DRACUNCULIASIS ERADICATION: THE TIDE HAS TURNED

148

75%, may reduce deaths from diarrhoea by 11-22%,10 but the impact on infant deaths should be smaller since the vaccine is generally not given before the child is 9 months old. That some children are still dying of diarrhoea despite ORT needs closer investigation. Some may have prolonged diarrhoea due to incorrect use of antibiotics;12 others may have needed intravenous resuscitation instead. However, better treatment of diarrhoea, as promoted by the NCDDP, seems to have been largely responsible for the decline in mortality, especially after 1982. We cannot specify exactly which were the critical inputs. The decline was an acceleration of an existing trend whose origin is not known in detail. Perhaps control of diarrhoea mortality is most likely to succeed where a primary care infrastructure exists and mortality is already falling. Sustained reduction will be achieved only when the incidence of diarrhoea is lowered by

REFERENCES

1. Hirschhorn N. The

Ahmed

Nagaty, NCDDP,

55

of acute diarrhea in children: An historical and

physiological perspective. Am J Clin Nutr 1980; 33: 637-63. 2. Kielmann AA, Mobarek AB, Hammamy MT, et al. Control of deaths from diarrheal disease in rural communities. Design of an intervention study and effects on child mortality. Trop Med Parasitol 1985; 36: 191-98. 3. Kielmann AA, Nagaty A, Ajello CA. Control of deaths from diarrheal disease in rural communities. 2. Motivating and monitoring the community Trop Med Parasitol 1986, 37: 15-21. 4. NCDDP Annual Reports. Cairo: NCDDP. 5. Terce B. Oral rehydration therapy: an assessment of mortality effects in rural Egypt Studies Family Planning 1982; 13: 315-27. 6. Population, Housing, and Establishment Census 1986. Preliminary results. Cairo: Arab Republic of Egypt Central Agency for Public Mobilization and Statistics. 1987.

Egyptian Child (draft). Arab Republic of Egypt Central Agency for Public Mobilization and Statistics, and UNICEF. Cairo: 1988. Infant and child mortality in Egypt. Cairo. Arab Republic of Egypt Central Agency for Public Mobilization and Statistics. 1986. Nasser S, Nossair N, Riyad S, et al. The clinical epidemiology of acute diarrheal disease m Egyptian children. J Trop Pediatr (in press). Feachem RG, Koblinsky M. Interventions for the control of diarrheal diseases among young children: measles immunization. Bull WHO 1983; 61: 641-52. Hussein AAHS, El-Khoratazty MN, Way AA. Fertility and family planning in Egypt 1984. Cairo: Egypt National Population Council and Westinghouse Public Applied System, 1985. Kassem AS, El Araby I, Massoud B. Effect of antibiotics on the duration of diarrhea and speed of rehydration. Gaz Egypt Pedr Assoc 1983; 31: 36-39.

7. The State of the

8 9.

10. 11.

specific preventive measures. Correspondence should be addressed to Mousaddaq Street, Dokki, G17A, Egypt.

treatment

12.

Water and Sanitation Decade DRACUNCULIASIS ERADICATION: THE TIDE HAS TURNED DONALD R. HOPKINS Global 2000, Carter

