Progress Toward Global Dracunculiasis Eradication, June 2000 FREE

MMWR. 2000;49:731-735

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In 1986, an estimated 3 million persons were infected with dracunculiasis (Guinea worm disease) and another 120 million were at risk for infection.¹ That year and in 1991, the World Health Assembly called for the eradication of dracunculiasis,^2- 3 and as a result of the implementation of the Dracunculiasis Eradication Program (DEP),* the annual incidence was reduced by approximately 95% by 1995.⁴ This report updates the status of the eradication program as of June 2000, which indicates that dracunculiasis has been eliminated from seven of 20 countries where it was endemic in 1995; however, in parts of Africa, particularly Sudan, dracunculiasis remains a serious public health problem.

For surveillance purposes, village-based health workers search for infected persons in each village with endemic disease and complete a register that provides the basis for monthly zonal, district, and national surveillance reports.⁵ During 1999, dracunculiasis was endemic in 13 countries in Africa.† These countries reported 96,293 cases in 10,914 villages. Of the total number of cases, Sudan reported 66,097 (69%) cases in 7271 villages; 2606 of the known villages with endemic disease in Sudan were not accessible to program surveillance. Outside Sudan, 93% of 3068 villages reported monthly; in Sudan, 44% of 4892 accessible villages reported monthly. Outside Sudan, 20% of all villages with endemic disease reported 1 case each. Seven of the 13 countries with endemic disease reported less than 500 cases each in 1999.

During January-June 2000, the number of cases reported by all countries except Sudan was 12,097, 18% less than the 14,828 cases reported during the same period in 1999. The rate of reduction in all countries outside of Sudan was 35% except in Ghana, which reported a slight increase in cases during the first half of 2000. Niger reported 59% fewer cases during January-June 2000. Benin, Cote d'Ivoire, Ethiopia, Mali, Mauritania, and Uganda have reduced the number of cases by an average of 55% during January-June 2000. Nigeria reported 35% fewer cases during January-June 2000 than during the same period in 1999.

All programs attempt to control the spread of disease using case containment (i.e., patients were not allowed to contaminate water and transmit infection) aimed at detecting cases within 24 hours of emergence of the worm and instituting prevention measures immediately. Approximately 62% of the case-patients reported outside of Sudan during 1999 were contained; 68% were contained during January-June 2000. The long-standing civil war in Sudan is the primary reason for the high rate of dracunculiasis in the southern part of that country; however, the 10 northern states of Sudan have reported 66% fewer cases during the first 6 months of 2000 compared with the same period last year (21 versus 61 cases); 16 (76%) of the 21 cases were contained.

Global 2000, The Carter Center, Atlanta, Georgia. World Health Organization Collaborating Center for Research, Training, and Eradication of Dracunculiasis. Div of Parasitic Diseases, National Center for Infectious Diseases, CDC.

Dracunculiasis is a parasitic infection acquired by drinking water from ponds contaminated by copepods (water fleas) that contain immature forms of the parasite. A year after entering the infected person, the 40-inch (1 meter) worm(s) emerge, usually on the lower limbs through skin wounds that frequently become contaminated secondarily. Reinfection can occur if the person again drinks contaminated water. No effective treatment exists; however, two countries in which dracunculiasis was endemic at the beginning of the program (Pakistan and India) have been certified by the World Health Organization (WHO) to have interrupted transmission. WHO also has certified the absence of transmission from almost all countries outside Africa.⁶ All countries with endemic disease are required to submit a report to the International Commission for the Certification of Dracunculiasis Eradication, documenting the absence of indigenous cases of the disease for at least 3 consecutive years to be recommended for certification.

Most eradication programs have begun listing villages with endemic disease in descending order of number of cases reported to help monitor the status of interventions. Nylon filters have been distributed to all households in 47% of villages with known endemic disease, including 67% outside Sudan. The larvicide Abate®‡ (temephos) (American Home Products, Princeton, New Jersey) is being used in approximately 35% of villages with endemic disease outside Sudan, and 43% of villages with endemic disease outside Sudan have access to at least one source of safe drinking water. Health education and community mobilization activities (e.g., radio announcements; posters; town criers; and talks by religious, political, and traditional leaders) aimed at persons in villages endemic with disease or at high risk for disease have been intensified.

