Progress toward global eradication of dracunculiasis,January-June 2003

In 1986, when the World Health Assembly adopted a resolution calling for the eradication of dracunculiasis (Guinea worm disease), an estimated 3.5 million persons in 20 countries had the disease, and approximately 120 million persons were at risk for infection. By the end of 2002, annual incidence of the disease had been reduced >98%; seven countries in which dracunculiasis formerly was endemic (Cameroon, Chad, India, Kenya, Pakistan, Senegal, and Yemen) were free of the disease, and four countries (Central African Republic, Ethiopia, Mauritania, and Uganda) reported <100 cases each. During 1993-2002, the number of villages outside Sudan that reported cases decreased from approximately 23,000 to 2,022. This report describes the status of the global Dracunculiasis Eradication Program (DEP)* as of June 2003. The data indicate that incidence of the disease outside Ghana and Sudan has declined substantially since June 2002. Continuing efforts in all countries in which the disease is endemic, intensified efforts in Ghana, and an end to the ongoing war in Sudan are required for the eradication of dracunculiasis.     

Progress toward global eradication of dracunculiasis, January 2004-July 2005

In 1986, an estimated 3.5 million cases of dracunculiasis occurred in 20 countries, and 120 million persons were at risk for the disease. That year, the World Health Assembly adopted a resolution calling for the eradication of dracunculiasis, also known as Guinea worm disease. This report describes the status of the global dracunculiasis eradication program as of July 2005, indicating that, during January-July 2005, a total of 8,191 indigenous cases of dracunculiasis were reported from nine countries, with at least 150 million persons at risk. Despite the substantial reductions in dracunculiasis cases since 1986, eradication of dracunculiasis will require international commitment and ongoing surveillance and intensified interventions at national, state, and local levels.     

Progress toward global dracunculiasis eradication,June 2002

In 1986, when the World Health Assembly first adopted a resolution calling for the eradication of dracunculiasis (Guinea worm disease), an estimated 3.5 million persons in 20 countries had the disease, and approximately 120 million persons were at risk for infection. By December 2001, annual incidence of dracunculiasis had decreased approximately 98%, and seven countries (Cameroon, Chad, India, Kenya, Pakistan, Senegal, and Yemen) in which dracunculiasis had been endemic previously had eliminated the disease. This report describes the status of the global Dracunculiasis Eradication Program (DEP) as of June 2002. The findings indicate that DEP has succeeded in reducing incidence of dracunculiasis substantially; the disease can be eradicated if the remaining 13 countries in which it is endemic detect and contain transmission from the final cases.     

Strategies for dracunculiasis eradication.

In 1991 the Forty-fourth World Health Assembly declared the goal of eradicating dracunculiasis (guinea worm disease) by the end of 1995. This article summarizes the recommended strategies for surveillance and interventions in national dracunculiasis eradication programmes. It is based on personal experience with dracunculiasis programmes in Ghana, Nigeria and Pakistan. Three phases are described: establishment of a national programme office and conduct of a baseline survey; implementation of interventions; and case containment. The relevance of dracunculiasis eradication activities to strengthening of primary health care in the three countries is discussed briefly. Similar strategies would help eradicate this disease in the remaining endemic countries.     

Progress toward global eradication of dracunculiasis, January 2010-June 2011

In 1986, the World Health Assembly (WHA) called for the elimination of dracunculiasis (Guinea worm disease), a parasitic infection in humans caused by Dracunculus medinensis. At the time, an estimated 3.5 million cases were occurring annually in 20 countries in Africa and Asia, and 120 million persons were at risk for the disease. Because of slow mobilization in countries with endemic disease, the 1991 WHA goal to eradicate dracunculiasis globally by 1995 was not achieved. In 2004, WHA established a new target date of 2009 for global eradication; despite considerable progress, that target date also was not met. This report updates published and previously unpublished data and describes progress towards global eradication of dracunculiasis since January 2010. The number of indigenous cases of dracunculiasis worldwide decreased 44%, from 3,185 cases in 2009 to 1,793 in 2010. As of June 2011, dracunculiasis remained endemic in three countries (Ethiopia, Mali, and South Sudan). Of the 814 cases that occurred during January-June 2011, a total of 801 (98%) were reported from 358 villages in South Sudan. By October 2010, Ghana had gone 12 months without an indigenous case, thereby interrupting transmission; Ethiopia and Mali are close to interrupting transmission, as indicated by the small and declining numbers of cases in these two countries. An outbreak of 10 cases was discovered in Chad in 2010. The current target is to interrupt transmission in the remaining countries as soon as possible. Insecurity (e.g., sporadic violence or civil unrest) in areas of South Sudan and Mali, where dracunculiasis is endemic, poses the greatest threat to the success of the global dracunculiasis eradication campaign.     

