A geospatial approach to understanding transmission patterns of onchocerciasis in Ghana

Background Onchocerciasis (river blindness), caused by the filarial nematode Onchocerca volvulus and transmitted by Simulium blackflies, remains a public health challenge in sub-Saharan Africa. Following the transition from vector control to large-scale ivermectin distribution, microfilariae (mf) prevalence has declined substantially across Ghana. The World Health Organization targets onchocerciasis elimination, defined as sustained mf prevalence below 1%. This requires identifying areas of persistent or resurgent transmission to guide targeted mapping surveys and interventions. Methods A Bayesian spatiotemporal, multilevel, generalized additive model with a zero-inflated beta-binomial outcome was fitted to mf prevalence data from 1353 surveys across 671 villages and environmental and socio-economic predictors. Temporal prevalence trends for ecozones within operational transmission zones (OTZ) were modelled using a 2D spatial smooth to account for residual spatial autocorrelation. Temporal autocorrelation in prevalence was accounted for using a random effect for village nested within ecozone. Results Runoff probability and surface wetness were positively associated with prevalence, consistent with Simulium breeding in fast-flowing water. Despite high initial mf prevalence, by 2015 the median prevalence across all OTZs in Ghana was estimated to be between 0.43 and 1.97%. The probability that prevalence was <1% in 2015 ranged from 0.15 to 0.87. Assuming testing rates and mass drug administration have remained consistent (twice a year and >80% coverage), linear extrapolation predicted that the three OTZs have some probability of exceeding the elimination threshold by 2030, while two were predicted to have near-zero prevalence. The Tano-Ankobra OTZ, which includes both savanna and forest agro-ecological zones, was a persistent hotspot. Conclusions This first comprehensive spatio-temporal analysis of onchocerciasis in Ghana reflects the well-documented challenge of onchocerciasis control in forested riverine environments. Persistent transmission foci in eastern and southern Ghana, particularly in forest zones with sustained vector habitat, warrant targeted investigation and intensified intervention to meet WHO elimination thresholds.