The current goal of DEP is to eliminate transmission in all remaining countries with endemic disease outside Sudan by 2001. An estimated 3 to 4 years of intense activities will be required to halt dracunculiasis transmission after a peace agreement is signed in Sudan. To attain these targets, ministries of health in the remaining countries with endemic disease must make dracunculiasis eradication a top national, regional, and local public health priority. The infection can be prevented by teaching at-risk persons to filter their drinking water through a finely woven cloth, to avoid entering sources of water when worms are emerging, by treating water sources with Abate to kill copepods, or by providing clean drinking water from sources such as borehole wells. Each national program needs to intensify supervision and motivation of village-based health workers, extend and diversify efforts to educate and mobilize villagers in communities with endemic disease, advocate for provision of safe water sources to villages with endemic disease, monitor the status of all interventions, and ensure that active surveillance is maintained in all communities with endemic disease and in areas at risk for dracunculiasis.

*Program partners include The Carter Center, CDC, United Nations Children's Fund (UNICEF), the World Health Organization (WHO), ministries of health in countries where dracunculiasis is endemic, private industry, and many other donors, including the Bill and Melinda Gates Foundation.

†Benin, Burkina Faso, Central African Republic, Cote d'Ivoire, Ethiopia, Ghana, Niger, Nigeria, Mali, Mauritania, Sudan, Togo, and Uganda.

‡Use of trade names and commercial sources is for identification only and does not constitute endorsement by CDC or the U.S. Department of Health and Human Services.

MMWR. 2000;49:797-801

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In the United States, cigarette smoking is the leading cause of preventable morbidity and mortality, and smokers who stop at any age reduce their risk for premature death.¹ Because older smokers are more likely to report having seen a physician during the preceding year (84% in 1992) compared with younger smokers (69%),² health-care providers have many opportunities to advise older smokers to quit. To characterize smoking and advice to quit among Medicare managed-care recipients, the Health Care Financing Administration and CDC analyzed data from the 1998 Health Outcomes Survey (HOS). This report summarizes the results of that analysis, which indicates that approximately 13% of enrollees in Medicare managed care reported they were current smokers, and among those who visited a physician or health-care provider, approximately 71% reported receiving advice to quit.

HOS is an ongoing, 2-year, longitudinal cohort survey administered to Medicare beneficiaries enrolled in managed-care plans nationwide. The survey measures health status and health outcomes to provide risk-adjusted measures of managed-care plan performance and to track population-based care outcomes. Medicare enrollees were initially contacted by mailed questionnaire, and nonrespondents were followed up by mail and telephone. Respondents were asked about current smoking status, quitting behavior during the preceding 12 months or longer, receipt of advice to quit from a doctor or other health-care provider, and the number of health-care visits during the preceding year.

A random sample of approximately 1000 Medicare managed-care enrollees was selected from each of 287 separate strata, representing 268 different health plans. Thirteen of these plans had two to four geographically distinct subplan market areas for 19 additional strata. A total of 279,135 Medicare beneficiaries were in the sample. The sample included both Medicare beneficiaries aged ≥65 years (91.5%) and persons aged <65 years and in Medicare because of disabilities (8.5%) who were enrolled in their plan for at least 6 months. It also included institutionalized beneficiaries but excluded persons eligible for Medicare because of end-stage renal disease alone. Baseline data were collected during May-July 1998.

The overall response rate to the baseline survey was 59.9% (167,201); 152,259 reported their smoking status, and 19,604 (95.6%) of those who reported smoking during the previous year responded to the question about whether they received advice to quit. Data were weighted to the total population of each stratum and adjusted to the overall population age, race, and sex distribution.

In 1998, 10.4% of Medicare managed-care enrollees reported smoking every day and 2.9% reported smoking some days. Daily smoking prevalence was highest among enrollees aged less than 65 years and lowest among enrollees aged greater than or equal to 85 years. Daily smoking prevalence was higher for men than for women, and smoking prevalence was greater among those with less education and less income. Among all enrollees, 1.6% reported having quit during the preceding 12 months, and 39.3% reported having quit smoking greater than 1 year before the survey. Smoking prevalence was lowest and quit rates highest among enrollees from the western region.

