Optimization of Slash and Clear Community-Directed Control of Simulium damnosum Sensu Stricto in Northern Uganda.

Onchocerciasis, caused by infection with Onchocerca volvulus, has been targeted for elimination by 2030. Currently, onchocerciasis elimination programs rely primarily on mass distribution of ivermectin. However, ivermectin alone may not be sufficient to achieve elimination in some circumstances, and additional tools may be needed. Vector control has been used as a tool to control onchocerciasis, but vector control using insecticides is expensive and ecologically detrimental. Community-directed removal of the trailing vegetation black fly larval attachment sites (slash and clear) has been shown to dramatically reduce vector biting densities. Here, we report studies to optimize the slash and clear process. Conducting slash and clear interventions at Simulium damnosum sensu stricto breeding sites located within 2 km of afflicted communities resulted in a 95% reduction in vector biting. Extending slash and clear further than 2 km resulted in no further decrease. A single intervention conducted at the first half of the rainy season resulted in a 97% reduction in biting rate, whereas an intervention conducted at the end of the rainy season resulted in a 94% reduction. Vector numbers in any of the intervention villages did not fully recover by the start of the following rainy season. These results suggest that slash and clear may offer an inexpensive and effective way to augment ivermectin distribution in the effort to eliminate onchocerciasis in Africa.

Identification of Human-Derived Attractants to Simulium damnosum Sensu Stricto in the Madi-Mid North Onchocerciasis Focus of Uganda.

Human landing collections (HLCs) have been the standard method for the collection of black flies that serve as vectors for Onchocerca volvulus, the causative agent of onchocerciasis or river blindness. However, HLCs are inefficient and may expose collectors to vector-borne pathogens. The Esperanza window trap (EWT) has been shown to be a potential alternative to HLCs for the collection of Simulium damnosum, the principal vector of O. volvulus in Africa. To improve the performance of the EWT, sweat from individuals highly attractive or less attractive to S. damnosum sensu stricto was examined by gas chromatography and mass spectroscopy. Twelve compounds were identified which were solely present or present in increased amounts in the sweat of the highly attractive individuals. Two of these compounds (naphthalene and tert-hexadecyl mercaptan) were found to be attractive to S. damnosum s.s. in behavioral assays. Traps baited with these compounds outperformed those baited with the current standard bait of worn socks. Using these newly identified compounds as baits will make the EWT more efficient in collecting vector black flies and may enhance the potential utility of the EWT as a local vector control measure.

Accelerating river blindness elimination by supplementing MDA with a vegetation "slash and clear" vector control strategy: a data-driven modeling analysis.

Attention is increasingly focusing on how best to accelerate progress toward meeting the WHO's 2030 goals for neglected tropical diseases (NTDs). For river blindness, a major NTD targeted for elimination, there is a long history of using vector control to suppress transmission, but traditional larvicide-based approaches are limited in their utility. One innovative and sustainable approach, "slash and clear", involves clearing vegetation from breeding areas, and recent field trials indicate that this technique very effectively reduces the biting density of Simulium damnosum s.s. In this study, we use a Bayesian data-driven mathematical modeling approach to investigate the potential impact of this intervention on human onchocerciasis infection. We developed a novel "slash and clear" model describing the effect of the intervention on seasonal black fly biting rates and coupled this with our population dynamics model of Onchocerca volvulus transmission. Our results indicate that supplementing annual drug treatments with "slash and clear" can significantly accelerate the achievement of onchocerciasis elimination. The efficacy of the intervention is not very sensitive to the timing of implementation, and the impact is meaningful even if vegetation is cleared only once per year. As such, this community-driven technique will represent an important option for achieving and sustaining O. volvulus elimination.

Optimization and evaluation of the Esperanza Window Trap to reduce biting rates of Simulium damnosum sensu lato in Northern Uganda.

