Projected number of people with Onchocerciasis-Loiasis co-infection in Africa, 1995 to 2025

BACKGROUND: Onchocerciasis elimination through mass drug administration (MDA) is hampered by co-endemicity of Loa loa in Africa, as people with high L. loa microfilariae (mf) density can develop serious adverse events (SAEs) after ivermectin treatment. We assessed the geographical overlap of onchocerciasis and loiasis prevalence and estimated the number of co-infected individuals at risk of post-ivermectin SAEs in West and Central Africa from 1995 to 2025.METHODS: Focussing on regions with suspected loiasis transmission in 14 African countries, we overlaid pre-control maps of loiasis and onchocerciasis prevalence to calculate pre-control prevalence of co-infection by 5x5 km² pixel, distinguishing different categories of L. loa mf intensity. Using statistical and mathematical models, we predicted the prevalence of both infections and co-infection for 2015 and 2025, accounting for the impact of MDA with ivermectin.RESULTS: The number of people infected with onchocerciasis was predicted to decline from almost 19 million in 1995 to 4 million in 2025. Of these, 137,000 people were estimated to also have L. loa hypermicrofilaraemia (≥20,000 L. loa mf/mL) in 1995, declining to 31,000 in 2025. In 2025, 92.8% of co-infected cases with loiasis hypermicrofilaraemia are predicted to live in hypoendemic areas currently not targeted for MDA.CONCLUSIONS: Loiasis co-infection is a major concern for onchocerciasis elimination in Africa. We predict that under current strategies, at least 31,000 co-infected people will still require treatment for onchocerciasis in 2025 while being at risk of SAEs, justifying continued efforts in research and development for safer drugs and control strategies.