Parasitol Res (2008) 102:343–347 DOI 10.1007/s00436-007-0828-9

REVIEW

Dracunculiasis—the saddle is virtually ended Nnaemeka C. Iriemenam & Wellington A. Oyibo & Adetayo F. Fagbenro-Beyioku

Received: 20 November 2007 / Accepted: 26 November 2007 / Published online: 12 December 2007 # Springer-Verlag 2007

Abstract Dracunculiasis is a preventable parasitic disease that for many years has affected poor communities without a safe portable water supply. Transmission is basically limited among the nomadic in remote rural settings. Most countries, including Asia, are declared free from the Guinea worm disease restraining the burden of transmission to Africa especially Sudan, Ghana, Mali, Nigeria and Niger. This review focuses mainly on the progress made so far by the Global Guinea Worm Eradication Programme championed by the Carter Center, Centers for Disease Control and Prevention, World Health Organisation, The United Nations Children’s Fund and the individual efforts of endemic nations through their National Guinea Worm Eradication Programme aimed towards total global Guinea worm eradication.

Introduction Dracunculiasis, commonly called Guinea worm disease, is a nematode parasitic infection caused by Dracunculus medinensis. It affects mostly communities without portable and safe drinking water facilities (Hopkins et al. 2000). It has constantly deprived the local indigenes of their human socio-economic competence by limiting their work force. In southeastern Nigeria for example, it is responsible for about 11.6% decrease in the total rice crop production (Ogamdi and Onwe 2001; Anosike et al. 2003b). In many communities, it has been linked with school absenteeism in N. C. Iriemenam (*) : W. A. Oyibo : A. F. Fagbenro-Beyioku Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Idi-araba, PMB 12003 Lagos, Nigeria e-mail: [email protected]

addition to its primary impact on villages’ health (RuizTiben and Hopkins 2006). This review focuses on publications with view of the progress made so far by the Global Guinea Worm Eradication Programme championed by President Jimmy Cater, the Cater Center, Centers for Disease Control and Prevention (CDC), World Health Organisation (WHO), The United Nations Children’s Fund (UNICEF) and the individual endemic nations towards a dogged purpose of total eradication. The adult female worms measure up to 1 m (3 ft) in length, while the males are usually about 40 cm long. Humans are only infected by drinking contaminated water from stagnant ponds or wells with the infective-stage larva (copepods) of D. medinensis. The larvae penetrate their way through the intestinal walls into the body cavity, grow into full size in the subcutaneous tissue and migrate to the extremities. The female worms can live up to 14 months, while the male worms die within 7 months. The females are ovoviviparous, producing millions of eggs, usually in the lower limbs. The sudden release of larva causes a hot sensation under the skin of the host resulting in a blister. The burning (hot) sensation often makes the individual to place the affected area in water. The blister later burst with the release of millions of L1 larva into the water. Before the blister, the individual faces symptoms of rashes with severe itching, vomiting, diarrhoea, nausea and dizziness. The larvae when released in water are ingested by fresh water copepods (Cyclops) where they moult twice and become infective larvae (L3) within 12–14 days. When ingested, the L3 penetrates the duodenum and abdominal muscles and enter the subcutaneous tissues. The peak of transmission occurs when there is dearth of water, limiting the only source of water to those with high contamination. This increases the chance of infected individuals to come in contact with water and the large numbers of intermediate

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hosts. The female Guinea worm lives in the connective tissues of the limbs. She does not cause any noticeable pathological conditions, but most pathology is associated with the death of the female after discharging her larvae causing the formation of abscess—a potential source of secondary bacterial infection—and fibrosis of the skin, muscle, tendons and joints. Updates: dracunculiasis eradication The plan for the global eradication of dracunculiasis was developed in October 1980 (Hopkins and Foege 1981) and established in 1981 with the aim of eliminating dracunculiasis through water sanitation efforts (Greenaway 2004). Since 1986, the campaign has been led by the Carter Center, in close cooperation with CDC, UNICEF and WHO. The Global 2000, UNICEF and the US Agency for International Development have assisted the Guinea Worm Eradication Programmes in Ghana and Nigeria since 1987– 1988 (CDC 1995). In 1989, Ghana and Nigeria were ranked the top two endemic nations in the world with 179,556 and 640,008 cases, respectively (WHO 1993). The number of cases has gone down drastically (Table 1) but with civil disturbances, ethnic clashes, under-funding, fuel shortages and strikes in Nigeria and ethnic fighting and delayed funding in Ghana, the successes so far may be impaired. In October, 1993, Pakistan became the first

endemic country to fully eradicate indigenous cases of dracunculiasis through a nationwide coverage (village-byvillage), which began in 1987 (Hopkins et al. 1995). WHO certified Pakistan free of dracunculiasis in 1996, India in 2000 and Senegal and Yemen in 2004 (Hopkins et al. 2000; Ruiz-Tiben and Hopkins 2006). Asia is now declared free of dracunculiasis limiting endemicity to a few African countries. Most endemic African nations have also made some progress in curtailing the scourge of dracunculiasis (Table 1). Recently, Uganda celebrated her success of a full calendar year with no indigenous cases of the disease in 2004 (Rwakimari et al. 2006). The interventions started in 1992 and were maintained and intensified until the final case, which occurred in July 2003. Cameroon is at the threshold of eliminating dracunculiasis, but Borno State (Nigeria) continues to export cases to Mayo Sava (Cameroon), while Mayo Kebi Prefecture (Chad) could export cases to other divisions of northern Cameroon (Sam-Abbenyi et al. 1999). In 2001, a total of 108 cases were exported to other nations— Sudan accounting for 31, Ghana 17, Togo 17, Niger 11, Nigeria 11, Mali 5, Burkina Faso 5, Cote d’Ivoire 4 and Benin 3 (Hopkins and Foege 1981; Hopkins et al. 2002). Nigeria reported 653,000 cases during 1988–1989 and in 2006 reported only 16 cases. Benin, Ethiopia and Mauritania reported merely three indigenous cases as of 2004, and in 2006, reported zero, one and zero indigenous case,

