We encourage the malaria community to learn lessons from other disease elimination and eradication programs. Guinea worm appears to be on its last ‘legs’, and we need to consider how it dropped from over 3 million global cases annually in the 1980s to around 3,000 now.
Nicholas Kristof of the New York Times has encouraged people to take heart in efforts to eliminate the disease from Sudan, one of the apparent four remaining strongholds of the disease. He has written a ‘good news column’ from Sudan and stresses that, “This district (where he is visiting) is, in fact, one of the last places on earth with Guinea worms. If all goes well, Guinea worms will be eradicated worldwide in the next couple of years â€” only the second disease ever to be eliminated, after smallpox.”
The additional ‘couple years’ should be seen in the context of initial efforts that set the target date for global eradication at 1995.Â No one says eradication – the total elimination of a disease from the world – is an easy task, but preventing people from drinking guinea worm infested pond water is a little easier than preventing malaria.Â If guinea worm eradication is overdue, what can we say about hopes expressed in recent years to eradicate malaria?
Yes, we too like to look for good news. Donald Hopkins of the Carter Center (see photo) told the New York Times recently that, “After 20 years, the Carter Center is ready to declare a major victory in its war on guinea worm: Nigeria, once the worst-afflicted country in the world, appears to be free of the worms. It will take two more years for the World Health Organization to make it official, but not a single worm has been found in Nigeria for 12 consecutive months.”
Why more years? Certifying that a disease is no longer in a country requires continued surveillance after the last known case. Specifically, those countries that had active transmission when the eradication efforts started around 1986 “need to continue surveillance for three years after reporting zero cases and should then be visited by an International Certification Team (ICT) to ascertain that the country is disease-free. The country report and ICT report are presented to the Commission.”
Tayeh and Cairncross drawing lessons from the guinea worm eradication certification process for other diseases explain that, “It is important to reduce the cost of certification and at the same time to ensure that interruption of the disease transmission has really taken place. It is also important not to overload a countryâ€™s health system with work when the disease is no longer a public health problem and interest in it has waned.”
IRIN reports that, “Some 80 percent of cases worldwide are in Southern Sudan, a region left in ruins by a 22-year long civil war,” where a settlement was reached only in 2005.Â This is another lesson for malaria elimination since the disease actually thrives in war torn areas with diminished amenities, housing and health care.
Kristof ends his column thus: “My favorite moment came when we were bouncing along with Anyak (a local child) toward the Carter Center compound. I asked him what he wants to be when he grows up, and he answered with the most prestigious and altruistic position he could imagine: ‘Iâ€™d like to be a Guinea worm volunteer.'”
Hopefully guinea worm will truly be eradicated before Anyak grows up. Maybe he can then focus his career goals on malaria instead. We will need such people of dedication to maintain the long years of surveillance needed to certify the end of malaria when it comes.