The key to eradicating Guinea worm disease is “surveillance, surveillance, surveillance.” (More)
This is Part 3 of my interview with Craig Withers, the Director of Program Support at The Carter Center. In Part 1, we talked about the political and cultural challenges The Carter Center faces in their efforts to eradicate Guinea worm disease. In Part 2, we discussed how The Carter Center helps people gain and maintain access to safer water as part of their Guinea worm eradication efforts. Tonight our interview concludes with how The Carter Center responds to outbreaks of Guinea worm disease.
Craig Withers has more than 20 years experience in public health policy. He received a Master of Business Administration in international business and a Master of Health Administration in health planning from Georgia State University, and a Bachelor of Science from the University of Notre Dame. His honors include awards for work done as special assistant to the deputy director of the National Institute for Occupational Safety and Health program at the Centers for Disease Control and Prevention.
LT: Active monitoring is required to ensure that new cases of Guinea worm disease are caught early and to facilitate certification eradication of the disease. That must be an enormous undertaking. How do you gather and follow up on Guinea worm disease cases? And what are the most critical parts of that effort?
CW: First, before I answer that question, there is a quote that comes to mind from Dr. D. A. Henderson. He was the director of the smallpox eradication program for the World Health Organization and seconded from the U.S. Centers for Disease Control at the time. When he was asked: “What was the key to eradicating smallpox?” he said “Surveillance, surveillance, surveillance.”
And that is pretty much the attitude we that have here at The Carter Center. We try to do everything we can to make sure we have a strong surveillance system and that feeds into the opportunities for intervening and stopping transmission.
The first critical component is that we engage each endemic village, and help them select one or more village volunteers. Their role is to look for cases, to help with health education, provide supplies like filters to help stop transmission, and to facilitate containing cases. I’ll elaborate a little bit more on that.
First, after the village selects one or more village volunteers, the program will train, supply, and supervise them on a regular basis. And all three of those components are essential to keeping the village volunteer engaged and working effectively for the program. We don’t pay them, but we have found that volunteers are effective if you provide good training and keep them well supplied with the materials they need to carry out their job – whether that’s a case registry for reporting cases, or in some cases if they’re in a large village and they have to get around, providing them something like a bicycle to get around. We also need regular supervision in which the supervisor is not only collecting information but also giving feedback on their performance, checking their work, giving advice on how to do things better, and acting as a sounding board if they have questions. All of this is very important in keeping the village volunteer motivated and doing their job.
Now what we want the village volunteers to do is, on a daily basis, go around the village and look for active cases. If they find a case, then what they would try to do is within twenty four hours of the worm emerging, they bandage and treat the case, warn the community, get a history of any movements this person may have made within the past twenty-four hours, and treat any water sources the patient might have contaminated. And they try to do that within twenty-four hours.
Then, once they have a case, they notify their supervisor. The supervisor, who we want to a village visit as frequently as on a weekly basis, will be aware of the case and try to get to that village quickly and confirm whether this is a true case. They will then try to verify the information and make a determination whether that case has been contained. Containment means that it did not contaminate any water sources by putting the burning wound in a water source, and that the case was identified within twenty four hours of the worm emerging.
Then the supervisor, on a monthly basis, will go and get what we call the case registers for each village volunteer. In this case register, the village volunteer records each and every case that has been found during the month, and its status. The supervisor will take that data, aggregate it with data from other villages, and give a summary report for each village, to the next level up. And this will continue all the way up. The way that the system works is that, twenty-one days after the end of each month, the central level will have data on all the cases of Guinea worm found for the month.
So by July 21st, the national program coordinator in South Sudan will have a summary report of every Guinea worm case that occurred in June. Then they will report that to The Carter Center and the World Health Organization. It’s a very demanding system, and we do this rigorously.
In addition to that, each village volunteer has a first aid kit. That will have bandages, scissors, some analgesic to help reduce pain, and may have antibiotic cream to prevent infection. They will treat each and every case that they find, and we will keep them supplied with all of the materials needed for a first aid kit.
Another thing a village volunteer does is go around household by household and inspect the household water filters for holes. If there is a hole, the infectious agent could slip through into the drinking water, and you don’t want that. They replace those filters on an as-needed basis. Usually, a filter will last four to six months, so we typically replace filters two or three times a year.
In addition to that, we have what we call case containment centers (photo link). If a village volunteer believes a worm is about to come out, or has just come out, oftentimes we will encourage the patient to voluntarily go to a case containment center. It may be in that village, or may be in a health facility nearby. And in those situations we encourage them to stay in those case containment centers where they receive free daily care. They will receive three square meals a day for free, and will be taken care of until all of the worms – because 50% of the time you’ll have more than one – have emerged.
Oftentimes, as part of an incentive for them to remain, when they stay for the whole period of a worm to emerge and be removed – which can take several weeks – we will give them something like a blanket and allow a family member to stay with them. Or, in Ethiopia for instance, we used to give them a goat to take with them, as a reward for staying in the containment center. That becomes very valuable. If the experience is a positive one, that person will go back to the village and say listen: “If you’ve got Guinea worm, you ought to report that, because you’ll be taken care of.”
That provides an additional surveillance system, if you will, and impetus for people to report cases.
Also, when a case is found, a village volunteer will get a case history. As I said earlier, if any pond, or water source has been touched by a worm, they will treat that pond with the safe chemical larvicide ABATE® immediately. It takes about two weeks for the larvae to mature to the point where they’re infectious, so if you treat immediately, you can take care of the problem, and no transmission will take place. So that’s a very quick summary that describes how we function in the field.