Of persons who reported any smoking during the preceding 12 months and who visited a physician or other health-care provider at least once during that time, 70.7% reported they had been advised to quit smoking. Advice to quit increased with increasing numbers of visits: 61.5% of smokers with one visit during the year reported receiving advice to quit compared with 76.2% of those with five or more visits. Across all visit categories, women who made one to four visits reported receiving advice to quit at slightly higher rates than did men, and smokers aged ≥75 years reported receiving less advice to quit than did younger smokers. Blacks and Hispanics reported receiving less advice than did whites. Overall, those with more education reported receiving less advice. Differences were reported in receipt of advice to quit between the types of managed-care plans, with providers in independent practice associations giving less advice than those in staff or group model practices, especially when a single visit was reported.

D Arday, MD, Office of Clinical Standards and Quality, Health Care Financing Administration. Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

The findings in this report indicate that receipt of advice to quit smoking probably has improved since the early 1990s, when 38.8% of smokers aged ≥65 years reported receiving advice.³ Self-reported receipt of advice is higher in this survey than the national average (62.5%) reported by the National Committee for Quality Assurance (NCQA).⁴ The NCQA report is based on 1998 Health Plan Employer Data and Information Set (HEDIS) data from plan-administered surveys. However, the HEDIS data used a different sampling frame that applied to all adult beneficiaries in managed-care plans, not just those in Medicare.

On the basis of these results, of 5.8 million Medicare enrollees in the sampling frame, approximately 92,000 had quit during the preceding year. Increasing the delivery of smoking cessation advice to 90% of those who still smoke would reach approximately 150,000 additional smokers and might encourage 25,000 more smokers to initiate quitting each year. Based on these survey findings, public health programs should target health-care providers in independent practice associations (IPAs) to deliver cessation advice. IPAs represent most physicians in private or small group practices who have contracted with HMO plans, and counseling rates for IPAs are lower than for group or staff model plans.

The difference in receipt of advice to quit among racial/ethnic groups may be influenced by social or cultural factors. For example, among elderly Hispanics and Asian Americans, language barriers may affect the lower rates of receiving advice to quit or in understanding the advice. Health-care providers should offer culturally appropriate or tailored interventions for racial/ethnic populations.⁵

The findings in this report are subject to at least four limitations. First, the overall response rate for the 1998 HOS survey was 59.9%. Response rates varied widely by plan and somewhat by age and race. Although the HOS data were weighted to account for the stratified design and the overall population distribution by age, race, and sex, some differences could be the result of response biases. Second, because the HOS design does not include any oversampling of racial/ethnic minority groups or the oldest Medicare recipients, sample sizes within some substrata were inadequate to allow complete comparisons by all smoking or visit categories. Third, not all persons who reported quitting during the previous 12 months may have been candidates for advice. Because smoking status at the time of each doctor visit was not known, some may have quit before their first visit. Finally, because the reason for each visit was not included in the survey, some visits may have been for emergencies and other conditions during which counseling would not have been appropriate.

Smoking prevalence among Medicare managed-care enrollees is similar to that among older adults.⁶ Despite the lower prevalence of current smoking among older adults compared with middle aged and young adults, older smokers are at greater risk from smoking because they have smoked longer, tend to be heavier smokers, and are more likely to suffer already from smoking-related illnesses.⁷ Overall, 1.6% of the Medicare managed-care population reported quitting during the preceding 12 months, representing approximately 10% of the smokers who reported any smoking within that period. However, it is likely that some of those who quit during the preceding year will begin smoking again. Health-care providers should be aware that smoking cessation counseling, even brief advice to quit smoking, can be effective in encouraging older smokers to quit.

All health-care providers should deliver tobacco-use treatment interventions to their patients.⁵ Basic components of a counseling session include asking each patient whether he or she uses tobacco, urging all tobacco users to stop, identifying tobacco users willing to quit, providing assistance to these patients (e.g., establishing a quit date, providing support and practical advice on the quitting process, and encouraging the use of approved pharmocotherapies such as nicotine replacement therapy and buproprion when appropriate), and arranging follow-up visits for support.⁵ Use of office reminders, such as chart stickers or vital sign, can increase the provision of cessation advice by providers.⁵ Reimbursement of treatment services and products has been shown to increase use of cessation services and overall quit rates.⁸

MMWR. 2000;49:445-449

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In 1988, the World Health Assembly resolved to eradicate poliomyelitis globally by 2000.¹ The African Region (AFR) of the World Health Organization (WHO) began implementing polio eradication strategies in 1996, including National Immunization Days (NIDs*) and acute flaccid paralysis (AFP) surveillance.^2- 3 This report summarizes progress toward polio eradication in AFR during 1999-March 2000, and suggests that although substantial progress has been reported toward interrupting poliovirus transmission in eastern and southern Africa, poliovirus remains endemic in other African countries in west and central Africa, especially among those experiencing internal strife or civil war.

