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close this book Opportunities for Control of Dracunculiasis (1982)
close this folder Recommendations
View the document For Government Authorities In Endemic Countries
View the document For International Or Bilateral Assistance Agencies

Recommendations

Workshop participants discussed various methods for assessing the problem, possible intervention strategies, several options for monitoring and evaluation of programs, and suggested priority areas for research related to dracunculiasis. The results of these discussions are included in this report to help authorities in countries where dracunculiasis is endemic to determine which control measures may be most appropriate.

Many other water-related diseases affect large numbers of people in countries where dracunculiasis is endemic, and program efforts targeted solely on this one problem may appear difficult to justify. However, taking humane and practical considerations into account, dracunculiasis is exceedingly painful, is easily diagnosed, and effective methods for controlling it are already known. Moreover, the International Drinking Water Supply and Sanitation Decade (1981-1990) presents an unprecedented, transient opportunity to reduce the incidence of this disease everywhere it occurs. The obvious next step is for endemic countries to start implementing control activities suited to their needs and resources immediately, and for international and bilateral agencies to assist them, if requested.

Many of the recommendations that follow are intended to apply to those situations in which water supply improvements are not imminent, thereby warranting initiation of control efforts targeted solely on dracunculiasis. The additional costs of such efforts are easily justified in these special circumstances, given the high likelihood of eliminating the infection from a given area within 2-4 years, and the possibility of assigning control activities to existing national and state programs. By comparison, maternal and child health care services, water supply and sanitation systems, and many communicable disease control programs will have recurring costs for many years to come.

Workshop participants were reluctant to make estimates of costs for each type of control activity because there is so little experience from which to generalize. They agreed that it would be important for national authorities and assistance organizations to design and carry out pilot projects so that costs can be carefully monitored. Control activities should be integrated into existing programs (e.g., immunization, agricultural extension services) whenever possible to reduce fuel, salary, and transportation costs.

For Government Authorities In Endemic Countries

- It is recommended that public health authorities in all countries with any reported (or suspected) cases of dracunculiasis assess the extent of the dracunculiasis problem at the national level. Such an assessment can be based on analysis of reported cases and/or responses to a questionnaire sent to district or provincial health officers and to other appropriate officials in the country.

- In each endemic country, appropriate steps should be taken to facilitate the reporting of cases of dracunculiasis.

- Each endemic country should select strategies for controlling dracunculiasis and should prepare a written plan of action that includes a pilot-project phase and a training component. The plan of action should specify the collaborative roles of health, water, education, administrative, agriculture, and finance sectors, where appropriate, in implementing the program. The ministry of health should probably be responsible for identifying endemic regions and villages within regions and for making that information known to water works authorities and other relevant agencies. Water works authorities should give priority to dracunculiasis-affected areas wherever feasible.

- Endemic countries should take maximum advantage of resources mobilized for the International Drinking Water Supply and Sanitation Decade to provide dracunculiasis-endemic villages with protected water sources on a priority basis. When all endemic villages have been identified, the proportion of those that can be provided safe drinking water as a part of already planned activities should be determined, after which other national or international resources should be sought to support provision of safe water to the remaining endemic villages and to support other program activities designed to reduce the incidence of dracunculiasis. Relevant donor activities should be coordinated systematically within a countrywide plan.

- Control efforts should include health education of people living in endemic areas. The goal of these efforts is to mobilize members of affected communities to act against dracunculiasis, including local efforts for improving and maintaining water supplies, preventing people with patent dracunculiasis from contaminating water sources, adopting personal protective measures, reporting cases, and cooperating with other aspects of the program.

- A standardized treatment protocol should be developed for health clinic personnel, specifying the appropriate care for patent dracunculiasis cases and emphasizing that preventive measures should receive first priority. Because of its rural distribution, dracunculiasis patients are likely to make initial contact with the primary health care system.

-The school system of affected countries should help extend the program throughout the country by reporting cases and disseminating information about personal protective measures. Some endemic countries may wish to encourage university researchers to address applied research issues identified during the national control program.

- Endemic countries may wish to designate the elimination of dracunculiasis as a national goal. Progress can be monitored and achieved through effective control efforts in affected villages, leading to elimination of the disease at the village, provincial, and district, and then national, levels.

- It is recommended that priority be given to applied research in the following areas:

- Development and evaluation of prototype health education materials for use in affected communities

- Development and standardization of field methods for species identification and quantification of cyclops vectors and D. medinensis larvae

- Comparison of the efficacy and cost of different intervention methods

- Evaluation of techniques for analysis of patterns of community water use.

-It is recommended that priority be given to biomedical research in the following areas:

- Development of therapeutic (e.g., chemotherapy) or preventive (e.g., chemoprophylaxis) measures that either are capable of destroying or sterilizing female D. medinensis worms to prevent subsequent patency and/or release of,viable larvae or are capable of destroying early stages of the worms soon after infection. Controlled clinical trials of antihelminthic drugs to find one that will kill D. medinensis larvae before the worms mature and emerge, with no harm to the human host, should be strongly encouraged.

- Ecologic studies of conditions in surface waters favorable or unfavorable to infestation of cyclops, should be conducted.

For International Or Bilateral Assistance Agencies

- It is recommended that international and bilateral assistance agencies encourage endemic countries to give priority support to villages with dracunculiasis as part of national and regional potable water plans.

- Internationsl and bilateral agencies should review rural development projects under way or planned in countries with endemic dracunculiasis for opportunities to incorporate or initiate specific activities designed to control the infection,especially in those instances where agriculture, health, and education programs would not reduce the incidence of dracunculiasis.

- International agencies should undertake themselves, or should coordinate programs and funding, to:

- Make consultants available to countries that wish to assess their national dracunculiasis problem, establish surveillance systems, or carry out control activities. Such consultants might include specialists in epidemiology, vector biology, health education, parasitology, or rural water supplies and sanitation.

- Fund research and operational studies pertinent to control of dracunculiasis, especially in association with water development projects.

- Help document the impact on the disease of projects that already provide safe drinking water to populations in dracunculiasis-endemic areas and obtain reliable estimates of program costs associated with various types of control strategies.

- Publish and publicize training manuals and guides for dracunculiasis control programs in languages appropriate for mayor endemic regions of the world.

- Monitor progress in eliminating dracunculiasis from endemic areas.

- Promote and assess technical or scientific breakthroughs pertinent to control of dracunculiasis.

- Supply temephos or other recommended pesticides to national control programs at reasonable cost.

- Sponsor demonstration projects in several endemic regions with different climatic and cultural conditions.

- Sponsor annual or biannual meetings of a small group of international experts to review the status of global anti-dracunculiasis efforts and to make further recommendations for future efforts. The site for such meetings might rotate among the mayor endemic areas of India and West Africa, and perhaps WHO headquarters in Geneva.