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Eradication Program

Global Eradication Campaign

The global campaign to eradicate Guinea worm began in 1980 at the US Centers for Disease Control and Prevention (CDC). Guinea worm disease (GWD) eradication was targeted as an ideal indicator of success for the United Nations 1981-1990 International Drinking Water Supply and Sanitation Decade (IDWSSD) because the disease could only be transmitted through contaminated drinking water. A year later, GWD eradication was adopted as a sub-goal of the IDWSSD[1, 2, 3]. In 1984, CDC was designated as the WHO Collaborating Center for Dracunculiasis Eradication.*

In 1986, there were 20 countries with GWD. These countries had about 3.5 million cases per year. Most (90%) cases occurred in Africa. An additional 120 million people in Africa were at risk for GWD because of unsafe water supplies[2, 4]. That year, the World Health Assembly (WHA) adopted a formal resolution calling for the eradication of GWD. Eradication was defined as the absence of GWD (and therefore the interruption of transmission) for 3 or more years[1, 2, 3]. The Carter Center, working closely with Ministries of Health, took the lead for the global Guinea Worm Eradication Program (GWEP) and built local, national and international partnerships. Support came from numerous donor agencies, foundations, institutions and governments.

* In January 2017, the name of the WHO Collaborating Center was changed from the WHO Collaborating Center for Research, Training, and Eradication of Dracunculiasis (the original name) to the WHO Collaborating Center for Dracunculiasis Eradication.

Criteria for Eradication

WHA targeted GWD for eradication because it met specific criteria:

  • It is biologically and technically possible to eradicate this disease[2, 5, 6, 7].
    • There is no chance for the disease to return after the last human case occurs.
    • GWD is easily diagnosed because of its signs and symptoms. Few diseases can be confused with GWD and the public in affected communities know and recognizes the worm.
    • In each affected country the worms emerge from the skin during certain predicable times of the year.
    • GWD was previously eliminated from parts of the Former Soviet Union during the 1920s and from endemic areas of Iran in the 1970s.
  • The benefits of eradication outweighed the costs[2, 5, 6, 8].
    • The World Bank assessed the socio-economic impact of GWD in 1997. It concluded that the costs for GWD eradication and morbidity reduction would be significantly less than the continued costs of the disease.
    • Other direct benefits of eradication would include:
      • The development of a group of trained health workers who could provide both GWD management and other basic health services
      • Improvements in water supplies
        • Water no longer contaminated with Guinea worm
        • Enhanced advocacy for new safe water sources
    • The global community would indirectly benefit from the enhanced culture of disease prevention and social equity afforded by this disease eradication program. Countries and organizations supporting GWD eradication would be helping to reduce the suffering of some of the world’s most underprivileged people.

While support for eradication was felt to be strong in endemic countries, there were political and societal barriers to eradication that were also considered by the WHA. Political support was and still is variable, even in endemic countries. International donor support was and is difficult to maintain for this Neglected Tropical Disease (NTD). NTDs affect the poorest populations, including people living in remote rural areas or conflict zones who often have little political voice. Therefore, diseases such as GWD generally have a low profile and status in the list of public health priorities[1, 2, 3]. Nevertheless, in 1986, the WHA adopted the resolution to eradicate GWD.

Criteria for Certification of GWD Eradication

GWD transmission is broken in a country once no new GWD cases occur for 12 consecutive months (i.e., one incubation period). At this point, countries can apply for certification of GWD-free status from the International Commission for the Certification of Dracunculiasis Eradication (ICCDE)[9]. The ICCDE is a panel of international GWD specialists. It was established by WHO in 1995 to verify and confirm information from countries applying for certification. The ICCDE considers GWD eradication achieved in a country when:

  • Adequate active surveillance systems have confirmed the absence of GWD for 3 or more years.
  • A rumor log of suspected cases has been maintained for a 3-year period detailing:
    • The particulars of each case
    • The origin of each case
    • The final diagnosis of each case (i.e., a true case of GWD or some other condition?).
  • All confirmed cases imported from endemic countries have been traced to their origins and have been fully contained.

The ICCDE certifies a country as being free from GWD after it confirms these criteria have been met and receives a report detailing the history of GWD in that country[9].

Moving Forward with GWD Eradication

Extracting a Guinea worm from the ankle by wrapping it around a stick. Photo credit: WHO Collaborating Center at CDC archives.

Great progress has been made in the last three decades. GWD is now poised to be the next disease after smallpox to be eradicated. As of March 2016, the ICCDE has certified 198 countries, territories, and areas, representing 186 WHO Member States as being free from GWD transmission, with only 8 countries remaining to be certified: Angola, Democratic Republic of the Congo, Kenya, Sudan and the four remaining endemic countries of Chad, Ethiopia, Mali, and South Sudan [10] – of note, Mali reported zero cases in 2016 compared to five cases in 2015. Thanks to the efforts of the global Guinea Worm Eradication Program, there were only 25 human cases reported worldwide in 2016 from Chad, Ethiopia, and South Sudan.[11] GWD is poised to be the first disease to be eradicated using core public health practices, such as surveillance, case containment, and simple interventions, without the use of vaccines or medicines. Many believe that the symbol of medicine, the Staff of Asclepius, which shows a snake wrapped around a stick, may actually represent a Guinea worm. With future generations not knowing this disease, medicine’s very symbol will have a new significance [7].

  1. Hopkins, D.R., et al., Dracunculiasis eradication: neglected no longer. Am J Trop Med Hyg, 2008. 79(4): p. 474-9.
  2. Ruiz-Tiben, E. and D.R. Hopkins, Dracunculiasis (Guinea worm disease) eradication. Adv Parasitol, 2006. 61: p. 275-309.
  3. Hopkins DR, et al., Update: Progress Toward Global Eradication of Dracunculiasis, January 2007-June 2008. MMWR, 2008.Oct 31;57(43):1173-6.
  4. Watts, S.J., Dracunculiasis in Africa in 1986: its geographic extent, incidence, and at-risk population. Am J Trop Med Hyg, 1987. 37(1): p. 119-25.
  5. Aylward, B., et al., When is a disease eradicable? 100 years of lessons learned. Am J Public Health, 2000. 90(10): p. 1515-20.
  6. Molyneux, D.H., D.R. Hopkins, and N. Zagaria, Disease eradication, elimination and control: the need for accurate and consistent usage. Trends Parasitol, 2004. 20(8): p. 347-51.
  7. Hopkins, D. and E.M. Hopkins, Guinea Worm: The End in Sight, in Medical and Health Annual, E. Bernstein ed. 1991, Encyclopedia Britanica Inc.: Chicago.
  8. Greenaway, C., Dracunculiasis (guinea worm disease). CMAJ, 2004. 170(4): p. 495-500.
  9. World Health Organization, Criteria for the Certification of Dracunculiasis Eradication, in WHO/FIL/96.187 Rev.1.
  10. World Health Organization. 11th Meeting of the International Commission for the Certification of Dracunculiasis Eradication and scientific meeting to address Guinea worm disease infection in dogs. Wkly Epidemiol Rec, 2016. 91(17):217–236.
  11. WHO Collaborating Center for Research Training and Eradication of Dracunculiasis. Guinea Worm Wrap Up #245, 2017, Centers for Disease Control and Prevention (CGH): Atlanta.