And Then There Were Four: More Countries Beat Guinea Worm Disease

by Michelle Lodge

Reproduced from [Michelle Lodge, British Medical Journal 2010;340:c496] with permission from BMJ Publishing Group Ltd.

The number of countries remaining affected by guinea worm disease, or dracunculiasis, fell by two last year, leaving just four countries in Africa that continue to harbour the waterborne parasitic disease.

Provisional figures collected by the World Health Organization's Collaborating Center for Research, Training and Eradication of Dracunculiasis indicate that Nigeria recorded no cases at all and Niger no indigenous cases of the disease in 2009. Success is especially welcome in Nigeria, which recorded the world's largest number of cases between 1988 and 1989, when 653 620 people in 5879 villages were affected by the painful and debilitating disease.

That leaves Sudan, Mali, Ghana, and Ethiopia with just over 3100 indigenous cases of the disease. Most of these cases are in the autonomous and war torn region of Southern Sudan.

The disease is caused when larvae of the guinea worm, Dracunculus medinensis, enter the body through drinking water (BMJ 2009;339:b3892, doi:10.1136/bmj.b3892). Inside the body the larvae grow, mature, and mate. When a female develops into a long white spaghetti-like worm and prepares to lay her eggs, her machinations cause severe pain, blisters, and swelling, often sending those affected to seek relief in water, where the worm can lay its eggs and continue to breed. If the host is not adequately treated he or she can be disabled and left with permanent health problems.

One key to eradicating the disease is teaching people to always filter their water.

Ernesto Ruiz-Tiben, director of the guinea worm eradication programme at the Carter Center, Atlanta, said, "Sixteen of the 20 endemic countries, including Nigeria, have interrupted transmission, and all have used the same strategies, including the same array of interventions to interrupt transmission."

As well as encouraging people to filter drinking water and avoid going into communal water, health campaigners also aim to treat water with temefos (Abate), a larvicide that is not toxic to human and animals. However, this has to be done within 10 days of the eggs being laid.

The Carter Centre was set up by former US president Jimmy Carter and his wife, Rosalyn. Together with WHO the centre has, since the mid-1980s, been the main agency aiming to eradicate guinea worm disease.

Of the remaining affected countries Sudan poses the greatest challenge. In 2009 it provisionally recorded 2760 cases. Violence in Southern Sudan disrupted the delivery of the eradication programme there. More unrest is expected in the next few months as the country gears up for elections in April, experts say.

Makoy Samuel Yibi Logora, director of the Southern Sudan guinea worm eradication programme, said, "The violence that took a very nasty turn in 2009 disrupted the infrastructure for the guinea worm eradication programme.

"In two instances of such violence in Warrap state, two facilities and materials provided by the Carter Center for the programme were completely vandalised, and the expatriate and full-time national staff had to be evacuated for a couple of weeks during the peak of the transmission season."

With such uncertainty in Sudan, Dr Ruiz-Tiben expects that transmission of guinea worm disease will not be halted until at least 2012. He predicts that Ethiopia and Ghana will break the guinea worm cycle this year and that Mali will see an end of transmission in 2011.

"We look forward to the completion of this historic campaign in the next few years," said Dr Ruiz-Tiben.