AFR includes 48 countries and territories and is divided geographically into five major epidemiologic blocks: eastern, western, southern, central, and countries in special situations. Reported regional coverage with three doses of oral poliovirus vaccine (OPV3) among children aged 1 year was approximately 55% in 1999 and has remained relatively stable since 1990. OPV3 coverage by country ranged from 65%-75% in the eastern and southern blocks, 50%-55% in the western block, and approximately 40% in the central block. Coverage was lower (approximately 30%) among countries in difficult circumstances (e.g., Angola, Democratic Republic of Congo [DR Congo], and Ethiopia).

From January 1999 through March 2000, two or more rounds of NIDs or Subnational Immunization Days (SNIDs) were conducted in all 35 (73%) countries and territories of the region where polio is either endemic (20 countries) or was considered endemic until recently (15). An estimated 133 million children received at least two supplemental doses of OPV during 1999, representing a 50% increase over the number of children reached in similar campaigns in 1998. NIDs coverage was reported to be greater than 80% in all countries, with the exception of Sierra Leone (76%) and Congo Brazzaville (55%). Countries conducting SNIDs (predominantly eastern and southern block countries) reported coverage greater than 80%.

To accelerate progress toward eradication, intensified NIDs were conducted in nine countries in the region (Angola, Benin, Chad, DR Congo, Guinea-Bissau, Liberia, Niger, Nigeria, and Sierra Leone) during 1999. Intensified NIDs consisted of either additional rounds or administering the vaccine house-to house. DR Congo conducted three rounds of NIDs during July-September 1999 and reported coverage rates of 81%, 91%, and 80% for the first, second, and third rounds, respectively.⁴ Nigeria targeted 13 million children residing in 15 (35%) of 37 states during April-May 1999; all OPV doses were administered in house-to-house vaccination campaigns. This effort reached 10%-40% more children in each state than had been reported from previous NID rounds.⁵ SNIDs also were conducted in the capitals of Central African Republic (Bangui) and Burkina Faso (Ouagadougou) in May and June 1999.

AFP surveillance improved rapidly in AFR during 1999; 4999 AFP cases were reported in 1999 compared with 1754 in 1998, an increase of nearly 200%. The nonpolio AFP rate more than doubled from 0.3 cases per 100,000 children aged less than 15 years in 1998 to 0.8 in 1999 (target: greater than or equal to 1 nonpolio AFP case per 100,000 population aged less than 15 years). However, the proportion of AFP cases with two stool specimens collected within 14 days of onset of paralysis declined from 35% in 1998 to 31% in 1999. Of the 15 polio laboratories in the region, 13 were accredited during 1999, and all stool specimens were processed in accredited network laboratories.

In 1999, wild poliovirus was isolated from 238 AFP case-patients residing in 16 AFR countries, mainly in central and western Africa and Angola. Angola experienced the largest polio outbreak ever recorded in Africa with 1093 cases and 89 deaths.⁶ Wild poliovirus circulation was detected in stool specimens from AFP cases in Nigeria (95), Angola (53), Chad (35), Liberia (11), Niger (10), Cote d'Ivoire (nine), and Benin (eight). Wild poliovirus also was detected in Cameroon, Central African Republic, DR Congo, Ethiopia, Ghana, Guinea, Mali, Sierra Leone, and Togo. No wild poliovirus was detected in southern Africa.

Expanded Program on Immunization, World Health Organization Regional Office for Africa, Harare, Zimbabwe; Vaccines and Biologicals Div, World Health Organization, Geneva, Switzerland. Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Vaccine Preventable Disease Eradication Div, National Immunization Program, CDC.

Intensified efforts to achieve polio eradication were implemented in the remaining countries of AFR where polio is endemic during 1999. Specific actions to improve the quality of supplemental vaccination campaigns (NIDs and SNIDs) included (1) intensified NIDs using the house-to-house strategy; (2) increased provision of technical assistance (e.g., logisticians, epidemiologists, and social mobilization experts); (3) dissemination of guidelines to achieve quality NIDs; and (4) synchronization of NIDs among countries having contiguous borders, including special cross-border coordination strategies. In addition, SNIDs were implemented in at least two countries, and special attention was given to improving the quality and geographic coverage of AFP surveillance.

