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Maximum control of disease and improvement of health are the goals of every effective public health programme, whether stated or not. Each successful milestone in the reduction of a disease, each new tool for diagnosis and prevention, and each refinement in control strategy allows the establishment of new and more demanding objectives along the path to achieving these goals. Smallpox was eradicated two decades ago, and today programmes are under way to eradicate poliomyelitis and dracunculiasis (guinea-worm disease). The malaria, yellow fever, and yaws programmes in the past failed to achieve eradication, but were associated with appreciable health benefits to many and contributed to a better understanding of the biological, social, political, and economic complexities associated with disease eradication.
Achieving the ultimate goal of disease eradication has been the focus of numerous conferences, symposia, workshops, planning sessions, and public health actions for more than a century. The most recent, the 1997 Dahlem Workshop on the Eradication of Infectious Diseases, addressed the science of disease eradication. The Conference on Global Disease Elimination and Eradication as Public Health Strategies extended the Dahlem Workshop findings to consider specific infectious and noninfectious diseases and conditions in the context of sustainable health development and global priorities.
The Conference brought together over 200 participants from 81 organizations and 34 countries. It provided an unprecedented forum for the exchange of ideas among persons with different training, experience, organizational responsibilities, and points of view, each one aiming at the same goal and contributing in some way to reducing the global burden of disease. Participants from local, national, and global levels brought to the Conference a wealth of experiences that encompassed disease control and prevention programmes, health systems infrastructure development, laboratory research, epidemiology, economics, and the behavioural sciences. The Conference considered five major areas: sustainable health development; noninfectious diseases; and bacterial, parasitic, and viral diseases. Key findings and critical issues that emerged during the Conference are summarized below in relation to these five areas.
Sustainable Health Development
There are intrinsic and unavoidable tensions between the concepts of eradication and sustainable health development. These tensions arise because of polarization between specific rather than comprehensive goals, and a time-limited rather than long-term agenda. Acknowledging, accepting, and overcoming these tensions are essential if full advantage is to be taken of what each programme can contribute to the achievement of public health goals.
Eradication programmes should have two objectives: eradication of the disease; and strengthening and further development of health systems. Potential benefits for health development should be identified and delineated at the start of any eradication initiative. Measurable targets for achieving the development benefits should be set and the eradication programme held accountable for their realization. Resources for eradication activities should be supplementary to those available for basic health care services. Care must be taken that programmes do not divert resources from basic health services, health development, and other priorities.
Successful eradication programmes are powerful examples of effective management and should incorporate efforts to design programme activities that enhance leadership development and managerial skills which can be carried to other health programmes. Eradication programmes also should aid in the development and implementation of surveillance systems that can be readily adapted to other national priority programmes after eradication has been achieved. Finally, coordination of the development and implementation of eradication efforts with primary care services can produce biological complementarity (e.g. improvement in nutritional status, which may enhance immune responsiveness and resistance to some infectious diseases).
The Conference concluded that better control was achievable for certain micronutrient deficiencies (iodine, vitamin A, iron, and folic acid), lead intoxication, and silicosis, even though none of these conditions meets the requirements for eradication. Recommendations were made for reducing protein-energy malnutrition and lead intoxication and for accelerating the attainment of global goals for the control of micronutrient deficiencies. Micronutrient supplementation should be enhanced by taking advantage of food fortification and the opportunities presented by the existing health infrastructure and immunization programmes.
Congenital syphilis, trachoma, and Haemophilus influenzae type b (Hib) infection in some countries are candidates for elimination, but no bacterial diseases were judged to be current candidates for eradication. The WHO neonatal tetanus "elimination goal" of less than 1 case per 1000 live births in every district was considered laudable and attainable. Eradication was considered to be a long-term goal for tuberculosis and Hib infection. Bacterial diseases represent a major disease burden and have substantial research needs before eradication goals can be established. Aggressive action was strongly recommended to improve global control of bacterial conditions.
Dracunculiasis (guinea-worm disease) eradication is in progress. Although no additional parasitic diseases were considered to be current candidates for eradication, the increasing availability of potent, long-acting drugs brings extraordinary opportunities for overcoming onchocerciasis and lymphatic filariasis, and the effectiveness of the strategy for controlling the triatomid vectors provides similar opportunities for American trypanosomiasis (Chagas disease). The workgroup concluded that onchocerciasis (river blindness) and lymphatic filariasis (caused by all Wuchereria and most Brugia infections) could be eliminated and possibly eradicated in the future. For the 5% of cases of lymphatic filariasis caused by Brugia malayi, which also has an animal reservoir (in South-east Asia), elimination of disease, but not infection, is feasible. Similarly, for Chagas disease where animal reservoirs exist, elimination of disease, but not infection, is feasible.
Poliomyelitis eradication is in progress. Measles and rubella were concluded to be possible candidates for eradication within the next 10-15 years. Measles transmission appears to have been interrupted for various periods in many countries in the Americas; elimination has not yet been demonstrated in other regional settings. The workgroup recommended that developed countries should proceed with elimination of measles as a step towards eradication. In other countries, accelerating measles control should be the priority, especially in areas with high mortality. Developing countries should proceed cautiously to more costly measles elimination programmes to avoid undermining the poliomyelitis eradication effort. Experience gained from regional and country interventions should be used to refine the strategies for eventual eradication.
The eradication of rubella as an add-on to measles eradication was felt to be biologically plausible. However, several issues first need to be addressed, including the burden of rubella disease (human and financial), the marginal cost of adding rubella to a measles eradication effort, and demonstration that elimination is programmatically feasible and sustainable in a large geographical area.
The workgroup urged stronger international efforts to control rabies, yellow fever, and Japanese encephalitis by using existing measures, but none of these diseases was considered suitable as a candidate for eradication because of the existence of a nonhuman reservoir. Viral hepatitis A eradication was concluded to be biologically feasible but further demonstration of sustainable elimination was first required.
Viral hepatitis B was not considered to be a current candidate for eradication because of the multi-generation programme necessary to overcome the effect of long-term virus persistence. However, the workgroup recommended immunization in all countries to maximize the likelihood of eliminating transmission of hepatitis B virus.
The Conference provided a multidisciplinary forum for addressing issues related to disease elimination and eradication and their relationship to sustainable development in health. There was widespread agreement that an eradication programme could have many positive effects on health systems development and that explicit efforts should be made to maximize these positive effects as well as minimize any negative effects. Community mobilization and organization should be seen as a component of sustainable health development, with the additional potential for disease control and eradication. Poliomyelitis and dracunculiasis eradication efforts are already under way. Measles and rubella are possible candidates for eradication. Congenital syphilis, trachoma, and Hib infection are candidates for elimination in some countries. River blindness (onchocerciasis) and lymphatic filariasis (W. bancrofti) could be eliminated and possibly eradicated at some time in the future.
Discussions in the final plenary session centred on concerns about the misuse and misunderstanding of the term elimination, since this term is often not clearly distinguished from eradication. Also addressed was the need to bring the findings of the Conference to other forums to expand discussion of international health goals and strengthen the mutual ties between sustainable health development and disease control and eradication efforts. Finally, the Conference suggested that a small group convene to further address the topic of definitions and to identify next steps for disseminating and implementing the recommendations of the Conference (see report on p. 152).
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