International Health
Volume 7 Issue 5 September 2015
http://inthealth.oxfordjournals.org/content/current

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Disease Elimination Special Issue
EDITORIAL
Eradication and elimination: facing the challenges, tempering expectations
David H. Molyneux
Extract
The words eradication, elimination and control have been regularly defined in attempts to avoid inappropriate use of terminology while addressing the realities and challenges of public health programmes.1,2
Whitty3 has recently outlined the dangers of raising expectations in the face of political, financial, biological and logistical efforts of eradication or elimination programmes, emphasising these risks in search of a holy grail. Bockarie et al.4 noted five categories that defined the elimination or endgame challenges—biological, socio-geographic, logistic, strategic and technical—providing examples from current programmes. These have created significant strategic and resource impediments to progress in implementation, requiring changes in approach often with significant financial implications.
A variety of strategies are used to reduce incidence and prevalence of infectious diseases: vaccination (smallpox, polio, measles), chemotherapy (onchocerciasis, lymphatic filariasis, schistosomiasis), vector control, (onchocerciasis, malaria, schistosomiasis) and provision of improved clean water and sanitation (trachoma, guinea worm, soil transmitted helminths, schistosomiasis). Such strategies are more effective when combined, for example, chemotherapy, vector control and behaviour change, thereby achieving proportionately greater and more rapid impact on transmission.
Eradication as a concept is specifically defined as a reduction to zero global incidence of a specific pathogen, not a disease, which results from such an infection. This represents a crucial distinction—the words disease and infection are often used interchangeably but incorrectly. Even WHO reporting recently on the yaws programme in India entitled their publication ‘Eradication of yaws in India.’ Thus, even WHO are unable to consistently use correct terminology. Another example is the call for the eradication of malaria. However, eradication is defined as the removal from the planet of a specific infection; raising the question, which of the five human species of Plasmodium is to be targeted? This is yet to be specified…

Political, social and technical risks in the last stages of disease eradication campaigns
Christopher J. M. Whitty*
Author Affiliations
London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
Abstract
Eradication of a disease is one of the greatest gifts any generation can give to subsequent ones, but most attempts have failed. The biggest challenges occur in the final stages of eradication and elimination campaigns. These include falling public support as a disease becomes less common; the emergence of groups who do not support eradication; spiralling costs; and the evolution of drug, vaccine or insecticide resistance. Mass campaigns become less effective as the disease fragments and modelling becomes less reliable. Optimism bias is the biggest risk to any eradication campaign and the long endgame must be planned for from the beginning.

From ‘control to elimination’: a strategic change to win the end game
Adrian Dennis Hopkins*
Author Affiliations
Mectizan Donation Programme, Atlanta, GA, USA
Abstract
Strategies for elimination evolve from early use of available tools, to elaboration of control strategies, through to ‘elimination.’ Onchocerciasis control in Africa demonstrates this evolution. Early strategies used vector control but later used mass distribution of ivermectin. Elimination in Africa though was not thought to be possible; however, with excellent coverage of ivermectin distribution it was demonstrated that treatment could be stopped on the Senegal Mali border stimulating a new policy of elimination of transmission where possible. This new policy must not be business as usual but will require redefining treatment areas, improving quality of data, and flexibility of strategies to fit the new paradigm.

Non-communicable disease training for public health workers in low- and middle-income countries: lessons learned from a pilot training in Tanzania
Evelyn P. Davilaa,*, Zubeda Suleimanb, Janneth Mghambab, Italia Rollec, Indu Ahluwaliad, Peter Mmbujib, Maximilian de Courtene, Andrea Baderf, S. Christine Zahniserg, Marlene Kragh and Bassam Jarrara
Author Affiliations
aDivision of Public Health Systems and Workforce Development, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, USA
bField Epidemiology Laboratory Training Program Tanzania, Ministry of Health and Social Welfare, Tanzania
cOffice on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, USA
dDivision of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, USA
eDepartment of International Health, Immunology and Microbiology and Copenhagen School of Global Health, University of Copenhagen, Denmark
fDeloitte Consulting, Atlanta, USA
gGEARS Inc., Atlanta, USA and Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, USA
hCopenhagen School of Global Health, University of Copenhagen, Denmark
Abstract
Background
Non-communicable diseases (NCDs) are increasing worldwide. A lack of training and experience in NCDs among public health workers is evident in low- and middle- income countries.
Methods
We describe the design and outcomes of applied training in NCD epidemiology and control piloted in Tanzania that included a 2-week interactive course and a 6-month NCD field project. Trainees (n=14 initiated; n=13 completed) were epidemiology-trained Ministry of Health or hospital staff. We evaluated the training using Kirkpatrick’s evaluation model for measuring reactions, learning, behavior and results using pre- and post-tests and closed-ended and open-ended questions.
Results
Significant improvements in knowledge and self-reported competencies were observed. Trainees reported applying competencies at work and supervisors reported improvements in trainees’ performance. Six field projects were completed; one led to staffing changes and education materials for patients with diabetes and another to the initiation of an injury surveillance system. Workplace support and mentoring were factors that facilitated the completion of projects. Follow-up of participants was difficult, limiting our evaluation of the training’s outcomes.
Conclusions
The applied NCD epidemiology and control training piloted in Tanzania was well received and showed improvements in knowledge, skill and self-efficacy and changes in workplace behavior and institutional and organizational changes. Further evaluations are needed to better understand the impact of similar NCD trainings and future trainers should ensure that trainees have mentoring and workplace support prior to participating in an applied NCD training.