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Progress Toward Global Eradication of Dracunculiasis, January 2008--June 2009

Dracunculiasis is a parasitic infection caused by Dracunculus medinensis. Persons become infected by drinking water from stagnant sources (e.g., ponds) contaminated by copepods (water fleas) that contain immature forms of the parasite. In 1986, the World Health Assembly (WHA) called for the eradication of dracunculiasis (Guinea worm disease) at a time when an estimated 3.5 million cases occurred annually in 20 countries in Africa and Asia and 120 million persons were at risk for the disease (1,2). Because of slow mobilization in countries with endemic disease, the global dracunculiasis eradication program did not meet the 1995 target date for eradicating dracunculiasis set by WHA in 1991 (3). In 2004, WHA established a new target date of 2009 (4); despite considerable progress toward global eradication, that target date also will not be met. This report updates continued progress toward global eradication of dracunculiasis since January 2008 (5,6). At the end of December 2008, dracunculiasis was endemic in six countries (Ethiopia, Ghana, Mali, Niger, Nigeria, and Sudan). The number of indigenous cases of dracunculiasis had decreased 52%, from 9,585 in 2007 to 4,619 in 2008. Of the 1,446 cases that occurred during January--June 2009, 1,413 (98%) were reported from Sudan and Ghana. Currently, insecurity (e.g., sporadic violence or civil unrest) in areas of Sudan and Mali where dracunculiasis is endemic poses the greatest threat to the success of the global dracunculiasis eradication program.

No effective drug or vaccine exists to treat dracunculiasis, and persons who contract D. medinensis infection do not become immune. After a 1-year incubation period in infected persons, adult worms approximately 1 meter (39.4 in) long emerge through skin lesions that frequently develop secondary infections. The emerging worm is removed by rolling it on a stick a few centimeters each day. Disabilities caused by dracunculiasis are related to the secondary bacterial infections in the skin, with associated pain and swelling (7,8). Dracunculiasis can be prevented by 1) filtering drinking water through a fine woven cloth, 2) treating contaminated water with Abate (temephos) larvicide, 3) providing safe water from borehole or hand-dug wells, and 4) educating persons to avoid entering water sources when the worms are emerging from their bodies.

Containment of transmission, achieved through voluntary isolation of each patient, provision of first aid, manual extraction of the worm, and application of occlusive bandages,* is a complementary component to the four main interventions. Countries enter the World Health Organization (WHO) precertification stage of eradication approximately 1 year (i.e., one incubation period for D. medinensis) after reporting their last indigenous case. Eight countries where dracunculiasis was formerly endemic (Benin, Burkina Faso, Chad, Côte d'Ivoire, Kenya, Mauritania, Togo, and Uganda) are in the precertification stage of eradication. WHO already has certified 180 countries and territories as free from dracunculiasis; Cambodia and 20 African countries remain to be certified.

In each country affected by dracunculiasis, a national Guinea worm eradication program receives monthly reports of cases of dracunculiasis§ from every village with endemic transmission. Reporting rates are calculated by dividing the number of villages with endemic dracunculiasis reporting each month by the total number of reports expected each month from all villages with endemic disease. All villages where endemic transmission of dracunculiasis is interrupted (i.e., zero cases reported for 12 consecutive months) are kept under active surveillance and response for 3 consecutive years. Village volunteers conduct daily household checks for dracunculiasis to ensure that any cases are reported promptly and immediate measures are taken to prevent transmission from the patient to sources of water.

Country Reports

Sudan. Since 2003, all reported indigenous cases of dracunculiasis have occurred in Southern Sudan. The Southern Sudan Guinea Worm Eradication Program, created in 2006 after Sudan's civil war ended in 2005, has approximately 28,000 village volunteers and health staff members working in the program, and 10,695 villages under active surveillance. The reporting rate improved from 63% in 2006, to 70% in 2007, to 87% in 2008. During 2007--2008, the number of cases and the number of villages reporting cases each were reduced by 38% (from 5,815 to 3,618 and from 1,998 to 1,243, respectively); the percentage of villages with cloth filters in all households increased from 38% to 79%, and the proportion with Abate larvicide treatment of water sources increased from 11% to 34% (Table 1). During January−June 2009, the number of reported cases decreased by 34%, from 1,789 to 1,188, despite 23 incidences of insecurity that resulted in program staff members being evacuated or confined to quarters, disrupting program operations.

