International Task Force for Disease Eradication

The eradication* of smallpox from the world in 1977 (1) proved the feasibility of infectious disease eradication. The International Task Force for Disease Eradication (ITFDE)** is assessing the potential for global eradication of other infectious diseases. This report summarizes the ITFDE's findings on the potential to eradicate eight diseases based on draft versions of criteria under development.

The ITFDE was initiated at the Carter Center of Emory University in 1988 by a grant from the Charles A. Dana Foundation. Modeled after the Task Force for Child Survival (2), the ITFDE's purposes are to evaluate systematically the potential eradicability of candidate diseases, identify specific barriers to their eradication that might be overcome through further research or other efforts, and encourage eradication efforts where appropriate.

In its first two meetings in April and October 1989, the ITFDE reviewed and modified draft versions of criteria used to evaluate the potential eradicability of eight diseases that are being or have been promoted for eradication by international agencies, national authorities, or others. Criteria included consideration of the epidemiologic vulnerability (e.g., lack of an animal reservoir and limited duration of infectiousness) of the disease; availability of an effective, practical intervention; impact of the disease on human well-being; existence of national and/or international commitment to attack the problem; and cost. Each disease was first presented by a technical expert, then discussed by the task force and staff. In these discussions, two diseases were judged to be eradicable and three to be candidates for elimination of transmission or of clinical symptoms; three were not considered candidates for eradication at this time (Table 1).

Guinea worm disease (dracunculiasis). Guinea worm eradication is feasible if the necessary commitment and resources can be mobilized. The ITFDE will help publicize efforts and funding needs (3).

Poliomyelitis. Worldwide polio eradication is deemed technically possible by the year 2000; an improved vaccine would facilitate eradication of polio. The ITFDE agreed to write to the heads of state of several nations in the Americas to solicit their support for this hemisphere's goal of eliminating polio by the end of 1990 (4,5).

Onchocerciasis. Elimination of blindness caused by onchocerciasis appears feasible through vector control and treatment with ivermectin. Because of the cost, duration, and difficulty of effective larviciding and the absence of a drug to kill the adult worms (6), eradication of the infection altogether is not now feasible.

Yaws and endemic syphilis. Eradication of yaws and endemic syphilis is not feasible under present conditions. However, elimination of the transmission of these diseases in certain areas appears feasible. Tests need to be developed that can reliably distinguish the organisms that cause yaws, endemic syphilis, and pinta from those that cause venereal syphilis (7).

Rabies. Rabies eradication is not feasible because of the extensive and varied animal reservoirs of the virus and the inability to eliminate those reservoirs with existing technology. However, elimination of human rabies in urban areas may be possible (8).

Measles. Global eradication of measles is not currently feasible because of the high communicability of measles and the suboptimal serologic responses to vaccines administered to young infants (9). After the ITFDE conference, WHO recommended use of high-titered Edmonsten-Zagreb vaccine beginning at 6 months of age in developing countries; however, an improved vaccine is still needed.

Tuberculosis. Global eradication of tuberculosis is not now feasible. Better tools for diagnosis, case-finding, prevention, and treatment need to be developed, and the application of current short-course therapy in developing countries needs to be greatly increased (10).

Leprosy. Leprosy (Hansen disease) eradication worldwide is not feasible now (11). Reported by: J Duffy, MD, Gillis W Long Hansen's Disease Center, Carville, Louisiana. CA deQuadros, Pan American Health Organization; BOL Duke, MD, Armed Forces Institute of Pathology, Walter Reed Army Medical Center, Washington, DC. RH Henderson, MD, A Meheus, MD, World Health Organization, Geneva, Switzerland. DR Hopkins, MD, Global 2000, Inc., Carter Center of Emory Univ, Atlanta, Georgia. Div of Tuberculosis Control, Center for Prevention Svcs; Office of the Director, Center for Infectious Diseases; Office of the Director, CDC.

Editorial Note

Editorial Note: Four factors/conditions enabled the eradication of smallpox: 1) no reservoir of the virus existed except in humans; 2) nearly all persons infected with smallpox had an obvious, characteristic rash and were infectious for a relatively short period; 3) the natural infection conferred lifelong immunity; and 4) a safe, effective (even in newborns), and inexpensive vaccine was available that was also highly stable in tropical environments (12).

The 12-year-old success of the Smallpox Eradication Program (SEP) provides an impetus for eradication or elimination of other diseases. A symposium sponsored by the Fogarty International Center of the National Institutes of Health to consider post-SEP possibilities in 1980 identified yaws, measles, and polio as the most likely candidates for eradication (13). In 1986, the World Health Assembly resolved to "eliminate" Guinea worm disease (Resolution WHA 39.21), the first such resolution since the smallpox campaign; in 1989, the Assembly added the deadline for eradicating Guinea worm disease in "the 1990s" (Resolution 42.29). (Global 2000*** and the African Regional Office of WHO have set the informal goal of eradicating Guinea worm disease by 1995.) In 1988, the World Health Assembly officially established the goal of eradicating polio by the year 2000 (Resolution WHA 41.28).

Different WHO regions have also established regional goals of eliminating polio, measles, or neonatal tetanus over the next decade, starting with the elimination of polio from the Americas by the end of this year. India and China aim to eliminate leprosy transmission within their borders by the year 2000, and the United States has set a national goal of eliminating tuberculosis by 2010 (defined as an annual case rate of less than one per million population (14)). Achievement of some or all of these interim milestones will increase support for global eradication of selected diseases.

The public health strategy of disease eradication offers considerable advantages over disease control when eradication is undertaken against appropriate, carefully chosen targets. The benefits of eradication are permanent and accrue after a finite cost, whereas the costs of controlling the same disease must be maintained indefinitely. For example, the United States invested $32 million in SEP over a 10-year period; this amount is equivalent to former U.S. costs and expenditures every 3 months for routine vaccination (discontinued in 1971) and management of its complications. The United States government is investing greater than $50 million annually to maintain its polio-free status and an estimated $25-$50 million to keep domestic measles at low levels (15). These figures do not reflect the cost of vaccination in the private sector or the annual occurrence of vaccine-associated polio.

A time-limited goal of eradication allows mobilization of support more readily than a control program. An important corollary requirement for global eradication is that unaffected countries will need to provide material assistance where needed, including geographic areas where small residual foci might not otherwise warrant use of scarce national resources.

References

1. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox

and its eradication. Geneva: World Health Organization, 1988.

2. The Task Force for Child Survival. Protecting the world's children: vaccines and immunization within primary health care. New York: Rockefeller Foundation, 1984.

3. CDC. Update: dracunculiasis eradication--worldwide, 1989. MMWR 1990;38:882-5.

4. CDC. Progress toward eradicating poliomyelitis from the Americas. MMWR 1989;38:532-5.

5. Hinman AR, Foege WH, de Quadros CA, Patriarca PA, Orenstein WA, Brink EW. The case for global eradication of poliomyelitis. Bull WHO 1987;65:835-40.

6. Duke BOL. Onchocerciasis--river blindness: can it be eradicated? Presented at the Symposium of the International Task Force for Disease Eradication, Atlanta, April 13-14, 1989.

7. Burke JP, Hopkins DR, Hume JC, Perine PL, St. John R, eds. International symposium on yaws and other endemic treponematoses. Rev Infect Dis 1985;7(suppl 2):S217-351.

8. Murphy FA. Rabies as a world problem. Presented at the Symposium of the International Task Force for Disease Eradication, Atlanta, April 13-14, 1989.

9. Hopkins DR, Hinman AR, Koplan JP, Lane JM. The case for global measles eradication. Lancet 1982;1:1396-8. 10. Styblo K. Overview and epidemiologic assessment of the current global tuberculosis situation with an emphasis on control in developing countries. Rev Infect Dis 1989;2 (suppl 2):S339-46. 11. Duffy JC. Hansen's disease (leprosy). Presented at the Symposium of the International Task Force for Disease Eradication, Atlanta, Georgia, April 13-14, 1989. 12. Hopkins DR. Beyond smallpox eradication. In: Mandl PE, ed. Assignment children. Geneva: United Nations Children's Fund, 1985;69/72:235-42. 13. Stuart-Harris C, Western KA, Chamberlayne EC, eds. Can infectious diseases be eradicated? A report on the international conference on the eradication of infectious diseases. Rev Infect Dis 1982;4:913-84. 14. CDC. A strategic plan for the elimination of tuberculosis in the United States. MMWR 1989;38(no. S-3). 15. Hinman AR, Bart KJ, Hopkins DR. Costs of not eradicating measles. Am J Public Health 1985;75:713-4. *Eradication is defined as achievement of a status whereby no further cases of a disease occur anywhere, and continued control measures are unnecessary. **The ITFDE includes five members of the Task Force for Child Survival (from World Health Organization, United Nations Children's Fund, United Nations Development Program, the World Bank, and the Rockefeller Foundation), the president of the Institute of Medicine, the director of CDC, a member of the Swedish Academy of Science, a director of the Charles A. Dana Foundation, a person from the Carnegie Corporation of New York, and a representative of the Japanese International Cooperation Agency. The principal investigator for the ITFDE is the executive director of the Carter Center of Emory University, and the project director is a senior consultant to Global 2000 of the Carter Center. ***Global 2000 is a nonprofit entity of the Carter Center of Emory University focusing on improving health and agriculture in developing countries.

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