BACKGROUND: Onchocerciasis, or river blindness, has historically been an important cause of blindness, skin disease and economic disruption in Africa and the Americas. It is caused by the filarial parasite Onchocerca volvulus, which is transmitted by black flies in the genus Simulium. Over the past decade, several international programs have been formed to control, or more recently eliminate onchocerciasis, using mass drug administration (MDA) of ivermectin. However, in many areas of Africa (particularly those which are endemic for the eyeworm, Loa loa, or where vector densities are very high) ivermectin MDA alone will not be sufficient to achieve elimination. In these situations, additional interventions may be necessary. METHODOLOGY/PRINCIPAL FINDINGS: The Esperanza Window trap (EWT), a simple trap originally developed to replace human landing collections for entomological surveillance of O. volvulus transmission was optimized, resulting in a 17-fold improvement in trap performance. The optimized trap was tested in trials in schools and in agricultural fields to determine if it could reduce vector biting locally. The traps resulted in a 90% reduction in biting in the school setting. In the field setting, results varied. In one location, the traps reduced biting by roughly 50%, while in a separate trial, the traps did not significantly reduce the biting rate. Examination of the two settings suggested that trap placement may be critical to their success. CONCLUSIONS/SIGNIFICANCE: These results suggest that the optimized EWT might be capable of reducing local vector black fly biting in areas commonly frequented by residents. Together with other recently developed methods of community directed vector control, the traps may augment ivermectin MDA, bringing the goal of onchocerciasis elimination within reach in much of Africa.

Community-directed vector control to supplement mass drug distribution for onchocerciasis elimination in the Madi mid-North focus of Northern Uganda.

BACKGROUND: Onchocerciasis a neglected tropical disease that historically has been a major cause of morbidity and an obstacle to economic development in the developing world. It is caused by infection with Onchocerca volvulus, which is transmitted by black flies of the genus Simulium. The discovery of the potent effect of Mectizan (ivermectin) on O. volvulus microfilariae and the decision by its manufacturer to donate the drug for onchocerciasis spurred the implementation of international programs to control and, more recently, eliminate this scourge. These programs rely primarily on mass distribution of ivermectin (MDA) to the afflicted populations. However, MDA alone will not be sufficient to eliminate onchocerciasis where transmission is intense and where ivermectin MDA is precluded by co-endemicity with Loa loa. Vector control will likely be required as a supplemental intervention in these situations. METHODOLOGY/PRINCIPAL FINDINGS: Because biting by the black fly vectors is often a major nuisance in onchocerciasis afflicted communities, we hypothesized that community members might be mobilized to clear the breeding sites of the vegetation that represents the primary black fly larvae attachment point. We evaluated the effect of such a community based "slash and clear" intervention in multiple communities in Northern Uganda. Slash and Clear resulted in 89-99% declines in vector biting rates. The effect lasted up to 120 days post intervention. CONCLUSIONS/SIGNIFICANCE: Slash and clear might represent an effective, inexpensive, community- based tool to supplement ivermectin distribution as a contributory method to eliminate onchocerciasis and prevent recrudescence.

The esperanza window trap reduces the human biting rate of Simulium ochraceum s.l. in formerly onchocerciasis endemic foci in Southern Mexico.

BACKGROUND: The Esperanza Window Trap (EWT) baited with CO2 and human sweat compounds is attractive to Simulium ochraceum s.l., the primary vector of Onchocerca volvulus in the historically largest endemic foci in México and Guatemala. METHODOLOGY/PRINCIPAL FINDINGS: The ability of the EWT to locally reduce numbers of questing S. ochraceum s.l. was evaluated in two formerly onchocerciasis endemic communities in Southern México. At each community, two EWTs were placed in or near a school or household and flies were collected sequentially for a total of 10 days. Black fly collections were then carried out for an additional 10 days in the absence of the EWTs. Flies were also collected outside the dwellings to control for variations in the local fly populations. When the EWTs were present, there was a significant reduction in the human biting rate at both the household and school locations at collection sites, with a greater effect observed in the schools. CONCLUSIONS/SIGNIFICANCE: These results indicate that the EWTs not only have potential as a black fly monitoring tool but may be used for reducing personal exposure to fly bites in Mesoamerica.

Elimination of Onchocerciasis from Mexico.

