Category Archives: Elimination

Epidemiology of Resurgent Malaria in Eastern Zimbabwe: Risk Factors, Spatio-Temporal Patterns and Prospects for Regaining Malaria Control

Mufaro Kanyangarara and her PhD thesis adviser, Luke Mullany, of the Johns Hopkins Bloomberg School of Public Health Department of International Health, have been looking into the challenges of controlling and eventually eliminating malaria in a multi-country context in southern Africa. We are sharing abstracts from her pioneering work. The first seen below provides an overview of the three components of the study.

Incidence 2012Despite recent reductions in malaria morbidity and mortality due to the scale up of malaria interventions, malaria remains a public health problem in sub-Saharan Africa, especially among children under five years of age, pregnant women and people living with HIV/AIDS. A recent resurgence in malaria, in areas where malaria control was previously successful, has brought to the forefront the importance of research to understand the epidemiology of malaria and the effectiveness of malaria control efforts in resurgent settings. Using cross-sectional surveys, routine data from health-facility based surveillance and freely available remotely sensed environmental data, this research examined the distribution of malaria and the impact of vector control in Mutasa, a rural district in Zimbabwe characterized by resurgent malaria.

Firstly, individual- and household level factors independently associated with individual malaria risk were identified using multilevel logistic regression models based on data from cross-sectional surveys conducted between October 2012 and September 2014. Secondly, geostatistical methods and remotely sensed environmental data were used to model the spatial and seasonal distribution of household malaria risk; then develop seasonal malaria risk maps with corresponding maps of the prediction uncertainty. Lastly, an evaluation of the effect of introducing an organophosphate for indoor residual spraying was conducted using routine health facility data covering 24 months before and 6 months after the campaign.

The results of multilevel model suggested that malaria risk was significantly higher among individuals who were younger than 25 years, did not sleep under a bed net, and lived close to the Zimbabwe-Mozambique border. The spatial risk maps depicted relatively increased risk of finding a positive household in low-lying areas along the Mozambique border during the rainy season. Lastly, the introduction of organophosphates to this pyretheroid resistant area resulted in a significant reduction in malaria incidence following spraying. These findings elucidate the heterogeneous distribution of malaria, identify risk factors driving malaria transmission and assess the quantitative impact of switching insecticide classes on health outcomes. Collectively, the findings provide evidence to guide country-specific decision making for regaining malaria control and underscore the need for strong between-country initiatives to curb malaria in Mutasa District and elsewhere.

Malaria Status in the 2014-15 Rwanda Demographic and Health Survey

Rwanda is experiencing low and very low levels of malaria test positivity rates, thought there are a few districts near the borders with Uganda, Tanzania and Burundi that have relatively higher transmission. Overall the country is strategizing how to move toward the pre-elimination phase on the pathway to malaria elimination. This is defined as a test positivity rate of less than 5% during the high transmission season.

DHS 2010 Malaria Prevalence in Children 6-59 MonthsIt is important to distinguish between test positivity rate and prevalence rate. The most recent survey report that gives prevalence is the DHS 2010 with a rate of 1.4% in children below 5 years of age and 0.7% among women of reproductive age. During 2010 the health management information system shows that among those tested (microscopy or RDT) for malaria, 24% were positive. The population for test positivity reports is a much smaller group that is already suspected of having malaria. That said, 24% or the 2013 rate of 29% is still far from the 5% cut-off for pre-elimination status.

Rwanda still maintains a policy of universal coverage with insecticide treated nets (ITNs). Rwanda also has a policy that every pregnant woman should receive an ITN during her first antenatal care visit. Ideally in order to reach pre-elimination status, a country needs to sustain high coverage of malaria prevention and treatment interventions at an 80% level for several years.

The newly released preliminary results of the 2014-15 DHS provide an opportunity to examine achievements. The 2014-15 DHS found that 81% of households had at least one ITN, while 43% had achieved the universal coverage target of one ITN per two household members. These numbers remain basically unchanged from the 2013 Malaria Information Survey (83% and 43%), while the 2010 DHS found 82% of households had a net, but did not report on the indicator of one net per two people. In short, it appears that coverage levels have been maintained at a certain level.