Update: progress toward global eradication of dracunculiasis, January 2007-June 2008

The World Health Assembly (WHA) first adopted a resolution calling for the eradication of dracunculiasis (Guinea worm disease) in 1986, when an estimated 3.5 million cases occurred annually in 20 countries (17 in Africa and three in Asia) and 120 million persons were at risk for the disease. Because of slow mobilization in countries with endemic disease, the global dracunculiasis eradication program did not meet the 1995 target date for eradicating dracunculiasis that was set by African ministers of health in 1988 and confirmed by WHA in 1991. In 2004, WHA established a new target date of 2009. This report updates the progress of the global dracunculiasis eradication program since January 2007. At the end of December 2007, dracunculiasis remained endemic only in Sudan, Ghana, Mali, Nigeria, and Niger. During 2007, a total of 9,585 cases were reported worldwide from 3,573 villages with endemic disease, including 15 cases exported from one country to another (Table 1). From 2006 to 2007, the number of indigenous cases decreased by 61% (from 25,195 to 9,770). Of the 2,308 cases occurring during January-June 2008, 98% were reported from Sudan, Ghana, and Mali (Table 2). Sporadic violence in areas with endemic dracunculiasis in Sudan and Mali is a major concern and poses the greatest challenge to the success of the global dracunculiasis eradication program.     

Progress toward global eradication of dracunculiasis, 2002-2003

In 1986, when the World Health Assembly adopted a resolution calling for the eradication of dracunculiasis (i.e., Guinea worm disease), an estimated 3.5 million cases occurred in 20 countries, and 120 million persons were at risk for the disease. This report describes the status of the global dracunculiasis eradication program (DEP) as of the end of 2003. The findings indicate substantial overall progress towards eradication in 2003 compared with 2002, a major reduction in cases in Sudan, and an increase in cases in Ghana. Further progress will require 1) increased surveillance in all areas in which dracunculiasis is endemic or was previously endemic, 2) access to areas that lack security, and 3) concentrated efforts in Sudan once peace is achieved.     

Progress toward global eradication of dracunculiasis, January 2009-June 2010

In 1986, the World Health Assembly (WHA) called for the elimination of dracunculiasis (Guinea worm disease), a parasitic infection in humans caused by Dracunculus medinensis. At the time, an estimated 3.5 million cases were occurring annually in 20 countries in Africa and Asia, and 120 million persons were at risk for the disease. Because of slow mobilization in countries with endemic disease, the 1991 WHA goal to eradicate dracunculiasis globally by 1995 was not achieved. In 2004, WHA established a new target date of 2009 for global eradication; despite considerable progress, that target date also was not met. This report updates both published and previously unpublished data and updates progress toward global eradication of dracunculiasis since January 2009. At the end of December 2009, dracunculiasis remained endemic in four countries (Ethiopia, Ghana, Mali, and Sudan). The number of indigenous cases of dracunculiasis worldwide had decreased 31%, from 4,613 in 2008 to 3,185 in 2009. Of the 766 cases that occurred during January--June 2010, a total of 745 (97%) were reported from 380 villages in Sudan. Ghana, Ethiopia, and Mali each are close to interrupting transmission, as indicated by the small and declining number of cases. The current target is to complete eradication in all four countries as quickly as possible. Insecurity (e.g., sporadic violence or civil unrest) in areas of Sudan and Mali where dracunculiasis is endemic poses the greatest threat to the success of the global dracunculiasis eradication program.     

Dracunculiasis eradication and the legacy of the smallpox campaign: what's new and innovative? What's old and principled?

Coming on the heels the declaration of smallpox eradication in 1980 was the launch of the dracunculiasis (Guinea worm) eradication program, as a key outcome indicator of the success of the United Nations 1981-1990 International Drinking Water Supply and Sanitation Decade (IDWSSD). The dracunculiasis eradication campaign has carried on well beyond the close of the IDWSSD largely due to the efforts of President Jimmy Carter and The Carter Center, to assist the national Guinea Worm Eradication Programs in collaboration with partner organizations, including the Centers for Disease Control and Prevention (CDC), UNICEF, and the World Health Organization. Dracunculiasis eradication efforts have as primary tools health education, filter distribution for drinking water filtration, and case containment, all guided by rigorous village based surveillance. Additional tools are treatment of selected water sources with ABATE(R) (temephos) larvicide and provision of protected drinking water supplies. Village volunteers provide monthly reporting of cases (including reports of zero cases). The global campaign has made remarkable progress through both innovation and adherence to eradication principles. Annual cases of dracunculiasis have decreased from 3.5 million in 1986 to less than 2000 in 2010. The challenge is to reach zero cases. The task, so often faced by eradication programs, is to finish the 'final inch' in some of the most difficult places on earth to work. In the case of dracunculiasis, that is the new Republic of South Sudan.     