Ghana. The country's Guinea Worm Eradication Program achieved an 85% reduction in cases in 2008, from 3,358 cases reported from 406 villages in 2007 to 501 cases reported from 131 villages in 2008. During January−June 2009, the number of cases decreased 45%, from 416 to 229, compared with the same period in 2008 (Table 2). Of all infected persons reported in Ghana during January−June 2009, 78% were treated voluntarily and contained in temporary case-containment centers or other health facilities, compared with 36% of infected persons reported in 2008.

Mali. An unexpected outbreak in the previously dracunculiasis-free region of Kidal occurred in 2006; notification of the outbreak and implementation of control measures were delayed by sporadic insecurity (6). Mali reported an increase in cases, from 313 in 2007 to 417 in 2008. With improved security and better case containment in 2008, Mali reported 90% fewer cases during January--June 2009, compared with the same period in 2008 (Table 2).

Ethiopia. After approximately 20 months with no reported indigenous cases, Ethiopia reported 41 cases in 2008, including 37 indigenous cases, from seven villages in Gambella Region. During January--June 2009, Ethiopia contained 100% of cases reported.

Nigeria. Nigeria reported 38 indigenous cases from five villages during 2008, a consequence of an unexpected outbreak discovered in early 2007. After 7 consecutive months with no cases, a single indigenous case was detected in the same area in November 2008. All cases in 2008 were contained. No indigenous cases were reported during January−June 2009 (Table 2).

Niger. Niger reported one case imported from Mali in February 2008 and two indigenous cases during September−October 2008. Only the case in October 2008 was not contained. During January−June 2009, Niger reported one case, imported from Ghana in March, which reportedly did not contaminate a source of drinking water.

Reported by: DR Hopkins, MD, E Ruiz-Tiben, PhD, the Carter Center, Atlanta, Georgia. ML Eberhard, S Roy, Div of Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC.

Editorial Note:

In 2008, for the first time, fewer than 5,000 cases of dracunculiasis were reported globally. At the end of 2008, dracunculiasis remained endemic in Sudan, Ghana, Mali, Nigeria, Niger, and Ethiopia. Transmission of dracunculiasis might have been interrupted in Nigeria and Niger in 2008. However, interruption cannot be confirmed until 1 year has elapsed since the last reported cases (i.e., late 2009). Because no uncontained cases have been reported since late 2007 in Nigeria, interruption of transmission seems more assured in Nigeria than in Niger. The 2008 setbacks in Ethiopia and Mali (including the possibility of cases exported to Algeria) are causes for concern, but with 90% reduction in cases and a containment rate of 100% during January--June 2009, Mali's Guinea Worm Eradication Program appears to be progressing rapidly toward halting transmission. Despite a small outbreak in a village in the Northern Region early in 2009, Ghana also made much progress in 2008 and through the first 6 months of 2009. A major challenge to the eradication programs remains the extensive seasonal travel and movement of populations in dracunculiasis-endemic countries together with the parasite's 1-year incubation period. These factors result in dracunculiasis cases in unexpected periods and places and lead to exportation of cases from known endemic areas to dracunculiasis-free areas of the same country, or to other countries.

The global campaign to eradicate dracunculiasis now has the support of all countries where the disease remains endemic, in addition to a large coalition of agencies, foundations, governments, and nongovernmental organizations. The major partners, apart from the ministries of health of the endemic countries, are the Carter Center, CDC, the United Nations Children's Fund (UNICEF), and WHO; substantial assistance also has been received from the Bill & Melinda Gates Foundation. The principal concerns at this stage of the dracunculiasis eradication program are the increasingly frequent programmatic disruptions resulting from sporadic insecurity, most notably in Southern Sudan in 2009.

References

  1. Watts SJ. Dracunculiasis in Africa: its geographic extent, incidence, and at-risk population. Am J Trop Med Hyg 1987;37:119--25
  2. World Health Assembly. Elimination of dracunculiasis: resolution of the 39th World Health Assembly. Geneva, Switzerland: World Health Organization; 1986. Resolution no. 39.21.
  3. Ruiz-Tiben E, Hopkins DR. Dracunculiasis (Guinea worm disease) eradication. Adv Parasitol 2006;61:275--309.
  4. World Health Assembly. Eradication of dracunculiasis: resolution of the 57th World Health Assembly. Geneva, Switzerland: World Health Organization; 2004. Resolution no. WHA 57.9. Available at http://www.who.int/gb/ebwha/pdf_files/wha57/a57_r9-en.pdf. Accessed October 9, 2009.
  5. World Health Organization. Dracunculiasis eradication: global surveillance summary, 2008. Wkly Epidemiol Rec 2009;84:162--71.
  6. CDC. Progress toward global eradication of dracunculiasis, January 2007--June 2008. MMWR 2008;57:1173--6.
  7. Imtiaz R, Hopkins DR, Ruiz-Tiben E. Permanent disability from dracunculiasis. Lancet 1990;336:630.
  8. Ruiz-Tiben E, Hopkins DR. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical infectious diseases: principles, pathogens, and practice. 2nd ed. New York, NY: Elsevier; 2006:1204--7.