Center,

1

Copenhill, Atlanta, Georgia 30307, USA

MUCH has happened since publication of the most recent review articles on dracunculiasis (guineaworm disease)l,2most importantly the convening of the Second African Regional Workshop on Dracunculiasis, at Accra, Ghana in March, 1988, and the report on this subject at the World Health Assembly two months later. The first African regional meeting on dracunculiasis was at Niamey, Niger in July, 1986 six weeks after the World Health Assembly adopted a resolution calling for the elimination of dracunculiasis. That resolution was the first such mandate adopted by the World Health Organisation (WHO) since the successful smallpox eradication campaign. By the time of the second meeting in Accra: 1. Pakistan had begun a national eradication programme in 1987, with assistance from Global 2000 and the Bank of Credit and Commerce Foundation. A national search conducted in 1987 revealed that the disease occurs in fewer than a thousand villages there.4 In India, the other main endemic country in Asia, evidence of the dramatic impact of that national eradication programme, which began in 1980, was presented, with cases having been reduced from 44 819 in 1983 to 14 296 in 1987. Moreover, one of the seven original endemic states in India, Tamilnadu, was already freed from guineaworm. Both India and Pakistan have set 1990 as their target date for achieving eradication. 2. Nigeria, apparently the most highly endemic country, with an estimated 25 million cases, had agreed to establish a national secretariat for dracunculiasis eradication, in collaboration with Global 2000 and the Bank of Credit and Commerce International (BCCI). Four of Nigeria’s twenty-one states had each established a state task force for guineaworm eradication, the first of which, Anambra, had mobilised a potent coalition of state and federal funding, with substantial contributions of local labour, and external support by UNICEF, Japan, the World Bank, and the American Cyanamid corporation.

3. Ghana had begun a national eradication programme late in 1987, also with the assistance of Global 2000 and BCCI, with a goal of eliminating the disease by 1993. Eradication programmes were likewise underway in Cameroon, Cote d’lvoire, and Togo. USAID and UNICEF were assisting a rural water supply project aimed at reducing the prevalence of dracunculiasis in the most highly endemic province of Benin. Burkina Faso has a national plan of action for dracunculiasis eradication that it has so far been unable to implement fully owing to lack of external support. 4. There was much better knowledge of the extent of the diseased5-15 million pesons are now thought to suffer from dracunculiasis annually, with some 120 million persons at risk in Africa and another 20 million at risk in Asia. New surveys were underway or had been conducted recently in parts of Ethiopia, Ghana, Mali, Pakistan, and Sudan. Teams in an area of Mali found 435 cases of dracunculiasis where ony 23 had been reported previously. Health authorities in Anambra State, Nigeria, treated 202 494 cases of guineaworm between November, 1986, and March, 1987-in a state with a total population of about 5 million. 5. The burden of the disease had been well documented, mostly by researchers in Nigeria. Dracunculiasis has been shown to be a major cause of school absenteeism and a serious cause of permanent dropouts 7-9 and there is increasing evidence that it is also highly detrimental to maternal and child health in affected areas (Brieger B, Yacoob M, Watts S, Third Regional Workshop on Dracunculiasis in Africa, March, 1988). In one fertile rice-growing area of 1-6 million persons in south-eastern Nigeria, the losses to rice production alone due to dracunculiasis disability were estimated at US$20 million per year." 6. The excellent efficacy of water supply interventions had been documented again by a missionary project in Kati, Togo," and by UNICEF-assisted rural water supply projects in Imo and Kwara States, Nigeria. 12,13 In the latter state, the water supply programme reduced the average prevalence of dracunculiasis in 20 communities from 59-6% during the 1983-84 guineaworm season to 11 3% during the 1986-87 season, with three of the villages’ prevalence rates having been reduced to zero, from 62-0%, 52-7%, and 44-8%, respectively. Similarly, researchers in Burkina Faso documented the efficacy of health education to promote filtration of drinking water through a nylon cloth, reducing transmission of the disease from incidence rates of 54%, 37%, and 24% in three villages to zero in only two transmission seasons.14 7. The disease was no longer quite so obscure, having been the subject of a 16-page cover story in one of Nigeria’s most popular pan-African newsweeklies, African Concord, and the subject of a

149

Congressional Hearing by

the US House of

Representatives’