Table 1 Distribution of countries with indigenous reported cases between 1996 and August, 2007 Countries

Sudan Nigeria Ghana Niger Burkina Faso Togo Cote d’Ivoire Uganda Benin Mali Mauritania Ethiopia Central African Republic Chad Cameroon Yemen Senegal India Kenya Pakistan

Number of cases 1996

1997/1998

2000

2003

2004

2005

2006

2007

118,578 12,282 4,877 2,956 3,241 1,626 2,794 1,455 1,427 4,218 562 371 9 127 17 62 19 9 0 0

47,977 13,419 5,458 2,683 2,227 2,126 1,407 899 677 545 379 360 34 25 19 7 4 0 6 0

49,471 5,355 4,738 405 1,021 1,340 223 51 156 708 94 10 34 3 23 0 0 0 7 0

20,299 1,459 8,290 293 203 669 42 26 30 829 13 28 0 0 0 0 0 0 0 0

7,266 495 7,268 233 35 232 20 0 3 354 3 3 0 0 0 0 0 0 0 0

5,474 120 3,977 175 24 70 9 0 0 657 0 29 0 0 0 0 0 0 0 0

20,580 16 4,134 108 3 25 5 0 0 323 0 1 0 0 0 0 0 0 0 0

5,074 42 3,171 5 0 0 0 0 0 123 0 0 0 0 0 0 0 0 0 0

Sources: Hopkins et al. (2000, 2002, 2005, 2007), CDC (2004, 2007), Barry (2006), WHO (2006)

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respectively. Only nine countries, all in sub-Sahara Africa, are still confined with dracunculiasis especially amongst the remote rural villages, and seven countries are in the precertification stage (Karam and Tayeh 2006). One hundred sixty-eight countries have so far been certified free of transmission. Apart from Ghana, the major West African countries at higher risk are Burkina Faso (nomadic Black Tuaregs, Djibo, Gorom-Gorom), Mali (Ansongo, Gourma Rharous, Gao) and Niger (Tera, Tillaberi; Hopkins et al. 2005). Togo has had a reduction in the number of indigenous cases by 58% in 2003 and 63% in 2004. She now has to deal with imported cases from adjoining Ghana. In March, 2005, Benin had 12 months without an indigenous dracunculiasis report, while Ethiopia and Mauritania had no cases in 9 months. In 2004, 114 cases were exported to other nations: 57 from Ghana, 25 from Sudan and 17 from Mali (Hopkins et al. 2005). All countries affected with dracunculiasis are working hard in its elimination except Sudan that is still ravaged with war, although the efforts so far has led to the reduction in reported cases of dracunculiasis. Sudan and Ghana each reported 45% of all the reported cases in 2004 (Hopkins et al. 2005). Ethnic fighting in endemic areas in Ghana has hampered the progress so far, but with the commitment of Ghana Red Cross Society Mothers Clubs and health education in endemic regions, the effort of the Government of Ghana will soon yield fruitful results (Hopkins et al. 2005). The consequences of war and famine, with the resultant increase in refugees and immigrants to nonendemic areas, may likely increase the risk of transmission. This has been confirmed with a Sudanese migrant in Australia (Menon 2005), and the unending civil strife in southern Sudan has favoured the spread of the disease along its borders with Ethiopia, Kenya, Uganda and the Central African Republic (WER 1995). Globally, however, less than 15, 000 individuals still suffer from the disease thanks to the successes of the Guinea worm eradication programmes. The number of indigenous cases has tremendously reduced from 892, 926 cases in 1989 to about 4,460 Fig. 1 Total number of indigenous reported cases between 1989 and May, 2007 (Adapted from Hopkins et al. 2005; Barry 2006, 2007; CDC 2007)

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cases in May, 2007 (Fig. 1) signifying a giant and convincing step towards total eradication.

Discussion Guinea worm is the only nematode infection that is capable of being eradicated in the nearest future. With the concerted efforts of the community, political will and full-functional policies, eradication is a reality. The recruitment of the former head of state in Nigeria (General Yakubu Gowon) has been of tremendous help bridging the gap of complacency and apathy (Hopkins et al. 2002). He visited all endemic areas in Nigeria, engaging political and public health leaders and extracting promises of action and revisiting to check on progress made so far. The reductions in Nigeria were led by the decrease of 84% in cases in Ebonyi State, which constitute 39% of the national total. The successes in Nigeria has been attributed to the systematic pond treatment, distribution and replacement of filters, intensive health education, provision of hand-dug wells, regular bore-hole installation, case management, prompt reporting and the mutual relationship between the community and the intervention team (Ogamdi and Onwe 2001; