Epidemiological, vectorial and landscape changes in the context of declining <i>Onchocerca volvulus</i> transmission across the Kakoi-Koda focus, Ituri, Democratic Republic of the Congo

Abstract 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. Author Summary Onchocerciasis, also known as river blindness, is a parasitic disease of public health concern in sub-Saharan Africa, transmitted by blackfly vectors. The disease is responsible for skin and eye clinical manifestations and is associated with neurological complications. We investigated an area in north-eastern Democratic Republic of the Congo called the Kakoi-Koda onchocerciasis focus, where the infection was once common. We reviewed and assembled data from past studies on infection in humans and blackflies, and analysed satellite imagery to assess the loss of tree cover that can affect where blackflies live and breed. We found that the prevalence of onchocerciasis in Kakoi-Koda has declined markedly in recent years. This decline appears linked to the disappearance (by deforestation) of the habitat suitable for some blackfly species, and to ivermectin distribution to treat onchocerciasis in parts of the focus. Our findings help to understand why onchocerciasis has decreased across the Kakoi-Koda focus and highlight a small number of fast-flowing river segments where other blackfly species may allow small pockets of local transmission. These results support continued, targeted monitoring to determine whether the disease is still transmitted in specific locations where elimination interventions may be needed.