BACKGROUND: Mexico is one of the six countries formerly endemic for onchocerciasis in Latin America. Transmission has been interrupted in the three endemic foci of that country and mass drug distribution has ceased. Three years after mass drug distribution ended, post-treatment surveillance (PTS) surveys were undertaken which employed entomological indicators to check for transmission recrudescence. METHODOLOGY/PRINCIPAL FINDINGS: In-depth entomologic assessments were performed in 18 communities in the three endemic foci of Mexico. None of the 108,212 Simulium ochraceum s.l. collected from the three foci were found to contain parasite DNA when tested by polymerase chain reaction-enzyme-linked immunosorbent assay (PCR-ELISA), resulting in a maximum upper bound of the 95% confidence interval (95%-ULCI) of the infective rate in the vectors of 0.035/2,000 flies examined. This is an order of magnitude below the threshold of a 95%-ULCI of less than one infective fly per 2,000 flies tested, the current entomological criterion for interruption of transmission developed by the international community. The point estimate of seasonal transmission potential (STP) was zero, and the upper bound of the 95% confidence interval for the STP ranged from 1.2 to 1.7 L3/person/season in the different foci. This value is below all previous estimates for the minimum transmission potential required to maintain the parasite population. CONCLUSIONS/SIGNIFICANCE: The results from the in-depth entomological post treatment surveillance surveys strongly suggest that transmission has not resumed in the three foci of Mexico during the three years since the last distribution of ivermectin occurred; it was concluded that transmission remains undetectable without intervention, and Onchocerca volvulus has been eliminated from Mexico.

Identification of communal oviposition pheromones from the black fly Simulium vittatum.

The suite of pheromones that promote communal oviposition by Simulium vittatum, a North American black fly species, was identified and characterized using gas chromatography-mass spectrometry, electrophysiological, and behavioral bioassays. Behavioral assays demonstrated that communal oviposition was induced by egg-derived compounds that were active at short range and whose effect was enhanced through direct contact. Three compounds (cis-9-tetradecen-1-ol, 1-pentadecene, and 1-tridecene) were identified in a non-polar solvent extract of freshly deposited S. vittatum eggs that were capable of inducing the oviposition response. Electroantennography demonstrated that two of these three compounds (1-pentadecene and 1-tridecene) actively stimulated antennal neurons. Identification of the oviposition pheromones of this family may be helpful in developing control measures for nuisance black flies and for medically-important species such as Simulium damnosum sensu lato.

Identification of human semiochemicals attractive to the major vectors of onchocerciasis.

BACKGROUND: Entomological indicators are considered key metrics to document the interruption of transmission of Onchocerca volvulus, the etiological agent of human onchocerciasis. Human landing collection is the standard employed for collection of the vectors for this parasite. Recent studies reported the development of traps that have the potential for replacing humans for surveillance of O. volvulus in the vector population. However, the key chemical components of human odor that are attractive to vector black flies have not been identified. METHODOLOGY/PRINCIPAL FINDINGS: Human sweat compounds were analyzed using GC-MS analysis and compounds common to three individuals identified. These common compounds, with others previously identified as attractive to other hematophagous arthropods were evaluated for their ability to stimulate and attract the major onchocerciasis vectors in Africa (Simulium damnosum sensu lato) and Latin America (Simulium ochraceum s. l.) using electroantennography and a Y tube binary choice assay. Medium chain length carboxylic acids and aldehydes were neurostimulatory for S. damnosum s.l. while S. ochraceum s.l. was stimulated by short chain aliphatic alcohols and aldehydes. Both species were attracted to ammonium bicarbonate and acetophenone. The compounds were shown to be attractive to the relevant vector species in field studies, when incorporated into a formulation that permitted a continuous release of the compound over time and used in concert with previously developed trap platforms. CONCLUSIONS/SIGNIFICANCE: The identification of compounds attractive to the major vectors of O. volvulus will permit the development of optimized traps. Such traps may replace the use of human vector collectors for monitoring the effectiveness of onchocerciasis elimination programs and could find use as a contributing component in an integrated vector control/drug program aimed at eliminating river blindness in Africa.

Evaluation of a community-based trapping program to collect Simulium ochraceum sensu lato for verification of onchocerciasis elimination.

BACKGROUND: Collection of the black fly vectors of onchocerciasis worldwide relies upon human landing collections. Recent studies have suggested that the Esperanza Window Trap baited with a human scent lure and CO2 had the potential to replace human hosts for the collection of Simulium ochraceum sensu lato in Southern Chiapas focus, Mexico. The feasibility of utilizing these traps in a community-based approach for the collection of S. ochraceum s.l. was evaluated. METHODOLOGY/PRINCIPAL FINDINGS: Local residents of a formerly endemic extra-sentinel community for onchocerciasis were trained to carry out collections using the traps. The residents operated the traps over a 60-day period and conducted parallel landing collections, resulting in a total of 28,397 vector black flies collected. None of the flies collected were found to contain parasite DNA when tested by a polymerase chain reaction assay targeting a parasite specific sequence, resulting in a point estimate of infection in the vectors of zero, with an upper bound of the 95% confidence interval 0.13 per 2,000. This meets the accepted criterion for demonstrating an interruption of parasite transmission. CONCLUSIONS/SIGNIFICANCE: These data demonstrate that Esperanza Window Traps may be effectively operated by minimally trained residents of formerly endemic communities, resulting in the collection of sufficient numbers of flies to verify transmission interruption of onchocerciasis. The traps represent a viable alternative to using humans as hosts for the collection of vector flies as part of the verification of onchocerciasis elimination.

