The world's newest nation, South Sudan, has succeeded in interrupting transmission of Guinea worm disease, the country's minister of health announced Wednesday at The Carter Center. As of the end of February 2018, South Sudan, which gained independence from Sudan in 2011, has recorded zero cases of Guinea worm disease for 15 consecutive months. Because the Guinea worm life cycle is about a year, a 15-month absence of cases indicates the interruption of transmission.
"This is a great achievement for our young nation," Dr. Riek Gai Kok, South Sudan's health minister, said during the global Guinea Worm Eradication Program's 22nd annual review at The Carter Center. "Our health workers and thousands of volunteers have done exemplary work eliminating this disease across our country, and I have no doubt that the World Health Organization will grant certification in due time."
Dr. Tebebe Yemane Berhan, goodwill ambassador for Guinea worm eradication in Ethiopia, participated in the announcement, as did Dr. Gautam Biswas of the WHO. Representing The Carter Center were Dr. Ernesto Ruiz-Tiben and Dr. Donald R. Hopkins, both original architects of the Guinea worm eradication campaign.
The WHO has certified 199 countries, territories, and areas as free of Guinea worm disease. Kenya received WHO certification in February, having detected no cases since 1994. As South Sudan enters the precertification stage, the only countries remaining to be certified are Angola, Chad, the Democratic Republic of the Congo, Ethiopia, Mali, and Sudan.
Chad and Ethiopia each reported 15 cases in 2017. Those 30 were the only cases in the world in 2017; when The Carter Center began leading the Guinea worm eradication campaign in 1986, there were an estimated 3.5 million cases annually in 21 countries on two continents.
The most recent case in South Sudan was Maralina Buolaa, a 13-year-old girl who lives in Khor Jamus village, Jur River County, Western Bahr al Ghazal state; her worm emerged on November 20, 2016.
Former U.S. President Jimmy Carter congratulated South Sudan.
"The people and government of South Sudan have achieved a great milestone in the worldwide effort to eradicate Guinea worm disease. Today's news is the fruit of good faith shown by all parties that agreed to the 1995 cease-fire during Sudan's terrible civil war, allowing health workers to start a campaign of interventions against this horrible parasitic disease," said Carter, who negotiated the cease-fire.
"South Sudan's success shows that people can collaborate for the common good. We look forward to certification by the WHO in the next few years that South Sudan has won the battle against this ancient scourge. We are within reach of a world free of Guinea worm disease."
Guinea worm in South Sudan
South Sudan reported no cases in the entire 2017 calendar year, only 11 years after starting with 20,582 reported cases in 2006. This success in a country with few resources and a complicated epidemiology ranks high among the program's major achievements, including elimination in 2008 in what was the world's most endemic country, Nigeria.
"South Sudan prevailed despite the most complex Guinea worm transmission among humans of any country, peak prevalence during a long rainy season, vast territory, and poor infrastructure, as well as ongoing postwar insecurity," said Hopkins, the Carter Center's special advisor for Guinea worm eradication and former vice president for health.
The South Sudan Guinea Worm Eradication Program formally began operations after the 2005 Comprehensive Peace Agreement ended Sudan's two-decade-long civil war, but "it got a 10-year head start" from the almost six-month-long "Guinea Worm Cease-Fire" in 1995, said Ruiz-Tiben, director of the Carter Center's Guinea Worm Eradication Program. Southern Sudan continued to build on this initial success, and cases consequently declined sharply from 118,578 reported in 1996 to 54,890 reported in 2000.
"South Sudan has been buffeted by insecurity of all kinds, and political difficulties, and at times famine since 2006 when the program began," Ruiz-Tiben noted.
The main factors in its success, Hopkins said, were the exceptionally strong and consistent political support provided to the program by the government of South Sudan, including South Sudanese President Salva Kiir Mayardit and national ministers of health, including Dr. Riek Gai Kok and his predecessors, the inspired leadership of Mr. Makoy Samuel Yibi, the national program's director, and the dedicated service of more than 18,000 village volunteers.
The WHO is helping to monitor South Sudanese refugees in Ethiopia, Uganda, and other neighboring countries; no Guinea worm cases have been found among the refugee population.