Renewed transmission of dracunculiasis--Chad, 2010

Transmission of dracunculiasis (Guinea worm disease), a waterborne, parasitic disease targeted for eradication, was thought to have been interrupted in Chad since 2000, when the last case was reported. However, in 2010, 10 cases were confirmed by the Chad Ministry of Public Health (Ministère de la Santé Publique [MSP]) and the World Health Organization (WHO) during field investigations in which rumored cases were investigated and nearby villages were actively searched for additional cases. Because patients were not prevented from contaminating water sources, new cases were expected in 2011. During January-February 2011, MSP, WHO, and CDC conducted an investigation to gather additional information to guide prevention and response activities before the 2011 transmission season. Seven districts where cases had been confirmed or suspected in 2010 or where dracunculiasis was endemic during 1994-2000 were surveyed. The results of those surveys indicated that residents of 116 (55%) of 210 villages and 13 (87%) of 15 nomad camps consumed water from unsafe sources; 157 (75%) of 209 village key informants (KIs) and five (33%) of 15 nomad camp KIs knew about dracunculiasis. Thirty-one villages had confirmed or suspected cases during 2009-2011 and were classified as at-risk, requiring weekly active surveillance and urgent pre-positioning of materials for the 2011 transmission season. Nomadic populations are at risk for dracunculiasis because of unsafe water consumption and minimal knowledge of the disease. These populations also require targeted surveillance and prevention efforts (e.g., filter distribution, education, and case containment) to interrupt dracunculiasis transmission .     

Progress toward global eradication of dracunculiasis, January 2005-May 2007

The World Health Assembly first adopted a resolution calling for the eradication of dracunculiasis (Guinea worm disease) in 1986, when an estimated 3.5 million cases were reported in 20 countries, and 120 million persons were at risk for the disease. This report describes the continued progress of the dracunculiasis eradication program worldwide during July 2005-May 2007. As of May 2007, dracunculiasis was still endemic in nine of the 20 countries cited in 1986; in 2006, approximately 98% of dracunculiasis cases worldwide were reported from Ghana and Sudan, and five other countries reported fewer than 30 cases each. The number of dracunculiasis cases increased from 10,674 in 2005 to 25,217 cases in 2006, with nearly all of the increase reported in Sudan, before decreasing from 9,510 during January-May 2006 to 4,460 cases during January-May 2007. Continued intensification of interventions against transmission of dracunculiasis will be necessary to eradicate dracunculiasis in the nine countries where the disease remains endemic.     

Surveillance: the foundation for control and elimination of dracunculiasis in Africa

The International Drinking Water Supply and Sanitation Decade (1981-1990) has stimulated a movement to eradicate human infection with the helminthic parasite Dracunculus medinensis (dracunculiasis), whose victims are disabled for weeks or months during the painful emergence of one or more worms from beneath the skin. Each year, millions of people acquire this infection by drinking unclean water. Among the critical activities that are necessary for the elimination of dracunculiasis, one of the most fundamental is that of epidemiological surveillance. Surveillance activities play a key role in the strategy to target affected villages for improved water supplies and other control activities. Accurate surveillance data also stimulate interest and support for national eradication programmes. Dracunculiasis is a condition with excellent characteristics for reporting through passive surveillance systems. However, active surveillance, as well as other innovative surveillance strategies, should be used to establish baseline information in those villages where cases occur, and later to monitor epidemiologically important indices needed to evaluate the progress of elimination efforts.     

Smallpox and its post-eradication surveillance

Since May 1980 when the 33rd World Health Assembly declared the global eradication of smallpox, WHO has been developing a comprehensive system of surveillance aimed at maintaining the world permanently free from this disease. By 1984, all countries had ceased vaccinating the general public against smallpox, and had withdrawn the requirement for smallpox vaccination certificates from international travellers. A number of countries had also discontinued the vaccinating of military personnel. Until now WHO has maintained a stock of smallpox vaccine sufficient to vaccinate 300 million persons, but considering that 10 years have elapsed since the last endemic case of smallpox, maintenance of this reserve is no longer indicated. WHO continues to monitor rumors and coordinate the investigation of suspected cases, all of which have actually been misdiagnosed chickenpox or some other skin disease, or other errors in recording or reporting. Variola virus is now kept in only 2 WHO Collaborating Centers which possess high security containment laboratories. Since the variola virus gene pool has been cloned in bacterial plasmids which provide sufficient material to solve future research and diagnostic problems, there is no need to retain stocks of viable variola virus any longer. The results of a special program for the surveillance of human monkeypox have confirmed that the disease does not pose any significant health problem. In addition to testing human and animal specimens, WHO collaborating laboratories have made progress in the analysis of DNA of orthopoxviruses and in the development of reliable serological tests.     

HIV / AIDS in South-East Asia: an update

As of July 1, 1996, 1,393,649 cumulative AIDS cases in adults and children had been reported to the World Health Organization (WHO) from 193 countries since the beginning of the pandemic. HIV infection is a serious public health and developmental problem in southeast Asia, with the WHO estimating more than 3.7 million people to be infected with HIV in the region. This infection extends into the general population and is not confined among people who practice high risk behaviors. As of July 1, 1996, Thailand, India, and Myanmar had reported the largest number of AIDS cases: 41,230, 2940, and 1093, respectively. However, WHO estimates that 2.5 million people are actually infected in India, 800,000 in Thailand, 350,000 in Myanmar, and 95,000 in Indonesia. While Bhutan and North Korea have not yet reported AIDS cases, people in Bhutan have been diagnosed with HIV infection. The health and socioeconomic impact of HIV/AIDS, national plans and programs, the 100% condom use program in Thailand, peer education among sex workers in Calcutta, WHO support for country responses, advocacy and support, promoting appropriate HIV prevention strategies and interventions, HIV/AIDS care as part of primary health care, HIV/AIDS and STD surveillance, and the future role of WHO are discussed.     

The distribution of dracunculiasis in Nigeria: a preliminary study

This paper presents a preliminary assessment of the distribution and endemicity of dracunculiasis in Nigeria. The disease is found in all 19 States of the Federation and in the Federal Capital Territory of Abuja. It occurs in areas with a dry season of more than nine months as well as those with a dry season of less than four months; the seasonal distribution of rainfall influences the peak period of disease transmission and patency. Altogether, an estimated 2.5 million cases occur every year, and at least 30% of the entire rural population is at risk from the infection. The widespread distribution of dracunculiasis throughout the country indicates the need for a national control campaign and a sustained programme of international cooperation.     

Oral health information systems--towards measuring progress in oral health promotion and disease prevention

This article describes the essential components of oral health information systems for the analysis of trends in oral disease and the evaluation of oral health programmes at the country, regional and global levels. Standard methodology for the collection of epidemiological data on oral health has been designed by WHO and used by countries worldwide for the surveillance of oral disease and health. Global, regional and national oral health databanks have highlighted the changing patterns of oral disease which primarily reflect changing risk profiles and the implementation of oral health programmes oriented towards disease prevention and health promotion. The WHO Oral Health Country/Area Profile Programme (CAPP) provides data on oral health from countries, as well as programme experiences and ideas targeted to oral health professionals, policy-makers, health planners, researchers and the general public. WHO has developed global and regional oral health databanks for surveillance, and international projects have designed oral health indicators for use in oral health information systems for assessing the quality of oral health care and surveillance systems. Modern oral health information systems are being developed within the framework of the WHO STEPwise approach to surveillance of noncommunicable, chronic disease, and data stored in the WHO Global InfoBase may allow advanced health systems research. Sound knowledge about progress made in prevention of oral and chronic disease and in health promotion may assist countries to implement effective public health programmes to the benefit of the poor and disadvantaged population groups worldwide.     