Optimization of the Esperanza window trap for the collection of the African onchocerciasis vector Simulium damnosum sensu lato.

A simple inexpensive trap (Esperanza window trap) was shown recently to collect significant numbers of Simulium ochraceum sensu lato, a major vector of Onchocerca volvulus in Mesoamerica. Here, we report studies optimizing this trap for the collection of Simulium damnosum s.l., the major vector of O. volvulus in Africa. A shortened, blue and black striped version of the Esperanza window trap, when baited with a combination of CO2 and worn trousers, rivalled human landing collections in the number of S. damnosum s.l. females collected. Traps baited with a commercially available human skin lure and CO2 resulted in collections that were not significantly different than those obtained from traps baited with worn trousers and CO2. This suggests that the Esperanza window trap may offer a replacement for human landing collections for monitoring onchocerciasis transmission in Africa.

Development of a novel trap for the collection of black flies of the Simulium ochraceum complex.

BACKGROUND: Human landing collections are currently the standard method for collecting onchocerciasis vectors in Africa and Latin America. As part of the efforts to develop a trap to replace human landing collections for the monitoring and surveillance of onchocerciasis transmission, comprehensive evaluations of several trap types were conducted to assess their ability to collect Simulium ochraceum sensu lato, one of the principal vectors of Onchocerca volvulus in Latin America. METHODOLOGY/PRINCIPAL FINDINGS: Diverse trap designs with numerous modifications and bait variations were evaluated for their abilities to collect S. Ochraceum s.l. females. These traps targeted mostly host seeking flies. A novel trap dubbed the "Esperanza window trap" showed particular promise over other designs. When baited with CO2 and BG-lure (a synthetic blend of human odor components) a pair of Esperanza window traps collected numbers of S. Ochraceum s.l. females similar to those collected by a team of vector collectors. CONCLUSIONS/SIGNIFICANCE: The Esperanza window trap, when baited with chemical lures and CO2 can be used to collect epidemiologically significant numbers of Simulium ochraceum s.l., potentially serving as a replacement for human landing collections for evaluation of the transmission of O. volvulus.

Winter severity predicts the timing of host shifts in the mosquito Culex erraticus.

In temperate regions, seasonal epidemics of many mosquito-borne viruses are triggered when mosquito populations shift from feeding on avian to mammalian hosts. We investigated effects of temperature on the timing of bird-to-mammal shifts using an 8 year dataset of blood-meals from a mosquito (Culex erraticus) in Alabama, USA. As expected, Cx. erraticus shifted from avian to mammalian hosts each year. The timing of the shift, however, varied considerably among years. Harshness of the preceding winter (chill accumulation) explained 93 per cent of the variation in the timing of bird-to-mammal shifts, with shifts occurring later in years following harsher winters. We hypothesize that winter temperatures drive the timing of bird-to-mammal shifts through effects on host reproductive phenology. Because mosquitoes target birds during the nesting season, and bird nesting occurs later in years following colder winters, later nesting dates result in a concomitant delay in the timing of bird-to-mammal host shifts. Global increases in winter temperatures could cause significant changes in the timing of seasonal host shifts by mosquitoes, with prolonged periods of epidemic transmission of mosquito-borne diseases.

Salivary gland thrombostasin isoforms differentially regulate blood uptake of horn flies fed on control- and thrombostasin-vaccinated cattle.

