern South Kivu, Democratic Republic of the Congo (DRC), with newly diagnosed HIV initiated tenofovir/lamivudine/dolutegravir. Two weeks later, he developed severe disseminated clade I mpox, confirmed by PCR, with more than 250 polymorphic lesions. Around day 7 of admission, while afebrile, he experienced paradoxical clinical worsening with confluent hemorrhagic and necrotic plaques, which were highly suggestive of mpox-associated IRIS. A pragmatic management protocol consisting of a 6-week tapered course of oral prednisone, broad-spectrum oral antibiotics (levofloxacin and clindamycin), high-dose acyclovir, and supportive care led to progressive skin healing and clinical recovery while ART was continued. He was discharged after 62 days at the family's request. Unfortunately, 3.5 weeks post-discharge, he died at home following the application of traditional topical preparations to residual lesions. Conclusions This case highlights the need to consider mpox-associated IRIS in the differential diagnosis of unexplained clinical worsening of mpox in PLHIV who recently initiated ART. Although definitive confirmation of IRIS was not possible because of limited immunological investigations, the temporal association with ART initiation and the clinical course were consistent with this diagnosis. This case underscores the need for standardized diagnostic criteria, prospective evaluation of adjunctive anti-inflammatory therapies, and strengthened post-discharge community follow-up in resource-limited settings.

Background: Onchocerciasis remains a public-health challenge in the Democratic Republic of the Congo (DRC). The Kakoi-Koda focus, Ituri Province, exhibited high endemicity in the early 2000s and received community-directed treatment with ivermectin (CDTI) in some health zones (e.g., Nyarambe), but not in others (e.g., Logo). Moxidectin clinical trials were conducted in these health zones, alongside onchocerciasis-associated epilepsy studies.  Methodology: We synthesised epidemiological (including nodule prevalence), entomological and CDTI programmatic data. We collated anti-Ov16 serological data from epilepsy-related studies (community, cohort, case-control designs, 2015-2021) and skin-snip microscopy results from two moxidectin trial screenings (2009-2011; 2021-2023) and epilepsy-related studies (2015-2017). Geospatial analyses were used to describe land-cover change relevant to vector ecology and to identify areas with recent transmission.  Principal findings: Onchocerca volvulus transmission declined markedly over time. In CDTI-naïve Logo villages, microfilarial prevalence fell from 69-79% (first trial, 2009-2011) to 9% (second trial, 2021-2023), and mean infection intensity from 17-26 to 1 microfilariae per skin snip, similar to declines observed in Nyarambe villages under CDTI (72% to 3% and 11 to 0.4, respectively). Anti-Ov16 seroprevalence among children aged 3-10 years was low (0-5%) from 2016 onwards, and seropositivity was geographically circumscribed, mirroring contemporary skin-snip results. Human landing catches and breeding-site prospections (2015-2017) identified Simulium dentulosum and S. vorax as the current anthropophagic species, with no evidence of S. neavei after 2009. Progressive deforestation and canopy opening provide a plausible mechanism for a shift from crab-associated S. neavei habitats towards more open-habitat vectors. Significance: Consistent parasitological, serological, entomological and geospatial evidence indicates substantially reduced transmission across Kakoi-Koda, with spatially-circumscribed residual transmission. Whether the current simuliid species can sustain transmission above elimination thresholds remains uncertain. Targeted, integrated surveillance is warranted to guide CDTI and stop-CDTI decisions. The dataset assembled here can be used to inform transmission modelling of these dynamics.  ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was conducted under approvals from the Ethics Committee of the University of Antwerp (B300201525249 B300201733350), the Ethics Committee of Ngaliema Hospital, Kinshasa (P: Eth/436/2015) and the Ethics Committee of the University of Kinshasa School of Public Health (ESP/CE/013/2018). Permissions were also obtained from provincial and health-zone authorities. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The datasets generated during and/or analysed during the current study are freely available to other researchers. Please refer to the S1 Dataset and S1 Appendix.

Objectives: Mpox keratitis is a sight-threatening complication of monkeypox virus infection, yet systematic evidence on treatment outcomes remains limited. To synthesize individual patient data on the clinical characteristics, treatment approaches, and visual outcomes of mpox keratitis. Methods: A systematic review registered on International Prospective Register of Systematic Reviews. (CRD420261345543) was conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyzes 2020 guidelines. Electronic databases were searched from 1970 to 2026. Eligible studies reported at least one patient with confirmed mpox keratitis with individual treatment and outcome data. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Results: The median age was 35 years (interquartile range 28–45); 86.6% were male; 46.3% were human immunodeficiency virus-positive; and 92.5% had Clade IIb. First-line success occurred in 16 of 63 (25.4% [95% confidence interval (CI) 16.3–37.3%]), whereas 39 of 63 (61.9% [95% CI 49.6–72.9%]) were treatment-refractory. Re-epithelialization was achieved in 47 of 67 (70.1% [95% CI 58.3–79.8%]). Permanent visual impairment occurred in 16 of 62 (25.8% [95% CI 16.6–37.9%]). Immunocompetent patients had higher re-epithelialization (78.6% vs 60.0%) and lower blindness (0% vs 11.3%) than immunocompromised patients. Conclusion: Mpox keratitis is characterized by low first-line success rates, high refractoriness, and significant visual morbidity. There is a need to establish prospective surveillance registries, including pharmacokinetic studies and clinical trials of promising antivirals, to evaluate their efficacy and safety for topical use.

IntroductionOnchocerciasis is a neglected tropical disease caused by Onchocerca volvulus and is primarily controlled through mass drug administration (MDA) of ivermectin. Current diagnostic tests perform sub-optimally for onchocerciasis elimination programs. According to the WHO, a test needs a sensitivity of ≥60% and a specificity of ≥99.8% for mapping, and a sensitivity of ≥89% and a specificity of ≥99.8% for MDA stopping decisions. We assessed the performance of the commercially available Ov16 SD Bioline rapid diagnostic test (RDT) and three novel RDTs: DDTD biplex type A, type C, and the monoplex type GADx.MethodsThe study included 319 pregnant/post-partum women in Maridi, an onchocerciasis-endemic area in South Sudan. Locally trained healthcare workers conducted RDT with whole blood and skin snip testing. Ov16 SD Bioline RDT was also performed using dried blood spots (DBS). Diagnostic performances were evaluated using three individual reference tests (anti-Ov16 ELISA, O-150 qPCR, skin snip microscopy) and two composite reference standards. DBS were tested for Mansonella spp. using qPCR to account for potential false positives.ResultsAnti-Ov16 ELISA detected O. volvulus antibodies in 49.6% (123/248) participants, while O. volvulus infection was documented by skin snip microscopy in 31.9% (46/144) participants and in 41.8% (50/141) by qPCR. Mansonella spp. infection prevalence was 13.4% (34/253). Monoplex RTDs (Ov16 SD Bioline, GADx) detected O. volvulus antibodies in >60%, while the biplex tests (DDTD A and C) detected 50% seropositivity. Estimated sensitivities of RDTs ranged from 69.4% (Ov16 SD Bioline) to 48.9% (DDTD A), while specificity ranged from 73.2% (DDTD C) to 42.5% (Ov16 SD Bioline).ConclusionO. volvulus and Mansonella spp. prevalence was high among pregnant and post-partum women in Maridi. The novel RDTs demonstrated sensitivities within the range of the commercially available Ov16 SD Bioline RDT, meeting the WHO threshold for onchocerciasis mapping but not for MDA stopping decisions. No RDT met the specificity threshold of 99.8%, although some exhibited slightly higher specificity than Ov16 SD Bioline RDT. This suboptimal specificity raises concerns, underscoring the need for better diagnostic tools to support onchocerciasis elimination efforts.