DSCN7129a pregnant women get ITNs when register for ANC RwandaDHS 2014-15 shows that 99% of pregnant women in Rwanda received antenatal care from a skilled provider. That means that basically all pregnant women should have received an ITN. 73% of pregnant women had slept under an ITN the night before they were surveyed, while 88% of all women of reproductive age slept under a net. 68% of children below the age of five years slept under an ITN the night before their household was surveyed, while 80% who lived in households that owned an ITN did so.

Indoor Residual Spraying (IRS) is focused on certain high transmission/burden districts. The preliminary 2014-15 DHS does not report on this and the 2013 MIS reports broadly by region, hence one sees coverage reports for IRS in the east (22%) and south (16%), where there is greater malaria burden, but this cannot be linked to specific districts that may have been targeted.

Rwanda also has a policy that all suspected malaria cases should be tested, whether with microscopy in health centers or rapid diagnostic tests by village health workers. It is only those persons testing positive for malaria who are supposed to be given malaria medicine.

DHS shows that 1439 children below five years of age (or 19% of the total) had fever in the two weeks prior to the survey. Of these 36% reported having a blood test performed, and 11% of those with fever received the approved artemisinin-based combination (ACT) therapy drug. The report does not indicate the actual testDSCN7282 results of those receiving ACT.

As Rwanda strategized toward reaching malaria pre-elimination status it can consider ways of enhancing ITN use, not only among vulnerable groups like small children and pregnant women, but all members of the household. As prevalence drops, so does acquired immunity, putting adults at greater risk.

The universal coverage target of at least 1 net for every two people in a household must be maintained, especially since it is nearing three years since the last universal coverage distribution campaign. Either another campaign will be needed or efforts to strengthen delivery of nets to families through routine health services.

In addition prompt and appropriate treatment based on diagnostics can be strengthened. One would have expected more children with fever to have been tested for malaria that the DHS reports.

Internal and external support is needed. Rwanda has been on the verge of reaching malaria pre-elimination status several times in the past decade. Even though malaria is no longer the top cause of death, we should not reduce our efforts to create a malaria-free Rwanda.

Congenital malaria: A neglected global health concern

Reena Sethi, DrPH Candidate in International Health, The Johns Hopkins Bloomberg School of Public Health and Senior Monitoring and Evaluation Adviser, Jhpiego shares with us the challenges of malaria acquired from the pregnant mother by their newborn child.

DSCN6805 mother of newborn in Malawi given LLINStrategies and recommendations to prevent the transmission of HIV from a mother to her child are known but less information is available on the epidemiology and management of malaria transmitted from pregnant women to their newborns. As presented in a review of congenital infections, one of the lesser known effects of malaria in pregnancy is the maternal-fetal transmission of infected erythrocytes that can result in poor perinatal outcomes. While clinical malaria in newborns is rare, most likely due to the transplacental transfer of maternal antibodies and the inhibitory effect of fetal hemoglobin on the development of malaria parasites, it is unclear what the true incidence of this condition is in Africa and Asia.

Recently published studies in Burkina Faso estimated the incidence of congenital malaria to be 2.1% and the prevalence of mother-to-child transmission of asymptomatic malaria to be 18.5% in one health center in Ouagadougou; in one hospital in Papua, Indonesia, congenital malaria was said to occur in 8 out of 1000 live births from 2005 to 2010; and in a study in one hospital in Madhya Pradesh, India, the incidence of congenital malaria was 29 out of 1000 live births. In a study involving six hospitals in Nigeria, the overall incidence of congenital malaria was found to be 5.1%. Transmission has been associated with both Plasmodium falciparum and Plasmodium vivax. The uncertainty and variation in estimates are likely related to the source of the tested blood (umbilical cord blood or infant peripheral blood), presentation of symptoms that are similar to neonatal sepsis, as well as the lack of capacity to conduct high quality diagnostic tests.

Since congenital malaria results from the transmission of parasites from the mother to the baby (presumably through placental transmission), prevention of malaria through the use of IPTp when appropriate reduces maternal parasitemia, most likely resulting in a lower rate of transmission of malaria to the newborn. In a study in Côte d’Ivoire, factors that protected mothers from placental malaria parasitaemia were the use of IPTp (SP) or ITNs during pregnancy and multigravidity. A study in Ibadan, Nigeria found that IPT-SP was effective in preventing maternal and placental malaria as well as improving pregnancy outcomes among parturient women. Researchers in Southern Ghana reported that placental malaria decreased after the implementation of IPTp.