Thrombostasin (TS) is an anticlotting protein found in saliva of Haematobia irritans (horn flies). The polymorphic nature of the ts gene was first associated with success of horn flies blood feeding on a laboratory host, New Zealand White rabbits. In this study, we report results of similar studies testing blood uptake of horn flies feeding on a natural host, cattle. These studies confirmed the association of ts genotype with blood uptake of horn flies and showed that it was host species specific. In contrast to rabbits, blood uptake volumes of homozygous ts10 horn flies were lower than those of other ts genotypes when fed on control (ovalbumin-vaccinated) cattle. Cattle vaccinated with recombinant protein isoforms, rTS9 or rTB8, resisted horn fly feeding by yielding lower blood volumes compared with flies feeding on control cattle. The specific impact of vaccination, however, varied by ts genotype of flies. Cattle vaccinated with isoform rTS9 resisted flies of ts2, ts9, and tb8 genotype. Vaccination with isoform rTB8 produced resistance to ts8, ts9, and tb8 genotype flies. Horn flies of genotype ts10 were not affected by vaccination with either TS isoform and fed as well on rTS9- and rTB8-vaccinated as on control-vaccinated cattle. These experimental results confirm the efficacy of vaccines targeting horn fly salivary proteins and provide new insight into the dynamics of horn fly-cattle interactions in nature.

Developing GIS-based eastern equine encephalitis vector-host models in Tuskegee, Alabama.

BACKGROUND: A site near Tuskegee, Alabama was examined for vector-host activities of eastern equine encephalomyelitis virus (EEEV). Land cover maps of the study site were created in ArcInfo 9.2 from QuickBird data encompassing visible and near-infrared (NIR) band information (0.45 to 0.72 microm) acquired July 15, 2008. Georeferenced mosquito and bird sampling sites, and their associated land cover attributes from the study site, were overlaid onto the satellite data. SAS 9.1.4 was used to explore univariate statistics and to generate regression models using the field and remote-sampled mosquito and bird data. Regression models indicated that Culex erracticus and Northern Cardinals were the most abundant mosquito and bird species, respectively. Spatial linear prediction models were then generated in Geostatistical Analyst Extension of ArcGIS 9.2. Additionally, a model of the study site was generated, based on a Digital Elevation Model (DEM), using ArcScene extension of ArcGIS 9.2. RESULTS: For total mosquito count data, a first-order trend ordinary kriging process was fitted to the semivariogram at a partial sill of 5.041 km, nugget of 6.325 km, lag size of 7.076 km, and range of 31.43 km, using 12 lags. For total adult Cx. erracticus count, a first-order trend ordinary kriging process was fitted to the semivariogram at a partial sill of 5.764 km, nugget of 6.114 km, lag size of 7.472 km, and range of 32.62 km, using 12 lags. For the total bird count data, a first-order trend ordinary kriging process was fitted to the semivariogram at a partial sill of 4.998 km, nugget of 5.413 km, lag size of 7.549 km and range of 35.27 km, using 12 lags. For the Northern Cardinal count data, a first-order trend ordinary kriging process was fitted to the semivariogram at a partial sill of 6.387 km, nugget of 5.935 km, lag size of 8.549 km and a range of 41.38 km, using 12 lags. Results of the DEM analyses indicated a statistically significant inverse linear relationship between total sampled mosquito data and elevation (R2 = -.4262; p < .0001), with a standard deviation (SD) of 10.46, and total sampled bird data and elevation (R2 = -.5111; p < .0001), with a SD of 22.97. DEM statistics also indicated a significant inverse linear relationship between total sampled Cx. erracticus data and elevation (R2 = -.4711; p < .0001), with a SD of 11.16, and the total sampled Northern Cardinal data and elevation (R2 = -.5831; p < .0001), SD of 11.42. CONCLUSION: These data demonstrate that GIS/remote sensing models and spatial statistics can capture space-varying functional relationships between field-sampled mosquito and bird parameters for determining risk for EEEV transmission.

Salivary gland thrombostasin isoforms differentially regulate blood uptake of horn flies fed on New Zealand White rabbits.

Thrombostasin (TS) is a previously characterized anticlotting protein with multiple isoforms found in the saliva of horn flies. In this report, the effect of TS isoforms on blood feeding was assessed using individual flies that carried corresponding ts allelles. Laboratory studies of horn fly blood feeding were conducted using colony-reared flies fed on New Zealand White (NZW) rabbits. After timed 20-min feeding periods, each fly was characterized for gender, blood volume uptake, and ts genotype. The results showed that mean blood volumes obtained by individual flies were not related to fly gender but were correlated to the ts genotype(s) carried by each fly. A fly having one or both ts alleles coding for the TS9 isoform took less blood than those possessing one or both ts alleles coding for the TS10 isoform. These results confirm the significant role that TS plays in horn fly feeding and highlight the differential impact of TS protein isoforms that vary by as few as three amino acids.