STATUS OF KEY ANTI-DRACUNCULIASIS BENCHMARKS IN KNOWN AND SUSPECTED ENDEMIC COUNTRIES

Hunger. A new movie, "Guinea Worm: Fiery Serpent", had just been completed to help educate more persons about the disease. And in November, 1987, the steering committee of the Water and Sanitation Decade had restated emphatically its endorsement of guineaworm eradication as an important subgoal of the Decade. Select Committee

on

The

I

I

I

I

I

I

THE ACCRA MEETING

At the second African regional meeting in Accra,15 Gambia and the Republic of Guinea reported that transmission seemed to have been interrupted for some time already. In Gambia, where dracunculiasis is an officially reportable disease, there have been no such reports in the past ten years. In Guinea, a consultant helped the Ministry of Health to investigate the infection in north-eastern areas where it was last reported, but found no evidence of recent indigenous transmission. During the workshop in Accra, representatives of each of the 17 African endemic countries presented specific plans for surveillance and control activities against dracunculiasis in their countries. India and Pakistan also sent representatives to the workshop. Whereas Nigeria was previously the only African country to convene a national meeting on dracunculiasis (in March, 1985), Benin, Burkina Faso, Ghana, Nigeria, and Togo expressed their intention to convene national meetings in 1988. India and Pakistan held national meetings in March, 1988. UNDP and AFRO/WHO announced substantial new financial support for dracunculiasis eradication during the workshop: each will make US$50 000 available for activities in the region in 1988. UNICEF/Ghana announced it would make a similar amount available for the Ghanaian Guinea Worm Eradication Programme. Another highlight of the meeting was the attendance by former US President and Mrs Jimmy Carter, as well as the WHO Regional Director for Africa, Dr G. Monekosso. President Carter expressed his determination, and that of Global 2000, to help mobilise efforts to eradicate dracunculiasis by 1995. The former President also visited two Ghanaian villages where the disease is highly endemic. En route to Accra, Mr Carter made a brief stop in Lagos, where he signed the agreement between Global 2000, BCCI, and the Nigerian Federal Ministry of Health, and discussed the problem of dracunculiasis with the Nigerian Federal Minister of Health, Prof 0. Ransome-Kuti, and with the President of Nigeria, General I. Babangida. AFTER ACCRA on dracunculiasis and the eradication campaign presented to the 41st World Health Assembly at Geneva in May, 1988, as required by the resolution adopted by the 39th WHA two years earlier (A41/INF doc/2). This subject will be discussed by WHO’s Executive Board in January, 1989, and reviewed again at the 42nd WHA in May of the

A report

was

same

year.

In West Africa, aggressive dracunculiasis elimination efforts are now underway in a contiguous bloc of 6 endemic countries, from Cote d’lvoire to Cameroon, including Nigeria. The adjacent tier of Sahelian countries from Mauritania to Central African Republic are not yet fully engaged in the campaign. Except for Burkina Faso, the disease is thought to be prevalent in only a limited part of each of those more arid states, none of which however has yet really assessed the national extent of the disease. In East Africa, civil disturbances in parts of Ethiopia, Sudan, and

0 = partial, . = national or all endemic areas t C = incomplete or outdated, . active :t: 0 pilot or partial, . national programme. =

=

=

have prevented implementation of control in all the endemic zones there. When the third African regional meeting on dracunculiasis convenes in a francophone country in 1990, the final year of the Water and Sanitation Decade, India and Pakistan should have eliminated the disease. Well before then we should know whether the disease still occurs in Saudi Arabia and Yemen, the two other Asian countries where it reportedly may still exist, and if so, how extensively. By then, international criteria should have been developed, ideally under the auspices of WHO, for officially certifying achievement of dracunculiasis elimination by individual countries. If the current momentum is intensified, it should be possible to eradicate dracunculiasis by December, 1995. With only 21years remaining in the International Drinking Water Supply and Sanitation Decade, however, those endemic countries that have not yet done so need to improve surveillance and reporting of dracunculiasis, and develop and implement national plans of action for eliminating the disease (table). Bilateral and multilateral donor agencies will need to help those countries that decide to get rid of guineaworm. If the hidden costs of dracunculiasis due to agricultural losses were fully appreciated, let alone its adverse effects on health and education, there would be no lack of national mobilisation against it. And if its direct relevance to child survival, primary health care, and "Health For All" in endemic areas were recognised, bilateral and multilateral agencies, and more non-governmental organisations, would have taken up the struggle against this wretched preventable disease much earlier. A few are doing so now, but not enough. Dracunculiasis is vulnerable. Its continued transmission is no longer acceptable or tolerable. Unlike many other terrible diseases, dracunculiasis has only a fragile hold on endemic communities. It has no animal reservoir; its