* Transmission from a patient with dracunculiasis is contained if all of the following conditions are met: 1) the disease is detected <24 hours after worm emergence; 2) the patient has not entered any water source since the worm emerged; 3) a volunteer has managed the patient properly, by cleaning and bandaging the lesion until the worm has been fully removed manually and by providing health education to discourage the patient from contaminating any water source (if two or more emerging worms are present, transmission is not contained until the last worm is pulled out); and 4) the containment process, including verification of dracunculiasis, is validated by a supervisor within 7 days of emergence of the worm.

Certification of a country as free from dracunculiasis requires a 3-year period after the last known indigenous case is reported, during which active surveillance and response to cases of dracunculiasis must be maintained.

§ A case of dracunculiasis is defined as disease in a person exhibiting a skin lesion or lesions with emergence of one or more Guinea worms; each person is counted only once in a calendar year.

What is already known on this topic?

Annual cases of dracunculiasis (Guinea worm disease) have decreased from 3.5 million to <10,000 since the World Health Assembly mandated eradication in 1986.

What is added by this report?

The number of indigenous dracunculiasis cases continues to decline and fell below 5,000 for the first time in 2008.

What are the implications for public health practice?

In 2009, global dracunculiasis eradication is threatened most by program disruptions from sporadic insecurity, violence, and unrest, particularly in Southern Sudan.


TABLE 1. Number of reported dracunculiasis cases, by country and local intervention --- worldwide, 2008

Country

No. of reported cases in 2008

% ofcases reported that were contained in2008

Villages/localities reporting cases in 2008

Villages/localities and interventions*

No. reporting one or more cases

No. reporting only cases imported into village§

No.reporting onlycases indigenous to village§

No. of villages reporting indigenous cases during 2008--2009

% reporting monthly

%withcloth filtersin all households

%using Abate

% with one or more sources of safe drinking water

%provided withhealth education

Indigenous

Imported

Sudan

3,618

0

49

1,243

296

947

2,301

87

79

34

15

96

Ghana

501

0

85

131

85

46

197

98

75

58

46

100

Mali

417

0

85

69

43

26

113

100

100

56

21

100

Nigeria

38

0

100

5

3

2

4

100

100

100

80

100

Ethiopia

37

4

78

9

7

2

2

100

98

70

50

100

Niger

2

1

67

3

1

2

7

100

100

86

71

100

Burkina Faso

0

1

100

1

1

0

0

---

---

---

---

---

Total

4,613

6

57

1,461

436

1,025

2,624

89

79

37

18

96

* Interventions include distribution of filters, use of Abate (temephos), provision of one or more sources of safe water, and provision of health education.

Sudan disputes Ethiopia's claim regarding two of four cases imported from Sudan because no endemic transmission of dracunculiasis has been observed in the reported area of origin of these cases in Sudan. The Niger case was imported from Mali, and the Burkina Faso case was imported from Ghana.

§ Definitions of imported and indigenous cases as they relate to villages/localities are available at http://www.cartercenter.org/health/guinea_worm/program_definition.html.

Data not available.


TABLE 2. Number of reported indigenous* dracunculiasis cases, by country --- worldwide, 2007 versus 2008 and January--June 2008 versus January--June 2009

Country

2007

2008

% change

January--June2008

January--June2009

% change

Sudan

5,815

3,618

-38

1,789

1,188

-34

Ghana

3,358

501

-85

416

229

-45

Mali

313

417

33

78

8

-90

Nigeria

73

38

-48

37

0

-100

Niger

11

2

-82

0

0

0

Ethiopia

0

37

---

38

21

-45

Total

9,570

4,613

-52

2,358

1,446

-39

* Excludes 15 cases imported from another country in 2007, six cases imported in 2008, and one case imported into Niger from Ghana during January--June 2009.

Provisional case counts.

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


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Date last reviewed: 10/15/2009

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