International Notes Update: Dracunculiasis Eradication -- Pakistan, 1990

Dracunculiasis (guinea worm disease) is a disabling infection that affects an estimated 10 million persons in 17 African countries and parts of India and Pakistan each year (1,2). In 1987, the Pakistan Dracunculiasis Eradication Program was established with the goal of eradicating dracunculiasis from Pakistan by 1990. This report summarizes progress toward that goal.

The program, which is assisted by Global 2000, Inc., and the Bank of Credit and Commerce International Foundation, conducted a national survey in 1987 for cases in Pakistan's estimated 48,000 villages to determine the location and incidence of the disease. In each village, surveyors used case recognition cards to ascertain whether cases had occurred during the previous 2 years and to determine the number of current cases (none, 1-9, or greater than or equal to 10). The search indicated that the distribution of dracunculiasis was focal and involved less than 500 villages and approximately 2400 cases in the disease-endemic provinces of North-West Frontier, Punjab, and Sind (3) (Figure 1). The estimated population in these affected villages was 361,000.

In February 1988, active surveillance and control activities were implemented in all known affected villages (4). Village "implementors" were assigned to each disease-endemic village to conduct monthly searches for cases, record each case in village case registers, report these cases monthly to regional managers, implement hygiene education to promote filtration of unsafe drinking water through cloth filters, and distribute cloth filters and monitor use of the filters by villagers. During the transmission season (May-September), field health workers applied temephos (AbatePr*) each month to unsafe sources of drinking water in each of the affected villages to reduce populations of the intermediate copepod hosts.

The coverage of intervention measures and the effectiveness of surveillance activities were evaluated in late 1988 and in 1989. Further epidemiologic investigations of the disease-endemic areas in 1988 increased the total number of villages under surveillance to 530. Early in 1989, 40 sector supervisors were assigned to improve supervision of village implementors.

In January 1990, a case-containment strategy was implemented to prevent secondary transmission from cases occurring during the transmission season. Specific goals established for health workers were to 1) detect each new case of dracunculiasis within 24 hours and apply topical antiseptics and occlusive bandages to infected patients to reduce contamination of drinking water sources, 2) instruct each infected patient about dracunculiasis and the importance of not entering a drinking water source, 3) reinforce the importance of filtering drinking water and ensure that each household has cloth filters and knows how to use them properly, and 4) ensure treatment of local water source(s) with AbateR. In greater than 86% of the cases that occurred through August 1990, control measures were initiated within 24 hours of emergence of the worm. Because of the 1-year incubation period of Dracunculus medinensis, however, the overall impact of the case-containment strategy cannot be assessed until the 1991 transmission season.

In 1990, a cumulative total of 160 cases in 56 villages were reported, compared with 534 cases in 146 villages in 1989 and 1110 cases in 156 villages in 1988 (Figure 2). Thus, the decline in the number of cases in 1990 from 1989 was 70%, compared with 52% for 1988 to 1989 and 54% for 1987 to 1988. Reported by: National Institute of Health, Pakistan. WHO Collaborating Centre for Research, Training, and Eradication of Dracunculiasis. Global 2000, Inc., Carter Center of Emory Univ, Atlanta, Georgia. Div of Parasitic Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The goal of a dracunculiasis eradication program is to reduce disease incidence to zero cases. Implicit in this goal is the need for active surveillance to 1) rapidly detect the location of all disease-endemic villages; 2) monitor operational campaign procedures to maximize efficiency, including the appropriate use of case-containment measures to prevent secondary transmission; and 3) adequately document the reduction in disease incidence resulting from control efforts. Substantial reductions in the incidence of dracunculiasis since 1987 indicate the potential for Pakistan to become the first disease-endemic country to document the eradication of dracunculiasis and attain World Health Organization certification of eradication.

In areas where dracunculiasis is widespread and incidence is high, active surveillance can target village-based control interventions with maximum effectiveness to produce rapid and substantial reductions in disease incidence. However, in areas with relatively few cases, incidence can be reduced to zero more quickly and effectively if all cases are rapidly detected and investigated and stringent containment measures are implemented to prevent secondary transmission. To halt transmission of dracunculiasis by a specified target date, eradication programs should incorporate efficient case-containment measures into existing surveillance and control strategies. Case-containment measures are particularly appropriate for achieving zero case levels in areas where incidence levels of dracunculiasis are already low (e.g., Cameroon, India, and Pakistan).

References

1. CDC. Update: dracunculiasis eradication--worldwide, 1989. MMWR 1990;38:882-5.

2. CDC. International Task Force for Disease Eradication. MMWR 1990;39:209-12,217.

3. World Health Organization. Dracunculiasis. Wkly Epidemiol Rec 1988;24:177-84.

4. World Health Organization. Dracunculiasis. Wkly Epidemiol Rec 1990;40:305-12.

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