Eradication = elimination, one country at a time

Guinea worm is close to being eradicated.  This disabling water-born helminthic disease attacked millions of people annually from West Africa through to South Asia about 20 years ago. International eradication activities took shape in the late 1980s, and today only Mali, Ethiopia, Sudan and Ghana had only 1948 cases among themselves during the first 7 months of 2009.

nigeria-erad-chart-line-carter-center.jpgTwenty years elapsed from Nigeria’s first national guinea worm case search survey, which documented that 653,492 people had suffered from the disease during the 1987-88 until the last victim was identified in November 2008. According to the Carter Center

… her worm has made her a minor celebrity. The fact that Otubo can be specifically identified as the final victim of the disease in her country shows the relentless tracking required to eliminate Guinea worm disease. Thousands of volunteers have worked in Nigeria since 1988, documenting every case of the disease and providing the tools and education necessary to defeat it.

Nigeria still needs to maintain surveillance for at least another year, or two years total after the last reported case, before it can be certified by WHO as having eliminated guinea worm.

Guinea worm was initially thought to be relatively easy to eradicate. The vector stays put in ponds until people come to collect drinking water. It is seasonal, and there are no other reservoirs of the disease besides humans. Thus, 1995 had been initially set as the date by which guinea worm was to have been eliminated from all endemic countries – i.e. eradicated. But in 2007, WHO said

… meeting eradication targets by 2009 is overly optimistic. To achieve this goal, it is necessary to deploy adequate human and financial resources. Guinea-worm disease is now solely a problem of the African continent: providing safe water to poor populations may immediately solve this problem. However, this is not anticipated to occur in the near future.

If guinea worm eradication has been so elusive, what of malaria? The financial resources are only now reaching levels that might have some impact if interventions can be scaled up AND sustained.

As Carlos Campbell observed in mid-2009, malaria “Programs in Equatorial Guinea, Ethiopia, Rwanda, Zambia, and Zanzibar have shown that when coverage of these interventions exceeds 50 to 60% of the population, the prevalence of infection withmalaria parasites and mortality among children from such infection falls by 20 to 25% within 12 to 36 months.”

If we can achieve 80% coverage in 2010 and reach 50% mortality reduction by 2015, we will be well on the road to elimination.  Detours may arise from drug and insecticide resistance, threats to funding and basic fatigue from communities, program staff, politicians and donors.  In the meantime advocacy, monitoring, surveillance, evaluation and biomedical and operations research need to continue to anticipate and prevent these detours.

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