Uganda

measures

150 is

highly seasonal in most areas; it is only contracted by drinking water, which must have been contaminated by human beings in the first place; its distribution is limited and focal; and there are at least three known ways to prevent it completely: health education,

prevalence

water

supply,

For what else

and

vector

are we

control. What

more

do

we

need?

waiting? REFERENCES

1.

Hopkins DR. Dracunculiasis eradication: a mid-decade status report. Am J Trop Med Hyg 1987; 37: 115-18.

2. Hopkins DR. The campaign against dracunculiasis. Lancet 1985; i. 96-97. 3. World Health Organization. Dracunculiasis: regional workshop on dracunculaisis in Africa. Wkly Epidem Rec 1986; 61: 321-24. 4. World Health Organization. Dracunculiasis surveillance: Pakistan. Wkly Epidem Rec

(in press). 5. Watts S Dracunculiasis in Africa: its geographical extent, incidence, and population. Am J Trop Med Hyg 1987; 37: 121-27.

at

risk

Hospital Practice CONTINUOUS ARTERIOVENOUS HAEMODIALYSIS IN CRITICALLY ILL PATIENTS P. E. STEVENS1 S. P. DAVIES1 E. A. BROWN1

B RILEY2 P. E. GOWER1 W. KOX2

Departments of Medicine1 and Anaesthesia,2 Charing Cross Hospital, London W6 8RF Continuous arteriovenous haemodialysis (CAVHD) is a new treatment for critically ill patients with renal failure that combines convective and diffusive solute removal. The clearance of urea (14·8-22·1 ml/min) is sufficient to achieve a steady-state urea concentration of 22 mmol/1, even in patients with a high catabolic rate and cardiovascular instability. The technique is simple and does not involve the use of blood pumps or specialised staff. Initial experience in 36 critically ill patients with renal failure indicates that it is safe and reliable, with less associated morbidity than other techniques.

Summary

INTRODUCTION

CONTINUOUS arteriovenous haemofiltration (CAVH) described by Kramer et al in 1977:1 the technique enables control of uraemia in critically ill patients with acute renal failure without the cardiovascular instability associated with conventional haemodialysis. These patients often have a high catabolic rate, and large volumes of fluid, sometimes 20-40 litres per day, need to be removed and replaced to obtain adequate control of plasma urea with CAVH alone. To exchange such large volumes of fluid, the original technique needs to be supplemented by pump-assisted was

circulation, suction, pre-dilution or post-dilution, and, ideally, computer control of fluid and electrolyte balance.2,3 This drawback can be avoided by the use of intermittent haemodialysis for control of the uraemia, with CAVH between dialyses to remove fluid and facilitate adequate nutrition,4but necessitates specialist staff and equipment. In 1984, Geronemus and Schneiders described the technique of continuous arteriovenous haemodialysis

6 World Health 7

Organization Dracunculiasis global surveillance summary-1986 Wkly Epidem Rec 1987, 62: 337-39. Ilegbodu VA, Kale OO, Wise RA, Chnstensen BL, Steele JH, Chambers LA. Impact of guinea worm disease on children in Nigeria. Am J Trop Med Hyg 1986; 35:

