certifying elimination of guinea worm – lessons for malaria

The efforts to eliminate guinea worm from Nigeria are coming to a close 28 years after the challenge was taken up at national conference in 1985. At the time there were over 650,000 cases in the country. In just eight years between 1988 and 1995 Nigeria saw a precipitous decline in cases down to 16,374 as seen in the attached map from the Carter Center.

nigeria-erad-chart-line-2009-zero-sm.jpg1995 had been posited as the first target date for global guinea worm eradication (see countdown calendar page below), and while efforts came close to eliminating it in Nigeria, the process dragged on for 14 more years until we reached zero annual reported cases. Now there are only a few countries left. The last verifiable case in Nigeria was November 2008. What is the process of ensuring that guinea worm has been eliminated from Nigeria?

A major step over the past few years has been to maintain surveillance since guinea work thrives from neglect.  As Steve Dada from This Day reported, “WHO officials say finding and containing the last remaining cases of the disease is the most difficult stage of the eradication process, because cases usually occur in remote, hard-to-reach areas.” The communities were involved, as evidenced from a radio announcement heard in Jos, Plateau State last Saturday in which people were encouraged to keep looking for the disease.Surveillance efforts have even made use of events like national immunization days to seek out information on possible cases.

As reported recently in the Vanguard, “The Federal government is offering a cash reward of N25,000 (~$160) for every report of authentic new guineaworm cases in any part of the country. In 2011, a N10,000 reward was offered for a similar report.” So far no authentic case has been found, but indigenous beliefs about the disease has meant many false positives over the years, accounting for the many rumors reported by the Vanguard. These efforts are part of the program to prepare Nigeria for a visiting team from the World health Organization in June 2013 to certify elimination.

dscn0361-a.jpgIn preparation for eventual certification of all countries, WHO established in 1995 “an independent International Commission for the Certification of Dracunculiasis Eradication in 1995. The Commission comprises 12 public health experts from all six WHO regions.”  WHO explains that, “A country reporting zero cases over a period of 12 consecutive months is believed to have interrupted transmission of dracunculiasis and is classified as being in the pre-certification stage … After at least three years of pre-certification and consistent reporting of zero indigenous cases, a country becomes eligible for certification.”

What does all this mean for malaria? First, even though we are talking about a process in Nigeria that spanned nearly three decades, this is relatively short.  The characteristics of guinea worm disease (and even small pox, its predecessor in eradication) make it relatively easy to spot. Few people could confuse a worm emerging from one’s body, as seen in the photo from the Carter Center, with another disease. One does not need a microscope either.

foot-close-up2-sm.jpgWe have been reminded recently that malaria parasites can even ‘hide’ at submicroscopic levels without causing any symptoms. Even with malaria symptoms there is easy confusion by the public with other diseases. We are certainly nowhere near the point of offering $100 rewards for detection of malaria cases.

There are a number of other key differences such as a ‘vector’ that stays in the pond for guinea worm, while malaria carrying mosquitoes can fly a few miles.  The key lesson therefore, is the need to adapt elimination efforts and timelines to the realities of each disease.  So while we will not be giving financial rewards for case detection just yet, we should continue to give recognition to Malaria Champions like President Joyce Banda of Malawi.

Another lesson is the fact that WHO established its guinea worm elimination certification process long before all countries were close to reaching goals.  This can help malaria program planners envision the surveillance processes they will need to out in place to eliminate the disease, especially since it will likely be, like guinea worm, hiding in the more remote and poor areas of a country.

Finally we must congratulate Nigeria in its guinea worm elimination success and hope this provides motivation for malaria elimination, too.

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