Serious constraints to improving the quality and the geographic coverage of NIDs persisted in 1999. Wars, civil unrest, and political instability made it impossible to reach all unvaccinated children in certain countries during NIDs (Angola, Congo Brazzaville, DR Congo, Nigeria, and Sierra Leone). In October and November of 1999, the global shortfall in the OPV supply made it necessary to postpone NIDs in Burknia Faso, Chad, Ghana, Kenya, Niger, Sierra Leone, and Togo. In addition, some countries received OPV without vaccine vial monitors.

Although AFP surveillance has improved substantially from 1998 to 1999, further improvements are needed to increase the nonpolio AFP rate from 0.8 to the standard threshold of greater than or equal to 1.0, indicating a sensitive surveillance system. The stool collection rate remains low in AFR. Although some of the decrease in the collection rate during 1998-1999 may be because not all cases associated with the 1999 Angola outbreak needed to be virologically confirmed, stool collection rates in the region did not increase in 1999.

Wild poliovirus is assumed to circulate in Sierra Leone and Congo Brazzaville, but surveillance was not operating for most of 1999 in these countries. In addition, the quality of surveillance is inadequate to determine whether wild poliovirus transmission continues in Madagascar, Malawi, and Mozambique. These three countries have low routine vaccination coverage and no longer conduct supplementary vaccination activities.

Efforts to improve the quality of AFP surveillance in 1999 and early 2000 include (1) increased funding for AFP surveillance; (2) expansion of active surveillance to the provincial level; and (3) provision of additional technical support for AFP surveillance through the Stop Transmission of Polio (STOP) Initiative in Chad, DR Congo, Ghana, Guinea, Kenya, Niger, Nigeria, and Uganda.

Although indigenous wild poliovirus is virtually absent in southern and eastern Africa and wild poliovirus circulation has declined to low levels in the some parts of west Africa, countries with intense circulation of wild poliovirus, including Angola, Chad, DR Congo, Ethiopia, Nigeria, and Sierra Leone, pose a risk for delaying global polio eradication. The remaining major challenges to polio eradication in AFR are (1) conducting high-quality supplemental vaccination activities and additional rounds and mopping-up activities where indicated, with emphasis on reaching previously unvaccinated children; (2) gaining access to all children in countries affected by conflict (e.g., Angola, Congo Brazzaville, DR Congo, and Sierra Leone); (3) assuring adequate quantities of potent OPV vaccines for routine and supplemental vaccination activities; (4) addressing basic routine EPI infrastructure in Angola, DR Congo, Liberia, Nigeria, and Sierra Leone; (5) filling the shortfall in funding† for polio eradication in AFR; and (6) rapidly improving the quality of AFP surveillance.

*Nationwide mass campaigns over a short period (days to weeks), in which two doses of oral poliovirus vaccine are administered to all children in the target age group (usually aged less than 5 years), regardless of vaccination history, with an interval of 4-6 weeks between doses.

†The polio eradication initiative in AFR is supported by AFR member countries. External funding is provided by Rotary International, United Nations Childrens' Fund, the governments of Canada, United States, United Kingdom, Norway, and Belgium, the United Nations Foundation, the Gates Foundation, the De Beers Corporation, WHO, and CDC.

MMWR. 2000;49:791

Influenza pandemics have occurred three times during the 20th century: 1918, 1957, and 1968. Experts predict that another influenza pandemic is likely, if not inevitable. Prepandemic planning is essential if influenza pandemic-related morbidity, mortality, and social disruption are to be minimized. To help state and local public health officials and policy makers prepare for the next influenza pandemic, CDC has developed FluAid, 2.0, a specialized software that estimates the number of deaths, hospitalizations, and outpatient visits that may occur during the next pandemic. The software also will help planners calculate the potential burden of an influenza pandemic on health-care resources (e.g., number of hospital beds required and doctors available to see outpatients as a percentage of existing capacity).

Starting September 1, 2000, FluAid, 2.0 will be available from the National Vaccine Program Office's World-Wide Web site, http://www.cdc.gov/od/nvpo/pandemics/. The software can be downloaded or can be accessed as an online calculator. A manual is provided explaining the software, required data inputs, and suggestions for data sources. FluAid is in the public domain and available free of charge.