It’s very demanding. It requires a lot of outreach in the field, and constant interaction with the village, villagers, as well as the village volunteer.
LT: The eradication program has been a lengthy effort that involved many partners. Who are some of the major contributors to the effort that you would like to mention and how did they help in the effort?
CW: As far as partners I think there is an important point to make. We differ from a lot of non-governmental organizations working overseas in this regard, in that our primary partner, in each country in which we have a presence, is the ministry of health. Because the way we work, it’s the ministry of health staff at the national and state and local levels that actually implement this program. The supervisors for the most part are health staff, they are not Carter Center staff.
Our role is to provide technical, administrative, and financial assistance to the program. But each program has a national program coordinator from the ministry of health, and they make the final decisions on what the program should or should not do. And that’s very, very important. So when we talk about partners, first and foremost, head and shoulders above all other partners is the host ministry of health.
Other partners are the World Health Organization, of course. They’re particularly responsible for surveillance in areas that have just been freed of Guinea worm. The way it works is while the ministry of health is responsible for all aspects of the program, The Carter Center focuses on helping get to zero cases. But once zero cases is achieved, the WHO works with the ministry to make sure their surveillance continues for at least three years. If they have zero cases for three years, then WHO starts a process of certifying that they have eradicated this disease.
UNICEF is another partner. And they been a lead partner in water. That’s one of the things that I think UNICEF does very well is provide clean water.
We have also worked very closely with the U.S. Peace Corps. Their volunteers oftentimes are working in villages and they can supplement or complement our supervisors, because they live in these villages. And they can help on a regular basis, in surveillance and also in treatment of cases.
And in some cases, we work with local organizations. For instance in Ghana we worked with a Red Cross women’s group who also supplemented surveillance and supervision. Same thing in Nigeria. Nigeria has what they call Nigeria Youth Service Corps, where college graduates have to give two years of volunteer service to Nigeria, before they can go on with their professional lives. And we used a lot of NYSC volunteers to supplement our surveillance and supervision.
The World Food Programme helps particularly in Sudan, where access for food is still an issue. They have what they call Food for Work. And oftentimes, for instance, when we do training, they will provide food for the training. And that also provides an incentive for village volunteers to continue to work.
And then of course we have a lot of donors: the Gates Foundation, Conrad N. Hilton Foundation, John P. Hussman Foundation, Franklin Mint, Nippon Keidanren, the United Kingdom’s Department for International Development, the U.S. Agency for International Development, Norway, Denmark, Luxembourg, the Canadian International Development Agency, Netherlands, Japan, Saudi Arabia, Kuwait, United Arab Emirates, Oman, Qatar, the Arab Fund, the Khalifa Bin Zayed Al Nahyan Foundation, and the OPEC Fund. Nigeria was also a donor to the program.
We also have some corporate partners, such as Vestergaard, a Danish company that manufactures our household filters. BASF Corporation donates the ABATE® larvicide we use. And in the past, before Vestergaard, DuPont, and Precision Fabrics Group donated a lot of nylon material that we used for household filters. Johnson & Johnson donated medical supplies, and ESRI donates mapping software. So the success of the Guinea worm program is very much an international and a local effort. Vestergaard developed a product that’s received several awards, called Lifestraw (photo link). If people are traveling in the field and don’t have access to clean water, they can use this Lifestraw and they get clean water.
LT: And drink right through it?
CW: Like a straw. It works!
LT: That’s pretty brilliant. So I imagine it gets rid of mud and everything?
CW: That’s correct, it filters out sediment, and also uses iodine to kill disease causing agents.
LT: So how optimistic are you that Guinea Worm disease will be eradicated in the next year?
CW: I’m cautiously optimistic. I think certainly, Ghana recently has broken transmission. So now we need to clean up the remaining cases in Ethiopia, Mali, and Chad – an isolated case – and focus on South Sudan. I think the first three countries, definitely we could do it this year. In South Sudan, we might be close to getting to the point where we can break transmission, but we’re not quite there. We need a little more oomph. But the next two or three months will tell us whether we have provided that oomph. But it’s in reach. It’s not out of our grasp. It’s a question of whether people will perform in the field under difficult circumstances. If the security holds up in South Sudan, then I’m cautiously optimistic that we can break transmission this year.
It’s not going to be easy though.
LT: No. I don’t imagine it will be. I was looking at the map, and you have ones and twos across equatorial Africa. I look at that and wonder how do these one or two cases show up in the middle of nowhere?
CW: People are resilient, and you would be amazed how far they can travel. We have had situations in which we have had farmers in Ghana show up in eastern Nigeria and establish transmission. That was several years ago, but we were amazed when we realized that.
And in Mali we had an outbreak in Kidal, which is sort of in the northern part of Mali. This is going back about four years and it was one student who walked from Gao to Kidal, which I think is over four hundred kilometers. And he introduced Guinea worm into an area which had never had Guinea worm before. So that’s how it gets done.
LT: So I imagine the strife in South Sudan is probably going to propel some people to flee the territory and make things a little more difficult that way too?
CW: We are very concerned about that and are monitoring it closely. And we have reserve supplies that we may need to call on to get out to help some refugee communities, depending upon the circumstances: where they are, where they came from, where they traveled through. We’ll monitor that, regularly.
LT: I can’t tell you how much I appreciate your time, and the work of The Carter Center.
CW: It’s been my pleasure. And thank you for your interest and your reports. I’ve read them and they’re very interesting.
LT: Well thank you. I appreciate that and, again, thank you for all you do.