However, in settings where IPTp is ineffective, the effect of alternative strategies, such as intermittent screening and testing in pregnancy (ISTp) on placental malaria should be examined. Little evidence is currently available on the efficacy of ISTp on maternal and newborn outcomes.

Further research also needs to be conducted in diverse settings to develop a standardized definition for congenital malaria and to understand the short and long-term consequences of this condition in order to establish guidelines for diagnosis and treatment. In pre-elimination contexts, where acquired malaria immunity may be reduced, further evidence is needed on the feasibility of screening all febrile babies and following newborns born to women with malaria during pregnancy and of other possible strategies to improve infant outcomes.

Moving toward Malaria Elimination in Botswana

elimination countriesThe just concluded 2015 Global Health Conference in Botswana, hosted by Boitekanelo College at Gaborone International Convention Centre on 11-12 June provided us a good opportunity to examine how Botswana is moving toward malaria elimination. Botswana is one of the four front line malaria elimination countries in the Southern African Development Community and offers lessons for other countries in the region. Combined with the 4 neighboring countries to the north, they are known collectively as the “Elimination Eight”.

The malaria elimination countries are characterised by low leves of transmission in focal areas of the country, often in seasonal or epidemic form. The pathway to malaria elimination requires that a country or defined areas in a country reach a slide positivity rates during peak malaria season of < 5%.

pathwayChihanga Simon et al. provide us a good outline of 60+ years of Botswana’s movements along the pathway beginning with indoor residual spraying (IRS) in the 1950s. Since then the country has expanded vector control to strengthened case management and surveillance. Particular recent milestones include –

  • 2009: Malaria elimination policy required all cases to be tested before treatment malaria elimination target set for 2015
  • 2010: Malaria Strategic Plan 2010–15 using recommendations from programme review of 2009; free LLINs
  • 2012: Case-based surveillance introduced

The national malaria elimination strategy includes the following:Map

  • Focus distribution LLIN & IRS in all transmission foci/high risk districts
  • Detect all malaria infections through appropriate diagnostic methods and provide effective treatment
  • Develop a robust information system for tracking of progress and decision making
  • Build capacity at all levels for malaria elimination

Botswana like other malaria endemic countries works with the Roll Back Malaria Partnership to compile an annual road map that identifies progress made and areas for improvement. The 2015 Road Map shows that –

  • 116,229 LLINs distributed during campaigns in order to maintain universal coverage in the 6 high risk districts
  • 200,721 IRS Operational Target structures sprayed
  • 2,183,238 RDTs distributed and 9,876 microscopes distributed
  • While M&E, Behavior Change, and Program Management Capacity activities are underway

Score cardFinally the African Leaders Malaria Alliance (ALMA) provides quarterly scorecards on each member. Botswana is making a major financial commitment to its malaria elimination commodity and policy needs. There is still need to sustain high levels of IRS coverage in designated areas.

Monitoring and evaluation is crucial to malaria elimination. Botswana has a detailed M&E plan that includes a geo-referenced surveillance system, GIS and malaria database training for 60 health care workers, traininf for at least 80% of health workers on Case Based Surveillance in 29 districts, and regular data analysis and feedback.

M&E activities also involve supervision visits for mapping of cases, foci and interventions, bi-annual malaria case management audits, enhanced diagnostics through PCR and LAMP as well as Knowledge, Attitudes, Behaviour, and Practice surveys.

Malaria elimination activities are not simple. Just because cases drop, our job is easier. Botswana, like its neighbors in the ‘Elimination Eight’ is putting in place the interventions and resources needed to see malaria really come to an end in the country. Keep up the good work!

Huambo: Thinking ahead toward investing in malaria elimination

wmd2015logoEight members of the Southern African Development Community are strategizing toward the pre-elimination phase of malaria.  The four frontline states are Namibia, South Africa, Swaziland and Botswana.  The second tier includes Angola, Zambia, Zimbabwe and Mozambique.

Huambo circled Pf_mean_2010_AGOMalaria prevalence varies by province in Angola with greater burden in the north (see map on right). Huambo in the central highlands is the second most populous province at 2 million and in some of the 11 municipalities malaria transmission is low.  This has led provincial health authorities to strategize how to invest in pre-elimination efforts where appropriate while maintaining full prevention interventions where needed.

An analysis of routine health information system (HIS) data is a first step. Rapid Diagnostic tests are part of the basic protocol for case management in all health centers. Data for 2014 was summarized by municipality. Test positivity rates for each municipality are shown in the map to the left. These range from a low of 2% in Katchiungo in the east to 54% Bailundo in the north.

