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CTD/UNICEF/JC/96.1
UNICEF/WHO
JOINT COMMITTEE
ON HEALTH POLICY
GUINEA WORM ERADICATION PROGRAMME
INTERSECRETARIAT MEETING
12-13 FEBRUARY 1996
GENEVA, SWITZERLAND
Division of Control of Tropical Diseases
WORLD HEALTH ORGANIZATION
Background
and 5 more had fewer than 100 cases in
1995; essentially half of the dracunculiasis
remaining was to be found in one single,
conflict-ridden country; several countries
were reporting reductions of 75-95% for
the final quarter compared to the same
period in 1994; and at least 8 endemic
countries reported containing over 80% of
cases, even using the strict criteria
established for making such a claim.
Guinea worm disease has been
the object of a global campaign that was
initiated in 1980, in conjunction with the
beginning of the International Drinking
Water Supply and Sanitation Decade
(1981-1990).
The
eradication
of
dracunculiasis is a common goal for WHO
and UNICEF.
The World Summit for
Children aimed to eliminate guinea worm
disease (dracunculiasis) by the year 2000,
and in 1991 World Health Assembly
declared (WHA44.5) its "commitment to
the goal of eradicating dracunculiasis by
the end of 1995, this being technically
feasible given appropriate political, social,
and economic support".
Similarly, the
mid-decade goal of the World Summit for
Children was also to interrupt guinea
worm disease transmission in all affected
villages by the end of 1995. In September
1995, the 45th session of WHO's Regional
Committee for Africa (WHO/AFRO) urged
all the affected Member States (i) to "take
appropriate measures to maintain the
commitment of communities and other
partners until the disease is eradicated"
and (ii) to "strengthen community-based
active surveillance, while integrating it into
primary health care activities". Among
other things,
it also
invited the
Collaborating
Agencies
involved
in
dracunculiasis eradication to "maintain
their support to endemic countries in their
efforts to eradicate dracunculiasis".
Eradication Strategies
The basic strategy adopted for
eradication comprises a combination of
effective interventions and approaches:
•
Identification of all infected villages
•
Establishment of community based
surveillance and intervention in all
endemic villages.
Health education, distribution of
filter materials and • community
mobilization.
•
By the time of our present
meeting, dracunculiasis eradication has
been 97% accomplished, with the global
number of cases reduced from an
estimated 3.5 million in 1986 to
approximately 110,000 by the end of
1995, and a reduction in the number of
endemic villages from over 23,000 at the
end of 1992 to fewer than 8,000 at the
end of 1995. By that time, many of these
villages were experiencing just a handful
of cases each, and even the average
number of cases/village was only 14; one
country had already been free of
dracunculiasis since October 1993,
•
Targeting of appropriate
supply systems.
•
Development of case containment
measures,
currently
being
implemented
in
all
endemic
countries.
•
Monitoring of the dracunculiasis
situation through the use of
Geographic Information Systems
(GIS).
Integration
of
dracunculiasis
eradication activities with other
community
based
health
interventions.
•
1
water
•
Interagency collaboration, and
•
Certification of eradication.
Disease Global Incidence and
Control Efforts.
Very substantial progress was
made towards the eradication of guinea
worm disease in the first half of the
decade.
However, there remains
considerable work to be done - and
opportunities to be capitalized on - in this
disease eradication effort. The number of
cases of guinea worm disease has been
reduced by more than 95% over the past
decade, from an estimated 3.5 million
cases in mid-1980s to a reported
approximately 110,000 cases in less than
8,000 endemic villages in 1995. Most
countries have reduced the number of
reported cases of the disease by one-third
or more compared to 1994 - during 1994,
the global incidence was approximately
170,000 cases in 10,296 endemic villages.
Guinea worm disease is now endemic in
16 African countries in addition to Yemen
and India. It is no longer endemic in
Guinea,
Gambia
and
Pakistan.
Cameroon, CAR, India, and Kenya are
also on the verge of eradication.
Eradication efforts are already
having significant and beneficial impacts
on overall health, agricultural productivity
and school attendance.
Success in
eliminating Guinea worm disease greatly
strengthens
the
confidence
of
communities, families and individuals.
These achievements of the 18
endemic countries and their international
partners is all more remarkable since
national Guinea worm disease eradication
programmes only got underway in most
countries in 1990 or later.
