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LOGISTICS OF GUINEA WORM DISEASE ERADICATION IN SOUTH SUDAN

Friday, 23rd of January 2015

LOGISTICS OF GUINEA WORM DISEASE ERADICATION IN SOUTH SUDAN

1. Alexander H. Jones*,
2. Steven Becknell,
3. P. Craig Withers,
4. Ernesto Ruiz-Tiben,
5. Donald R. Hopkins,
6. David Stobbelaar and
7. Samuel Yibi Makoy

+ Author Affiliations

1. Health Programs, The Carter Center, Atlanta, Georgia; Division of Public Health Systems and Workforce Development, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia; South Sudan Guinea Worm Eradication Program, Directorate of Preventive Health Services, Ministry of Health, Republic of South Sudan, Juba, South Sudan

+ Author Notes

• Authors addresses: Alexander H. Jones, P. Craig Withers, Ernesto Ruiz-Tiben, Donald R. Hopkins, and David Stobbelaar, Health Programs, The Carter Center, Atlanta, GA, E-mails: jonesahj@yahoo.com, cwither@emory.edu, eruizt@emory.edu, sdsulli@emory.edu, and resadv@cartercenter-ssudan.com. Steven Becknell, Division of Public Health Systems and Workforce Development, Centers for Disease Control and Prevention, Atlanta, GA, E-mail: ziq1@ug.cdc.gov. Samuel Yibi Makoy, Directorate of Public Health, Ministry of Health, Republic of South Sudan, Juba, South Sudan, E-mail: makoy@cartercenter-ssudan.com.

1. ↵* Address correspondence to Alexander H. Jones, 453 Freedom Parkway, Atlanta, GA 30307. E-mail: jonesahj@yahoo.com

 

Full text, with figures, is at  http://www.ajtmh.org/content/90/3/393.full

Abstract

From 2006 to 2012, the South Sudan Guinea Worm Eradication Program reduced new Guinea worm disease (dracunculiasis) cases by over 90%, despite substantial programmatic challenges. Program logistics have played a key role in program achievements to date. The program uses disease surveillance and program performance data and integrated technical–logistical staffing to maintain flexible and effective logistical support for active community-based surveillance and intervention delivery in thousands of remote communities. Lessons learned from logistical design and management can resonate across similar complex surveillance and public health intervention delivery programs, such as mass drug administration for the control of neglected tropical diseases and other disease eradication programs. Logistical challenges in various public health scenarios and the pivotal contribution of logistics to Guinea worm case reductions in South Sudan underscore the need for additional inquiry into the role of logistics in public health programming in low-income countries.

Introduction

As early as 2002, global disease eradication campaigners understood that South Sudan would likely be a last bastion of dracunculiasis,1 commonly known as Guinea worm disease (GWD). During the 23-year civil war, GWD eradication surveillance and interventions in South Sudan were supported through a loose consortium of non-governmental organizations with limited success because of lack of a strong central governmental coordinating body, weak information and logistical systems, poor infrastructure, heavy seasonal rains coinciding with peak disease transmission, and rampant insecurity. The 2005 Comprehensive Peace Agreement allowed the newly created Ministry of Health, Republic of South Sudan to launch the South Sudan Guinea Worm Eradication Program (SSGWEP). (South Sudan gained full independence from Sudan in July of 2012, becoming the Republic of South Sudan.) In 2006, the program reported 20,582 new GWD cases from 3,137 villages in 7 of 10 states and 39 of 80 counties. South Sudan then accounted for 82% of cases globally.2 In 2012, the program reported 521 new cases, a 97% reduction since 2006 (Ministry of Health, Republic of South Sudan, unpublished data).