From the field side of the binoculars: a different view on global public health surveillance

It is generally assumed by the donor community that the targeted funding of global, regional or cross-border surveillance programmes is an efficient way to support resource-poor countries in developing their own national public health surveillance infrastructure, to encourage national authorities to share outbreak intelligence, and ultimately to ensure compliance of World Health Organization (WHO) Member States with the revised (2005) International Health Regulations. At country level, a number of factors and constraints appear to contradict this view. Global or regional surveillance initiatives, including syndromic surveillance and rumour surveillance projects, have been conceived in neglect of fragile health systems, from which they extract scarce human resources. In contradiction with a rightful stance promoting 'integrated surveillance' by WHO, the nurturing of donor-driven, poorly coordinated and redundant surveillance networks generally adds further fragmentation to national health priorities set up by developing countries. In their current categorical format, ignoring the overwhelming deficits in governance and health care capacity, global surveillance strategies seem bound to benefit mainly the most industrially developed nations through the provision of early warning information or scientific data. In lower-income countries, a focus of resources on strengthening the health system first would ultimately be a more efficient way to achieve proper detection and response to outbreaks at national or sub-national level. As documented in several pilot initiatives at sub-national level (India, South Africa, Tuvalu and Cambodia), the empowerment of frontline health workers and communities is a key element for an efficient surveillance system. Such simple measures centred on human resources and community values appear to be more beneficial than massive and conditional monetary inputs.     

Population mobility and disease transmission: the example of guinea worm

Population mobility can bring people into contact with disease agents, and transfer these agents to new populations. This paper suggests ways in which population movements are implicated in the transmission of one communicable disease, guinea worm or dracunculiasis, a parasitic disease affecting 5-15 million people every year in Africa, India and Pakistan. A typology of population mobility which distinguishes between rural and urban sectors, and between circulation and uni-directional permanent migration is used. An understanding of population movements associated with guinea worm, and with other communicable diseases, can also provide useful guidelines for effective disease control strategies.     

A pandemic influenza vaccine in India: from strain to sale within 12 months

In the event of a highly pathogenic influenza pandemic, the Indian subcontinent would need 1.2 billion doses of vaccine to immunize its entire population, double if two doses were required to assure immunity. Serum Institute of India Limited (SII) thus became one of six initial grantees of the World Health Organization (WHO) technology transfer initiative to create capacity in developing countries to manufacture H5N1 pandemic influenza vaccine. At the outbreak of the A(H1N1) 2009 influenza pandemic, experience gained from the H5N1 project was used to develop a live attenuated influenza vaccine (LAIV), since this was the only option for the level of surge capacity required for a large-scale immunization campaign in India. SII took <12 months to develop and market its LAIV intranasal vaccine from receipt of the seed strain from WHO. As of November 2010, over 2.5 million persons have been vaccinated with Nasovac(?) with no serious adverse reactions or vaccine failure after 3 months' post-marketing surveillance. The product has been submitted for prequalification by WHO for purchase by United Nations agencies. In parallel, SII also developed an inactivated influenza vaccine, and is currently looking to ensure the sustainability of its influenza vaccine manufacturing capacity.     

Effectively introducing a new meningococcal A conjugate vaccine in Africa: the Burkina Faso experience

A new Group A meningococcal (Men A) conjugate vaccine, MenAfriVac?, was prequalified by the World Health Organization (WHO) in June 2010. Because Burkina Faso has repeatedly suffered meningitis epidemics due to Group A Neisseria meningitidis special efforts were made to conduct a country-wide campaign with the new vaccine in late 2010 and before the onset of the next epidemic meningococcal disease season beginning in January 2011. In the ensuing five months (July-November 2010) the following challenges were successfully managed: (1) doing a large safety study and registering the new vaccine in Burkina Faso; (2) developing a comprehensive communication plan; (3) strengthening the surveillance system with particular attention to improving the capacity for real-time polymerase chain reaction (PCR) testing of spinal fluid specimens; (4) improving cold chain capacity and waste disposal; (5) developing and funding a sound campaign strategy; and (6) ensuring effective collaboration across all partners. Each of these issues required specific strategies that were managed through a WHO-led consortium that included all major partners (Ministry of Health/Burkina Faso, Serum Institute of India Ltd., UNICEF, Global Alliance for Vaccines and Immunization, Meningitis Vaccine Project, CDC/Atlanta, and the Norwegian Institute of Public Health/Oslo). Biweekly teleconferences that were led by WHO ensured that problems were identified in a timely fashion. The new meningococcal A conjugate vaccine was introduced on December 6, 2010, in a national ceremony led by His Excellency Blaise Compaore, the President of Burkina Faso. The ensuing 10-day national campaign was hugely successful, and over 11.4 million Burkinabes between the ages of 1 and 29 years (100% of target population) were vaccinated. African national immunization programs are capable of achieving very high coverage for a vaccine desired by the public, introduced in a well-organized campaign, and supported at the highest political level. The Burkina Faso success augurs well for further rollout of the Men A conjugate vaccine in meningitis belt countries.