Key partners with governments of
endemic countries continue to be,
UNICEF, WHO, Global 2000, the Carter
Center, USAID, the US Peace Corps, the
World Bank, the Japanese International
Cooperation Agency (JICA), the Canadian
International
Development
Agency
(CIDA), the government of Norway, the
French
Cooperation
and
other
governmental
and
non-governmental
agencies.
Globally, surveillance and at least
two or three control interventions are in
place in most accessible endemic villages.
With support from UNICEF, WHO, Global
2000 and others,
countries are
strengthening
the
monitoring
of
surveillance systems and programme
interventions. UNICEF and WHO are in
particular
collaborating
to
maintain
computerised epidemiological maps of
endemic areas, an increasingly important
tool in the eradication of this disease. In
addition, during 1995, all endemic
countries have initiated case containment
activities and nearly 33% of cases
reported have been fully contained for the
year as a whole, while at least eight
endemic
countries
were
reportedly
containing over 80% of cases by the end
of 1995.
Principal obstacles to eradication
have included conflicts and insecurity
such as those in parts of Mali, Ghana,
Ethiopia, Nigeria, Uganda and the strife
torn areas in and around Southern Sudan
where additional technical, operational
and financial assistance will be required.
Now, the threat of insufficient funding is
clearly threatening some national Guinea
worm eradication programmes, in spite of
the remarkable results they are achieving.
2
UNICEF/WHO
Collaboration
Key
Areas
effectiveness of other disease
control programmes such as polio
and
neo-natal
tetanus;
(iii)
strengthen the capabilities of
communities to identify, monitor
and act on local health problems
responsive to behavioral and local
environmental changes; and (iv)
strengthen the capability of health
centers
to
reach
out
to
communities
with
essential
services, and to be responsive to
the needs of the communities.
of
Collaboration is taking piace in
three main areas:
•
The UNICEF/WHO Interagency
Technical
Assistance
Team
(Itech).
Created in 1992 and
based in Ouagadougou, Itech aims
at providing ongoing technical
support to national guinea worm
eradication programmes in West
and Central Africa, UNICEF and
WHO country offices and other
interested parties. It concentrates
on
helping
with
effective
surveillance
systems
and
interventions. More specifically the
team has played a critical role in
strengthening capacities of guinea
worm disease endemic countries
in Africa in the community based
surveillance also required for the
eradication of poliomyelitis, the
elimination of neonatal tetanus and
in measles control. Itech also
supports countries in the planning
and implementation of programme
interventions
including
health
education and case containment,
and in monitoring of programme
performance. In September 1993,
a UNICEF Senior Project Officer
was placed in Kenya to fulfill
Itech’s functions in the endemic
countries of East Africa.
The
WHO/UNICEF
Joint
Programme on Health Mapping
&
Geographic
Information
System (originally known as
DEPGIS, now DataMap). Created
in
late
1993
within
the
Dracunculiasis
Eradication
Programme in the Division of
Control of Tropical diseases at
WHO, the initial objective of this
programme was to provide support
to
Guinea
Worm
endemic
countries in the development of a
Geographic Information System
(GIS), for monitoring of the
disease and eradication activities.
To date, a monitoring system has
been put in place in 20 countries
in Africa through the establishment
of a large databank of essential
village-level data. A GIS has been
established in 14 of the 16
endemic
countries
on
that
continent. GIS focal points were
identified and trained in automated
cartography, Atlas GIS, and in the
basics of using hand-held Global
Positioning Systems (GPS) units
for satellite determination of the
coordinates
of
latitude
and
longitude.
Digitized maps and
baseline
village
databases
including the locations of water
points, schools and health centers
were distributed to countries for
which the relevant information is
available.
During 1996-1997, it is planned
that the interagency assistance
team called Itech will change its
focus, in that its purpose is to be
considerably broadened.
The
work of Itech is now to emphasise
assistance for actions which will
simultaneously; (i) help eradicate
dracunculiasis; (ii) strengthen the
3
bilateral and multilateral channels they
may find appropriate, both UNICEF and
WHO will continue to seek funding for
their own activities towards helping
countries
interrupt
guinea
worm
transmission. WHO has estimated that $8
million will suffice to completely stop
guinea
worm
disease
transmission
globally, unless major difficulties are
encountered in currently conflict-ridden
parts of Sudan. WHO's certification-oferadication activities are expected to cost
an additional $ 2 million.