The South Sudan program held a review in Juba in December 2017. Participants included First Vice President of the Republic of South Sudan Gen. Taban Deng Gai, the minister of health, and numerous other officials. The meeting recommended enhancing South Sudan's collaboration with Ethiopia's program to guard against cases along their mutual border.
Sudan and South Sudan were one country until they formally separated in 2011, so the two nations' Guinea worm histories are intertwined. When the Sudan Guinea Worm Eradication Program was initiated in 1995, civil war impeded access to many Guinea worm-endemic areas, especially communities in the south.
The same year, President Carter brokered the "Guinea Worm Cease-Fire," the longest humanitarian cease-fire in history at the time. Conflict was suspended for almost six months, allowing health workers to distribute medicine and preventative health measures, including cloth water filters, ivermectin for river blindness, childhood immunizations including polio, and vitamin A. During the cease-fire, the Guinea worm program was able to access more than 2,000 Guinea worm-endemic villages and distribute more than 200,000 cloth filters.
In 2001, The Carter Center and its partners, including Health and Development International, Hydro Polymers of Norsk Hydro, Johnson & Johnson, and Norwegian Church Aid, spearheaded the Sudan Pipe Filter Project. In only a few months, the project worked to produce, assemble, and distribute more than 9 million pipe filters, one for each at-risk person in Sudan. These portable, straw-like plastic pipes with filters (cloth at first, then more durable metal) would help ensure that drinking water was free of tiny water fleas (copepods) carrying Guinea worm larvae. Additionally, a targeted health education campaign was launched, including flip charts, radio public service announcements, and community demonstrations. The last indigenous case in the current Republic of Sudan was reported in 2002.
In 2005, the Comprehensive Peace Agreement ended Sudan's civil war, set a timetable for southern Sudan to decide on independence, and brought relative stability to the nation. The South Sudanese national program was able to begin surveillance activities in previously inaccessible areas, and the number of Guinea worm cases reported in this region increased fourfold to 20,582 in 2006.
A pair of visits in 2010 by President Carter solidified South Sudan's confidence in The Carter Center, Ruiz-Tiben said.
In a January 2011 referendum monitored by The Carter Center (the largest election observation in the Center's history), the people of southern Sudan voted to secede from Sudan. The newly independent Republic of South Sudan was officially established on July 9, 2011.
In June 2015, the South Sudan Ministry of Health announced that the program had gone seven consecutive months (Nov. 2014-May 2015) without reporting a confirmed case of Guinea worm disease, a remarkable accomplishment for the national program and the village volunteers, health workers, and communities working together toward nationwide elimination. January-December of 2015, South Sudan reported only five cases, a reduction of 94 percent from the previous year, and an overall reduction of more than 99.9 percent since 2006. In 2016, South Sudan reported six cases, all of which were contained to prevent further spread. With zero cases reported in 2017, these numbers represent great success for South Sudan, although continued efforts toward improved peace and stability will be vital to maintaining the levels of surveillance and supervision necessary to ensure certification of elimination.
"The world is much better today for South Sudan having made this achievement," Ruiz-Tiben said.
Three people involved in the Guinea Worm Eradication Program in South Sudan and Sudan were recognized in 2017 with awards given by the Crown Prince Court of the United Arab Emirates. The Recognizing Excellence Around Champions of Health (REACH) awards recognize individuals who have made outstanding contributions toward reaching the end of infectious diseases.
South Sudanese social mobilizer Mrs. Regina Lotubai Lomare Lochilangole was honored with an Unsung Hero Award for creating an original song and dance to teach her community about Guinea worm symptoms and prevention. The song was so effective that South Sudan's Ministry of Health created a position for her within its Guinea Worm Eradication Program. Lochilangole now travels to different parts of the country to train other volunteers to become social mobilizers. Lochilangole has personal experience with the disease: At one time, she had at least 10 worms emerging from her body. She says her experience keeps her motivated to work until the disease is officially eliminated from South Sudan.
Another Unsung Hero Award went to Mr. Daniel Madit Kuol Madut, a senior program officer with South Sudan's Federal Ministry of Health. Madut rose through the ranks from village volunteer in 1998 to senior program officer today. Over the past decade, Madut has moved to different parts of the country to help the South Sudan Guinea Worm Eradication Program respond to outbreaks and enhance surveillance in endemic areas. Madut says his commitment to the eradication effort comes from a personal desire to see his compatriots unite to accomplish something positive.