West Nile virus infection in mosquitoes in the mid-south USA, 2002-2005.

West Nile virus (family Flaviviridae, genus Flavivirus, WNV) was first detected in the Tennessee Valley and in Alabama in August 2001. In summer 2002, intensive viral activity was seen, but in subsequent years, viral activity settled into an enzootic pattern. Here, we report an analysis of viral activity in the mosquito fauna in the Mid-South from 2002 (the first year viral activity was detected in mosquitoes) through 2005. Eight mosquito species were infected with WNV during 2002. However, viral activity was only detected in four species--Culex salinarius Coquillett, Culex erraticus Dyar & Knab, Coquillettidia perturbans Walker, and Aedes vexans Meigen--in multiple years. The greatest number of positive pools was in Cx. erraticus and Cx. salinarius. Despite being specifically targeted for collection, Aedes albopictus Skuse was only found to be infected during the epiornitic year (2002), suggesting that under enzootic transmission conditions its role as a bridge vector in the region may not be significant. Virus-positive pools of Cx. erraticus were identified from winter-resting and early season dry ice-baited trap collections in 2005, implicating this species in WNV overwintering in Alabama. Molecular analysis of individuals initially identified as members of the Culex pipiens L. complex suggested that alleles characteristic of Cx. pipiens predominated in mosquitoes collected in Huntsville, AL, whereas alleles in the Auburn, AL, population were predominately characteristic of Culex quinquefaciatus Say. The southern boundary of the overlap zone of the two species seems to be located primarily between Huntsville and Auburn, a distance of 350 km.

A dynamic transmission model of eastern equine encephalitis virus.

Eastern equine encephalitis virus (EEEV) is one of several arthropod-borne viruses (arboviruses) endemic to the United States. Interactions between arthropod (mosquito) vectors and avian amplification host populations play a significant role in the dynamics of arboviral transmission. Recent data have suggested the hypothesis that an increased rate of successful feeding on young-of-the-year (YOY) birds might play a role in the dynamics of EEEV transmission. To test this hypothesis, we developed a model to explore the effect of the interactions of the vectors and avian host populations on EEEV transmission. Sensitivity analyses conducted using this model revealed eleven parameters that were capable of disproportionately affecting the predicted level of EEEV infection in the vertebrate reservoir and vector populations. Of these, four parameters were related to the interaction of the vector with young-of-the-year birds. Furthermore, adult birds could not substitute for young-of-the-year in initiating and maintaining a predicted enzootic outbreak of EEEV. Taken together, the model predicted that young-of-the-year birds play a key role in establishing and maintaining enzootic outbreaks of EEEV.

Chromosomal localization of two antihemostatic salivary factors in Simulium vittatum (Diptera: Simuliidae).

The chromosomal locations of two genes encoding the salivary protein products Simulidin (SVAT) and Simulium vittatum erythyma protein (SVEP) were identified using high-resolution cytogenetic mapping. Chromosomal subsection levels were determined from larval and adult salivary gland polytene chromosomes and adult Malphigian tubule chromosomes. Syntenic relationships occurred for both loci from a wild population of Simulium vittatum IIIL-1 collected in central Alabama and the colonized IS-7 S. vittatum sibling. cSVAT mapped to the short arm of chromosomes III, IIIS-72a4.5 and cSVEP mapped to the long arm of chromosome III, IIIL-96b1. cSVAT sits proximal to a common IIIS-2 paracentric inversion, which occurs predominately as the standard sequence in the IIIL-1 sibling and as the inverted sequence in the IS-7 sibling. cSVEP sits close to the differentiated X chromosomes in the IIIL-1 sibling.

Short report: impact of ivermectin community-level treatments on elimination of adult Onchocerca volvulus when individuals receive multiple treatments per year.

A reanalysis of several published reports indicates that when community-wide biannual treatment disrupts transmission of new infection, a profound macrofilaricidal effect of ivermectin (Mectizan) occurs that is accelerated for individuals treated 4 times a year (4x/yr). The effect is particularly obvious on adult male worms and suggests that this gender is susceptible to repetitive treatment after transmission has been blocked or greatly reduced as a result of community treatment.