Mapping has presented itself as an
important
entry-point for
an
integrated
approach to data
collection and management and
provides an opportunity in terms of
strengthened inter-agency and
inter-sectoral collaboration efforts.
In 1996-1997, there are plans to
continue this area of collaboration
between UNICEF and WHO.
Operational objectives include: (I)
extending
the
system
to
incorporate all villages in the
concerned
countries,
(ii)
developing a system to include
other health and social indicators;
and (iii) the strengthening of
technical capacities for mapping
and database development in all
20 countries of interest.
Joint UNICEF/WHO appeals to
donors for support of country
programmes. In the current
situation, where countries are at
risk
of
faltering
in
their
dracunculiasis eradication efforts
for lack of sufficient funding to
maintain case-containment and
disease surveillance activities at
the 1995 level, just when they are
closely approaching the goal of
guinea worm eradication, UNICEF
and WHO have explored the
possibility of co-ordinated appeals
to interested donors.
Both
UNICEF and WHO find
it
particularly disconcerting that this
funding gap is widening just as
countries are getting so close to
dracunculiasis eradication, and in
spite of the recent impressive
achievements described in the
introduction.
In addition to encouraging donor
countries
to
fund
dracunculiasis
eradication efforts through whatever
4
Next Steps
Future priorities
In reaching out to remote villages,
guinea
worm
disease
eradication
programmes have been able to build
health systems capacity which both
organizations hope can provide a
foundation for other basic, community
based health interventions - such as
surveillance for vaccine preventable
diseases, community health education
and improved nutrition - in these
previously under-served communities.
The
goal
of
dracunculiasis
eradication has enabled a vast monitoring
system to be put in place in 20 African
countries. This large databank, providing
essential village-level statistics, can be
used to track disease, identify targets,
support decision-makers and provide
information for overall management and
planning. Many other disease control
programmes such as the Onchocerciasis
Control Programme [OCP], the African
Onchocerciasis
Control
Programme
[APOC],
Dengue,
Leprosy,
Malaria,
Schistosomiasis and Sleeping Sickness
programmes have requested the resources
and technical expertise now available. To
respond to these requests and to ensure
that the technical capacities and resources
can be maximised to the full, GIS is being
expanded to:
The challenge now is to ensure
that the remaining cases of dracunculiasis
are eliminated as quickly as is technically
feasible - through surveillance combined
with
case-containment,
and
other
interventions - while accelerating efforts to
incorporate
guinea
worm
disease
eradication into a broader framework that
responds to other causes of infant and
child
morbidity
and
mortality and
contributes to the major goals for "Child
Survival, Development and Protection" in
a synergistic fashion.
•
provide mapping services to other
disease
control
and
public
health
programmes;
•
to cover a greater geographic area
comprising all countries in Sub-Saharan
Africa as well as to those countries who
specifically request a service;
In May 1995, WHO's Director
General established the International
Commission for the Certification of
Dracunculiasis Eradication, which is to
have its first meeting in Geneva on March
5, 1996.
WHO also added one
professional to its staff during 1995, to
help with the final phase of the eradication
effort and with the process of certifying
dracunculiasis eradication.
Seventy
countries will need special attention during
this certification process, which should be
completed 3 years after the last case of
guinea worm
disease is reported
anywhere in the world.
•
to
continue
developing/
strengthening
in-country
technical
capacities in mapping and database
management through the delivery of
specialised training programmes.
Whereas some expansion of the
system has taken place during 1995, most
of the efforts in this respect will be focused
on the biennium 1996-1997, for which a
Plan of Activities has been developed.
DIS'3o<>
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ano
Dracunculiasis
Currently endemic countries
Previously endemic countries considered at high-risk
Previously endemic countries considered at low-risk
Number of reported cases of dracunculiasis in 1994 and 1995 *
■■ 53'271
Sudan
I 49o08
39'774
Nigeria
Niger
Uganda
Ghana
Burkina Faso
Mali
Cote d'Ivoire
Togo
■ 1994
Mauritania
Benin
□ 1995
Ethiopia
Chad
India
Senegal
Yemen
Kenya
Cameroon
Pakistan
0
* Provisional
10'000
20'000
30'000
40'000
50'000
60'000
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