962-64. 8 Nwosu ABC, Ifezulike

EO, Anya AO. Endemic dracontiasis in Anambra State of geographical distribution, clinical features, epidemiology and socioeconomic impact of the disease Ann Trop Med Parasitol 1982; 76: 187-200 9. Edungbola LD, Watts S. Epidemiological assessment of the distribution and endemicity of guinea worm infection in Asa, Kwara State, Nigeria. Trop Geogr Med 1985; 37: 22-28 10. de Rooy C. Guinea worm control as a major contributor to self-sufficiency in rice production in Nigeria. Lagos: UNICEF/Nigeria, 1987 11. Foly A, Caudill D. Case study guinea worm. Oklahoma City: World Neighbors, 1987. 12 Udonsi JK. Control of endemic dracontiasis by provision of water supply in rural communities of Imo State, Nigeria. Publ Hlth 1987; 101: 63-70. 13. Edungbola LD, Alaki TO, Parakoyi BD. Evaluation of the impact of the UNICEF-assisted rural water project on guinea worm disease in Asa L G.A., Kwara State, Nigeria (First Report). Lagos: UNICEF/Nigeria, 1987. 14 Gbary AR, Guiguemde TR, Ouedraogo JB. [Dracunculosis: a scourge eradicated from 3 villages of Burkina Faso through health education] Bull Soc Pathol Exot Filiales 1987; 80: 390-95. 15. World Health Organisation. Dracunculiasis. Second regional workshop on dracunculiasis in Africa. Wkly Epidem Rec 1988, 63: 139-42.

Nigeria

(CAVHD) which uses both diffusive and convective solute transport and provides a higher clearance of urea and a more effective control of uraemia than CAVH alone, without the removal of large volumes of ultrafiltrate. Complete equilibration of small solutes should occur between blood and dialysate if the blood flow rate is greater than dialysate flow. CAVHD combines the advantages of CAVH and haemodialysis, and may be performed by existing intensive care unit staff without the need for dialysis machines and trained dialysis nurses. In March 1987, CAVHD was adopted as the sole renal replacement therapy in our intensive care unit. We describe our experience of CAVHD in the management of 36 renal failure.

critically

ill

patients

with

severe

PATIENTS AND METHODS

36 unselected critically ill patients with severe renal failure were treated by CAVHD with a 0-43 m2 polyacrylonitrile parallel-plate haemodialyser (HOSPAL AN69S; Hospal, UK). An APACHE n score was calculated for each patient at the start of CAVHD.6 .6 Vascular access was through Scribner shunts, to which the haemodialyser was connected in a pumpless circuit. Anticoagulation was attained by continuous infusion of either heparin (at approximately 10 units/kg per hour), or low dose heparin with prostacyclin (250 units/h of heparin with 2-3 ng/kg per minute of prostacyclin) into the arterial limb of the extracorporeal circuit: infusion rates were altered to achieve anticoagulation of the extracorporeal circuit, without a change in the patient’s coagulation. (Low dose heparin with prostacyclin was used on patients with low platelet counts or disseminated intravascular coagulopathy.) Warmed peritoneal dialysis fluid (1-5% ’Fresenius’ dextrose) was passed into the dialysate compartment of the haemodialyser at a rate of 2 1/h until the blood urea concentration was less than 25 mmol/l, when the flow rate was reduced to 1 1/h. Potassium supplements were added to peritoneal dialysis fluid as required, and phosphate supplements were given as part of the daily parenteral nutrition. Urea levels in both plasma and drainage fluid (a combination of ultrafiltrate and spent dialysate) and plasma electrolytes were measured twice daily, with daily estimations of plasma creatinine. Calcium, phosphate, albumin, and liver function tests were measured on alternate days. 10 sets of urea and creatinine clearances were measured in 9 patients when dialysate flow rate was 1 1/h: clearance values were calculated from drainage fluid volumes and plasma and drainage fluid concentrations of urea and creatinine by use of the standard formula. Blood flow rates were measured in 5 patients by the bubble transit-time technique.7 The haemodialysers were replaced when the drainage fluid urea concentration fell substantially below plasma urea concentration (usually after 48-72 h). "Survival" was defined for this study as an improvement