Background Historically, onchocerciasis has been recognised for its dermatological and ophthalmological manifestations, such as blindness. However, growing epidemiological evidence indicates that onchocerciasis is also associated with neurological complications, particularly onchocerciasis-associated epilepsy (OAE). These complications are not currently reflected in disease burden estimates and associated disability-adjusted life years (DALYs) for onchocerciasis.Main text The most recent global burden of disease estimates for onchocerciasis in 2019 reported 1.23 million DALYs without accounting for OAE. Yet, a preliminary study suggested that 128,000 years of life lost to disability (YLD, a key component of DALYs) may be attributable to epilepsy in onchocerciasis-endemic areas of East and Central Africa. This figure, which would represent over 13% of the total onchocerciasis morbidity burden and 10% of the global epilepsy morbidity burden, is likely still an underestimation. Current disability weights for epilepsy YLD estimation may not fully capture the spectrum of OAE, which often involves nodding syndrome, developmental delays, motor disabilities, cognitive impairments and stigma. In regions where access to antiseizure medication treatment is sparse, poorly controlled seizures can exacerbate disability and lead to premature mortality. Targeted integrated strategies—combining onchocerciasis control measures with improved epilepsy care—could help address these critical gaps.Conclusions Recognising OAE as part of the disease burden associated with onchocerciasis may encourage global health stakeholders to allocate resources for targeted interventions, thereby refining disease burden estimates, reducing disability, averting premature deaths and improving overall health outcomes.

Nodding syndrome (NS) for many years has been considered as a mysterious disease. Progress on NS research was finally made through multi-disciplinary and multi-country studies. NS is a form of onchocerciasis-associated epilepsy (OAE), an association which was already described in 1938. NS outbreaks appeared because of sub-optimal or absent onchocerciasis elimination programs and because people increasingly started living and farming close to blackfly breeding sites. OAE including NS is preventable by strengthening onchocerciasis elimination programs. A newly discovered Onchocerca volvulus RNA virus (OVRV1) could play a role in the pathogenesis of OAE including NS.

BackgroundPrevious studies in the Bono Region (middle belt) of Ghana have reported persistent Onchocerca volvulus infection and associated morbidities after nearly three decades of ivermectin treatment. This study aimed to assess the usability, acceptability, and cost of the Ov16 SD BIOLINE rapid diagnostic test (Ov16 RDT) in onchocerciasis surveillance activities in the middle belt of Ghana.MethodologyA cross-sectional study was conducted in 6 endemic communities in the Tain District and Wenchi Municipality. A total of 254 individuals (54% females; median age (range)=31 (5-83) years), agreed to participate in Ov16 RDT (100%), skin-snip microscopy (37%) and nodule palpation (100%). A total of 94 individuals participated in all three diagnostic tests, and post-test interviews were conducted with them, as well as with nine technicians. A cost analysis was also performed based on testing a hypothetical cohort of 400 individuals.Principal findingsSeropositivity of IgG4 antibodies against the Ov16 O. volvulus antigen was 23.6% (60/254, 95%CI = 18.8%-29.2%); microfilarial positivity 11.7% (11/94, 95%CI = 6.7%-19.8%) and nodule positivity 5.5% (14/254, 95%CI = 3.3%-9.0%). Female sex, age over 30 years, and farming occupation were all associated with higher odds of anti-Ov16 seropositivity. Among 5-9-year-olds, anti-Ov16 seropositivity was 11.1% (3/27), microfilarial positivity 23.1% (3/13) and nodule positivity 3.7% (1/27). Most participants and technicians preferred Ov16 RDT because of being less painful and invasive, easier to use and faster. Had 400 participants been tested, the total cost per individual would be US$24 (Ov16 RDT) and US$74 (skin-snip microscopy).ConclusionsOv16 RDT is more acceptable and affordable (a third of the cost) compared to skin-snipping for surveillance activities in transmission hotspots in Ghana.