Huambo Municipalities Malaria Test PositivityMore detailed geospatial analysis will be needed looking at variations within municipalities by health center catchment area, but a broad picture emerges that three municipalities in the northern part of the province have higher RDT positivity rates, and require sustained interventions like long lasting insecticide-treated nets and intermittent preventive treatment for pregnant women.

Reactive case detection such as being practiced in Swaziland might be considered in the remaining 8 municipalities after some initial pilot testing. Community based surveys using RDTs and more precise tests like polymerase chain reaction (PCR) could also be tried in order to supplement current HIS data and provide better targeting of interventions.

Hopefully government and partners will invest in helping Huambo test these processes. Huambo could then provide a good model for approaching malaria elimination for the rest if the country and the region.

Moving toward Malaria Elimination through Integrated Vector Control

As malaria control efforts are scaled up and sustained, we expect a drop in prevalence to the point where Ministries of Health may no longer devote a whole operational unit – a National Malaria Control Program – to the disease. This does not mean that malaria programming stops, otherwise countries would experience a resurgence.

Pf_mean_2010_NAMWe can learn from countries like Namibia and Rwanda that are on the frontline of malaria elimination efforts. In Namibia, “The National Vector-borne Disease Control Program (NVDCP) at the Namibia Ministry of Health and Social Services effectively controls the spread of malaria with interventions such as spraying dwellings with insecticides, distributing mosquito nets treated with insecticides, using malaria tests that can give accurate results within 15 minutes, and distributing medicines that kill the parasite.”

The NVDCP falls under the Primary Health Care Services Directorate with its five divisions: Epidemiology; Public and Environmental Health Services; Family Planning; Information, Education and Communication (IEC); Disability Prevention and Rehabilitation. Contrary to what one might think, malaria activities are not lost, but are teaming up with international partners like UCSF Global Health Group’s Malaria Elimination Initiative, the Novartis Foundation for Sustainable Development, the London School of Hygiene and Tropical Medicine, the Clinton Health Access Initiative and the Bill & Melinda Gates Foundation.

In Rwanda we now have the Malaria and Other Parasitic Diseases Division (MOPDD) within the Rwanda Biomedical Center within the Ministry of Health. Major donors like the US Presidents Malaria Initiative are supporting the MOPDD to achieve Rwanda’s national strategic plan of reaching the pre-elimination stage by 2018.

PAMCA logo smEven if a country is still highly malaria endemic, it is important to ensure that integrated vector management is taking place so that in the future the country’s malaria efforts will have a strong ‘home base’ to approach elimination. This is why the opportunity presented by upcoming the Second Pan-African Mosquito Control Association is important.  According to the organizers …

The 2nd Pan African Mosquito Control Association (PAMCA) Conference themed, “Emerging mosquito-borne diseases in sub-Saharan Africa” will be held in Dar-es- Salaam, Tanzania, from 6-8th October 2015. The 2nd Annual PAMCA conference will build on the momentum generated following the successful hosting of the 1st PAMCA Annual Conference in Nairobi, Kenya. The main objective is to bring professionals, students, research institutions and other stakeholders working in mosquito control and mosquito-borne diseases research together under common agenda to discuss the challenges of emerging and re-emerging mosquito-borne diseases across the African continent. The conference will seek to illuminate this subject of emerging mosquito-borne diseases and develop progressive resolutions that will serve as guidelines to tackling this challenge going forward. The conference will also offer a platform for participants to exchange knowledge and ideas on mosquito control, forge new collaborations and strengthen existing ones.

We hope that colleagues will submit abstracts soonest focusing on the various conference themes:

  • Emerging mosquito-borne diseases: new Public Health challenges
  • Mosquito resistance to insecticides and population genetics
  • Translating research into practice: Linking interventions to mosquito behavior
  • Multidisciplinary approaches to tackling mosquito-borne disease
  • Mosquito biology & ecology
  • Impact of climate change on mosquito control

 

Association of Women Doctors of Senegal joins the “Zero Malaria! Count Me In!” campaign to eliminate malaria in Senegal

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

International Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the first feature on women fighting malaria.

Amy Ndao Fall

Amy Niambo Ndao Fall, President of the Association of Women Doctors

Dr. Amy Ndao Fall is the President of the Association of Women Doctors of Senegal (AFEMS). This Association, composed of 400 members across the country, aims to undertake sustainable activities for the health of the Senegalese populations.