The REACH Awards also conferred a Courage Award on Dr. Nabil Aziz Awad Alla, who led the Sudan Guinea Worm Eradication Program from 1994 until 2002. During his tenure, he was known to travel across the country to personally search for cases, at times at great personal risk due to the civil war. Dr. Nabil helped convene a national conference in 1995 and invited both Gen. Omar al-Bashir, president of Sudan, and former U.S. President Jimmy Carter. Carter negotiated the historic "Guinea Worm Cease-Fire" that allowed the program to expand into formerly inaccessible areas.
President Carter received a REACH Lifetime Achievement Award for his long-term leadership in the Guinea worm eradication campaign. The Carter Center's Dr. Adamu Keana Sallau received the REACH Last Mile Award for his work in Nigeria.
About Guinea worm disease
Considered a neglected tropical disease, Guinea worm disease (dracunculiasis) is contracted when people consume water contaminated with tiny crustaceans that carry Guinea worm larvae. The larvae mature and mate inside the patient's body. The male worm dies. After about a year, a meter-long female worm emerges slowly through a painful blister in the skin. Contact with water stimulates the emerging worm to release its larvae into the water and start the process all over again. Guinea worm disease incapacitates people for weeks or months, reducing individuals' ability to care for themselves, work, grow food for their families, or attend school.
Without a vaccine or medicine, the ancient parasitic disease is being wiped out mainly through community-based interventions to educate and change behavior, such as teaching people to filter all drinking water and preventing contamination by keeping patients from entering water sources.
While human cases are dwindling, the Center and its partners also are addressing the challenge of Guinea worm infections in animals. In Chad, dog infections were down 19 percent in 2017, and the average number of worms per infected dog also fell. Smaller-scale infections in animals also were being tracked in Mali and Ethiopia. Mali, which has reported zero human cases for the last 27 months, is still considered endemic because of the isolated dog infections. South Sudan, which like other countries offers a hefty cash reward to anyone who reports a suspected animal infection, has had none since a single infected dog was found there in a household with a human Guinea worm case in 2015.
The Carter Center leads the international Guinea Worm Eradication Program and works in close partnership with national ministries of health, the World Health Organization (WHO), U.S. Centers for Disease Control and Prevention (CDC), UNICEF, and many other partners. The Carter Center provides technical and financial assistance to national Guinea Worm Eradication Programs to help interrupt transmission of the disease. When transmission is interrupted, the Center provides continued assistance in strengthening surveillance in Guinea worm-free areas for three years and helps prepare nations for official evaluation by the International Commission for the Certification of Dracunculiasis Eradication (ICCDE) and certification by the WHO. CDC provides technical assistance and verifies that worms from these final patients truly are Guinea worms. The presence of Guinea worm disease in an area usually indicates abject poverty, including the lack of safe drinking water; UNICEF mainly assists countries by helping governments provide safe sources of drinking water to priority areas identified by the national programs. The WHO is responsible for certifying countries as Guinea worm-free and is the only organization that can officially certify the elimination or eradication of any disease.
For a disease to be eradicated, every country must be certified, even if transmission has never taken place there.
In 1986, Guinea worm disease afflicted an estimated 3.5 million people a year in 21 countries in Africa and Asia. Today, thanks to the work of strong partnerships, including the countries themselves, the incidence of Guinea worm has been reduced by more than 99.999 percent.
Many generous foundations, corporations, governments, and individuals have made the Carter Center's work to eradicate Guinea worm disease possible, including major support from the Bill & Melinda Gates Foundation; the United Kingdom's Department for International Development (DFID); Children's Investment Fund Foundation (CIFF) - United Kingdom; the Conrad N. Hilton Foundation; and The Federal Republic of Germany.
Major support from the United Arab Emirates began with Sheikh Zayed Sultan Al Nahyan and has continued under Sheikh Khalifa and HH Crown Prince Mohammed bin Zayed.
The DuPont Corporation and Precision Fabrics Group donated nylon filter cloth early in the campaign; Vestergaard's LifeStraw® donated pipe and household cloth filters in recent years.
Abate® larvicide (temephos) has been donated for many years by BASF.
Key implementing partners include the ministries of health in endemic countries, The Carter Center, WHO, CDC, and UNICEF.