Background to GWD eradication.
The idea of a global initiative to eradicate dracunculiasis began in 1980 by the Centers for Disease Control (CDC), from a suggestion that GWD eradication would measure the progress of the International Drinking Water Supply and Sanitation Decade (IDWSSD)19. The first international meeting for GWD eradication, in June 1982, was the Workshop on Opportunities for Control of Dracunculiasis, where research was compiled to analyze the current state of the disease in order to determine the best approach to treatment. The workshop found that transmission occurred in sub-Saharan Africa, India, and Pakistan, and had stopped in endemic areas of Iran since the 1970s due to the use of dichlorodiphenyltrichloroethane (DDT) for malaria control and chlorination of water in the “birkehs,” or large, covered cisterns storing rainwater, where mosquitoes bred and dracunculiasis was transmitted. Dracunculiasis, therefore, could be best prevented by keeping individuals with emerging worms from contact with water sources, filtering all drinking water through cloth filters, providing of sources for safe drinking water, and the treating unsafe drinking water with 1 ppm concentration of ABATE larvicide (temephos) that kills the arthropod vector.
Woman filtering water through cloth filter. By courtesy of the Canadian Medical Association Journal, ©2004.
The CDC was designated the WHO Collaborating Center for Research, Training, and Eradication of Dracunculiasis (CCRTED) in 1984. This center monitored the efforts of the Dracunculiasis Eradication Program (DEP) and provided technical assistance to national eradication programs, thus have an instrumental role in the eradication initiative.20
The first World Health Assembly (WHA) Resolution and the first African regional conference on dracunculiasis eradication occurred in 1986. The 39th WHA implemented resolution WHA 39.21 on May 16, 1986, which promised to endorse national efforts to eliminate dracunculiasis in each country with the cooperation of IDWSSD. However, it became known that IDWSSD did not have the proper funding to back such initiatives, especially since further investigation of the disease status in Africa estimated an annual 3.2 million cases and 120 million individuals at risk of infection in the known endemic areas. The global burden of the disease was said to be 3.5 million annual cases, including India and Pakistan.2
Soon after, The Carter Center (TCC), a non-profit founded in 1982 by former U.S. President Jimmy Carter and former First Lady Rosalynn Carter, became the lead non-governmental agency advocating the global campaign, while providing technical and financial assistance to national eradication programs.3 TCC and CDC first began assisting Pakistan in organizing eradication beginning 1988. Ghana and Nigeria followed suit in 1989, Uganda in 1991, and Mali and Niger in 1993. In 1991, the WHA adopted a resolution calling for a global campaign for eradication by 1995, mostly due to strong advocacy from TCC. Although this benchmark was not met, twenty eradication programs were instituted by 1995 in all the endemic regions of dracunculiasis.
Table of eradication programs by country and year. By courtesy of Advances in Parasitology Vol.61, ©2006.
The strategy for eradication consists of three operational phases. Phase I includes the establishment of a national campaign coordinator, the completion of national baseline village surveys for case-detection and prevalence statistics, and the creation a national plan of action. Phase II follows with training program staff and village-based workers, implementing village-based surveillance, initiating a comprehensive health education strategy, providing cloth filters and safe drinking water (borehold wells), controlling copepod populations using Abate (temephos), and monitoring the coverage and quality of the surveillance and interventions. Finally, Phase III of the plan occurs when the case load is reduced to one case per worker per day. Surveillance increases to detect all emerging worms and to immediately contain transmission by tending to each individual case. Furthermore, surveillance is continued three years after the last case to ensure complete eradication.
Beginning in 1998, TCC decided that because the progress in some endemic countries since 1995 was stagnant, they would provide additional ad hoc technical advisors (TAs) to help with the national programs to improve management and monitor interventions. In the following years, the number of TAs increased from 28 person-months of TAs in 1999 to 127 in 2004. They played a large role in intervening during outbreaks. TCC also began to form a coalition of more than 30 agencies, organizations, governments, donors, and NGOs that assisted the national eradication programs. Among these were the Bill and Melinda Gates Foundation, which provided 28.5 million dollars in May 2000, and grants channeled through The World Bank Trust Fund for Guinea Worm Eradication, which offered $15 million to TCC for 2000-2002 to assist remaining endemic countries, $8.5 million to the World Bank, TCC, WHO, and UNICEF to provide support for expenditures, and $5 million to the WHO.2
By courtesy of Advances in Parasitology Vol.61, ©2006.
The eradication campaign has shown encouraging results throughout the years. Starting from an estimated 3.5 million cases occurring annually in 1986, 16,026 cases of dracunculiasis were reported from the 12 remaining endemic countries in 2004, which is a 99.5% reduction. Sudan, which previously had a very high endemic rate, reported fewer cases of dracunculiasis than all other 11 countries combined, which was the first time since 1996. Excluding Sudan, the overall reduction in 2004 was 60% for all the countries. The percentage of cases reported increased consistently, thus demonstrating a more accurate and effective surveillance2.
By courtesy of Advances in Parasitology Vol.61, ©2006.
The cost of the DEP during 1987-2004 is estimated to be $122-125 million, and it is expected that an additional $65 million will be required to complete full dracunculiasis eradication by 2010.2 Much of this funding would go to southern Sudan, which has very poor transportation and communications, and just emerged out of 21 years of civil war in 2005. The civil war had been a roadblock that prevented intervention programs from easily accessing these areas. This area will be a major focus in the DEP now that more access is available to the area. Also in the recent years, the resolution WHA 57.9 urges all remaining endemic countries to stop transmission of dracunculiasis as soon as possible. High level advocacy with national and international leaders are instrumental in continuing the success of the DEP and reaching the goal of eradicating dracunculiasis. Thus, TCC will continue to encourage national and international leaders to continue their efforts in the eradication.
Summary of DEP Success.
From the Weekly epidemiological record, 16 June 2006:7
1. There has been a highly significant reduction (99%) in the global number of cases from 892,055 in 1989 to 10,674 in 2005.
2. The number of endemic countries has reduced from 20 since the inception of the program in 1980 to 9 countries in 2005, of which 4 countries (Burkina Faso, Côte d’Ivoire, Ethiopia and Togo) each reported fewer than 100 cases in 2005; 3 countries (Mali, Niger and Nigeria) each reported between 100 and 1000 cases. Ghana (3981) and Sudan (5569) reported the highest numbers of cases in 2005, or 89% of the global total.
3. Seven countries that interrupted disease transmission earlier are in the pre-certification phase. Those countries reported zero indigenous cases in 2005 and are expected to be certified by the International Commission for the Certification of Dracunculiasis Eradication (ICCDE) in 2006 if eligible.
4. To date, the ICCDE has certified a total of 168 countries and territories, including 4 countries (India, Pakistan, Senegal and Yemen) that were endemic at the beginning of the program.