THE RELIABILITY OF ANTERIOR SEGMENT LESIONS AS INDICATORS OF ONCHOCERCAL EYE DISEASE IN GUATEMALA

KEVIN L. WINTHROP Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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ROBERTO PROAÑO Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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ORLANDO OLIVA Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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BYRON ARANA Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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CARLOS MENDOZA Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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ALFREDO DOMINGUEZ Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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JOSEF AMANN Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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GEORGE PUNKOSDY Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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CARLOS BLANCO Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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ROBERT KLEIN Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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MAURICIO SAUERBREY Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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FRANK RICHARDS Division of Parasitic Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia; Casey Eye Institute, Oregon Health Sciences University, Portland, Oregon; Medical Entomology Research Unit, US Centers for Disease Control and Prevention and Universidad del Valle, Guatemala City, Guatemala; Program for the Elimination of Onchocerciasis in the Americas, Guatemala City, Guatemala

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World Health Organization certification criteria for onchocerciasis elimination use anterior segment eye lesion prevalence as an indicator of mass ivermectin treatment program success. Lesions either contain visible microfilaria (noninflammatory punctate keratitis [PK] or microfilariae in anterior chamber [MFAC]), or microfilaria obscured by inflammation (inflammatory PK). To assess the utility of these disease indicators, two experienced ophthalmologists independently examined persons from endemic (N = 325) and nonendemic (N = 348) Guatemalan communities. Thirty-six (11.1%) and nine (2.6%) persons from endemic and nonendemic areas respectively had lesions found by either ophthalmologist (prevalence ratio = 4.3, 95% CI 2.1–8.8, P < 0.001). All lesions in nonendemic areas were inflammatory PK in whom no persons were seropositive for onchocerciasis. Overall, observer agreement was moderate (Kappa = 0.49), and most (61%) discordance occurred with inflammatory PK lesions. Our findings suggest that inflammatory punctate keratitis is neither a specific nor a reliable indicator of onchocercal eye disease. Future prevalence surveys should rely upon noninflammatory lesions as disease indicators.

Author Notes

Reprint requests: Kevin L. Winthrop, Casey Eye Institute, Oregon Health Sciences University, 3375 S.W. Terwilliger Boulevard, Portland, OR 97239-4197, E-mail: winthrop@ohsu.edu
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