On the eve of Women International Day, in partnership with the Ministry of health and UN women, AFEMS organized in Dakar on March 7, a conference on the theme “women’s health for an emergent Senegal”.

This conference attracted approximately 150 women from all over the country and was chaired by Professor Awa Marie Coll Seck, Minister of Health and Social Action of Senegal.

The conference started with Dr. Ndao signing a pledge, on behalf of AFEMS to support the “Zero Malaria, Count me In” campaign and the National Malaria Control Program in their elimination efforts.

Dr. Ndao stated the association’s commitment to support all efforts toward malaria elimination in Senegal and abroad and concluded with the following words:

ZeroPalu“It is a pleasure and an honour for me, to sign this engagement on behalf of AFEMS, to mobilize all our efforts to eliminate malaria in Senegal. We need to keep in mind that women are particularly vulnerable to this disease and that they can be change agents in their families for more efficient vector control in particular by promoting the systematic use of long lasting insecticide-treated mosquito nets for all their family members.”

On this International Women Day, we celebrate and thank Dr. Ndao and all the women Doctors of Senegal for their leadership and commitment to eliminate malaria and are proud to see such amazing partners joining efforts to make Zero Malaria a reality in Senegal.

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Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

A new working group to support malaria elimination in the Amazon region

DR Antonio Quispe of our Social and Behavioral Foundations of Primary Health Care has posted the following on the course blog site:

Malaria Elimination Working Group, Iquitos-Peru, February 2014

In February 2014, the Malaria Elimination Working Group (MEWoG), in partnership with the Peruvian Ministry of Health (MoH), hosted its first international conference on malaria elimination in Iquitos, Peru. The two-day meeting gathered 85 malaria experts, including 18 international panelists, 23 stakeholders from different malaria endemic regions of Peru, and 11 MoH authorities.

Several key conclusions and points of consensus arose from this meeting. The most important one is that malaria elimination in the Peruvian Amazon is an achievable and nationally and internationally important goal. It will be important to develop a Comprehensive Regional Strategic Plan, which must satisfy several key characteristics.

It was strongly recommended to first, pilot such strategy in suitable sites in the region to establish efficacy and acceptability.

As such strategy is implemented, it will be important to monitor and evaluate progress through a variety of metrics and to set intermediate goals on the path to regional elimination. Targeted parasite elimination strategies that are appropriate to the region must be used, stressing active case detection using sufficiently sensitive and effective RDTs and species-specific treatment of the asymptomatic reservoir.

This is particularly important in the case P. falciparum malaria, which must be treated with ACT and primaquine to interrupt transmission. The strategy must include and facilitate communication between key stakeholders from the region and political support at all levels of government, and the program should be incorporated into established health systems to improve acceptability and sustainability.

The progression of such strategy should be flexible to allow new knowledge of the social determinants of malaria, the cultural acceptability of key interventions, and novel tests and treatments to be incorporated throughout the effort. With this conference, an agreement on the relevance of pursuing malaria elimination as goal has been reached, and the necessary components characteristics of this effort described.

Moving forward, further detail should be elaborated as commitments from numerous key stakeholders are obtained.

(see more on malaria elimination in the Americas – PAHO)

Press Release: Bangladesh joins APMEN as new Country Partner

Bangladesh joins the Asia Pacific Malaria Elimination Network (APMEN) as Country Partner

apmen_bannerThe Asia Pacific Malaria Elimination Network (APMEN) is pleased to announce Bangladesh as the 16th Country Partner to join the Network.

APMEN brings together countries in the Asia Pacific region that have adopted a national or sub-national goal for malaria elimination, and connects them with a broad range of regional and global malaria partners to develop best practices for eliminating the disease. By strengthening linkages in eliminating countries, APMEN addresses important regional challenges such as Plasmodium vivax, and provides a forum for the discussion of important issues such as the spread of anti-malarial drug resistance.

Malaria remains endemic in 13 of the 64 districts in Bangladesh, and more than 13 million1 people are still at risk of the disease. Malaria control and elimination activities fall under the National Malaria Control Program (NMCP) of the Ministry of Health and Family Welfare. The NMCP is currently aiming for malaria pre-elimination in four districts, with the goal of Bangladesh becoming malaria-free by 2020.