Logistics provide the means to make the right thing possible at the right place and time.3,4 Defined by the Council of Supply Chain Management Professionals (2010) as “the process of planning, implementing, and controlling procedures for the efficient and effective transportation and storage of goods … from the point of origin to the point of consumption,” logistics are a primary reason for the 97% reduction in GWD annual incidence. For public health practitioners, useful logistical guidelines exist. (The John Snow, Inc/U.S. Agency for International Development [USAID] Deliver Project provides an array of useful practical guides and policy papers, including The Logistics Handbook, a Practical Guide for Supply Chain Managers in Family Planning and Health Programs [available at http://deliver.jsi.com]. Another useful handbook, written for logistics in humanitarian disasters, is McGuire, Handbook of Humanitarian Health Care Logistics [available at www.humanitarianhealthcarelogistics.com].) However, a search for publically available, peer-reviewed literature on the role of logistics in global health (generally) and disease eradication (specifically) reveals limited available sources. Logistical challenges have negatively impacted, to name a few, efforts to combat lymphatic filariasis,5 trachoma,6 polio,7 smallpox,3 malaria, tuberculosis, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)8; however, related literature on effective logistical system design and management approaches is sparse. This paper is intended for public health practitioners and policy-makers working in low-income countries. It discusses the key role of logistics in GWD eradication in South Sudan and its contribution to the how of disease eradication, including logistical system design considerations, characteristics, management approaches, and key lessons learned.

Design Considerations: Strategy and Tactics

“Logistics comprises the means and arrangements which work out the plans of strategy and tactics” (General Antoine Henri Jomini, Précis de l Art de la Guerre, 1838).

Disease eradication requires effective and efficient technical, logistical, and administrative support structures.9 GWD eradication strategy and tactics, designed around disease epidemiology in South Sudan and associated contextual considerations, shape SSGWEP support structures and associated management approaches.

GWD eradication strategy.

Eradication campaigns require a level of intervention delivery and surveillance substantially surpassing the level of disease control programs.10 Eradication programs must interrupt disease transmission everywhere as rapidly as possible. Therefore, case containment and sensitive and specific surveillance are fundamental to the strategy and foundational for program interventions. The SSGEWP attempts to detect every case (defined as a person with one or more worms emerging from his/her body in a calendar year) and contain every worm. Case containment prevents a worm from releasing its larvae into a water source (Figure 1). Containment requires detection within 24 hours of worm emergence, case management every 24 hours, and supervisory confirmation of containment within 7 days.

The village is the basic unit of surveillance. The program maintains an updated list of villages under active surveillance and a complete line list of all detected cases. Generally, villages remain under active surveillance until reporting no cases for 3 consecutive years and no established population movements with known endemic villages. The SSGWEP logistical system must support continuous daily active surveillance among households in villages under active surveillance and delivery of other interventions in all endemic villages. Program logistics must also support the necessary supervisory structures.

The epidemiology and programmatic environment in South Sudan dictate the design of program logistics. In 2006, based on data that would be subsequently validated over years of active surveillance, the SSGWEP understood that transmission took place in four foci (Figure 2). In endemic areas, GWD transmission typically occurs in rainy season settlements located on relatively higher and drier ground compared with dry season settlements. Because of heavy population movement and low safe water coverage, the level of transmission risk across villages within a county remains relatively static. The physical environment in endemic areas, such as Warrap and Lakes states, largely consists of seasonal swamps, restricting transport of supplies and making transport, when possible, slow and expensive.

GWD-endemic focal areas and ethnic groups in 2006.

SSGWEP tactics.

GWD eradication deploys a complementary intervention package applied simultaneously that is appropriate to the different stages of the transmission cycle. Program interventions include cloth and pipe filters (with a 100 × 100-μm mesh; Vestergaard, Lausanne, Switzerland), which remove the intermediate host of Guinea worm, called copepods, from drinking water. Chemical vector control using the larvicide ABATE temephos (BASF Corporation, Florham Park, NJ) controls copepod populations in unsafe water sources. Health education and behavior change efforts bolster community uptake of program interventions.

Logistical impact of person, place, and time on GWD eradication in South Sudan.

The village is the primary unit of surveillance, because it is the main location where targeted populations reside. In South Sudan, different ethnic groups populate endemic areas, but all communities are pastoralist. Villages can be, in whole or part, depopulated during the driest months, because whole families migrate with their cattle, only to return when the rains and planting season begin. Surveillance must track mobile populations throughout the year, and logistical support must enable surveillance in all places that target communities inhabit throughout the year.

Generally, the annual peak transmission season corresponds with the rainy season from April to September (Table 1). The timing and severity of the seasonal rains and resulting flooding are primary determinants for logistical system design. The program defines logistical coverage areas for support bases to mitigate poor road accessibility to endemic villages. The rainy season necessitates decentralization of materials and execution of technical and logistics activities according to a seasonal implementation calendar.