Director of Disease Control in Bangladesh and Public Health and Infectious Disease Specialist, Professor Be-Nazir Ahmed, expressed his gratitude towards APMEN at the formalization of this important partnership, saying that it is another step forward for Bangladesh and the region to eliminate the disease.

The spatial distribution of Plasmodium falciparum malaria endemicity map in 2010 in Bangladesh - http://www.map.ox.ac.uk/browse-resources/endemicity/Pf_mean/BGD/

The spatial distribution of Plasmodium falciparum malaria endemicity map in 2010 in Bangladesh – http://www.map.ox.ac.uk/browse-resources/endemicity/Pf_mean/BGD/

“Bangladesh is moving very quickly towards elimination after concerted national efforts to focus on malaria control,” Professor Be-Nazir said.

“By joining APMEN, Bangladesh now has many windows of opportunities to learn from other eliminating countries in our region as we face similar challenges.”

According to the World Health Organization, Bangladesh has reduced the number of confirmed malaria cases from nearly 440,000 in 2000 to less than 30,000 in 2012; a 93% overall decline2. The success is a result of intensive control interventions such as high coverage and increased use of insecticide-treated nets, increased use of rapid diagnostic tests and effective antimalarial treatment, as well as the deployment of a high number of community health workers in collaboration with NGOs and augmenting services at the health facilities. The combination of technical and human resource capacity serves as a strong example of how national and international efforts can lead to reduced malaria transmission3.

Bangladesh, like many other APMEN Country Partners, face many challenges en route to its national elimination goal of 2020, namely  ensuring services  reach mobile populations in highly endemic districts such as the Jhum cultivators4, and sustaining commitment by the government, communities and development partners to malaria control and elimination.

Malaria was nearly eliminated from Bangladesh pre-1970, but never disappeared in the eastern border regions which are associated with tea gardens and forests. These districts have international boundaries with the eastern states of India and partly with Myanmar. In the 1990s, malaria re-emerged as a major public health concern.

A key Bangladesh public health organization, the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), joined APMEN as a Partner Institution in August 2013.

APMEN Joint Secretariat (UQ) Office, School of Population Health | Room 117 | Public Health Building, Herston Road | Herston Qld 4006| Australia,  Email: apmen@sph.uq.edu.au | Website: www.apmen.org |  Phone (within Australia): 07 3365 5446 | Phone (from outside Australia): 61 7 3365 5446

Guinea Worm, Inching Toward Eradication

Twenty-eight years ago efforts to eradicate guinea worm began in earnest. It was the UN Water Decade, and there was optimism that guinea worm could be the test case for success of the global effort to guarantee adequate and safe water for all.

gw_infographicAs can be seen in the CDC infographic, we have gone from 3.5 million cases to 148 during this time. As we reach toward the tail end of the worm, we find some challenges remain.

On the list of currently endemic countries one finds Chad. Chad was supposed to be in the pre-certification phase, but new cases appeared a few years ago.

Preliminary Guinea Worm Cases from 2011-13Sudan was the most highly endemic country until South Sudan gained independence and took the guinea worm cases with it. Recently a few cases have also appeared again in the Sudan itself seen in charts derived from CDC’s newsletter, Guinea Worm Wrap-Up.

Looking at the most recent data from early 2014, one can see that Mali is back to reporting no cases as have Ethiopia and Sudan for 2014. Caution is needed since transmission is more likely in the upcoming rainy season months than in the current dry period.

Preliminary Guinea Worm Cases from January to AprilWhat is common in these areas is either being in a state of conflict or bordering a conflict zone.  This makes efforts to detect cases and put interventions in place in a timely manner to prevent the next season’s transmission very difficult.

Unlike some other diseases, guinea worm has some relatively simple, epidemiologically appropriate and less expensive interventions like cloth water filters, abate/temephos for water source treatment and case containment.  Of course investments in improved water supplies will also solve the problem. But without easy access to the communities where transmission is occurring, the disease will persist at this incredibly low level.

Other disease elimination programs are equally affected by the problems of access and conflict, polio being a good example.  We know that malaria is also exacerbated in conflict situations, but in the locations where pre-elimination is near, like Swaziland, Botswana, South Africa and Namibia, the main concern is ensuring a strong health system to handle the additional surveillance tasks. Still we should not be complacent, because malaria is also endemic in these very sites where guinea worm stubbornly lingers.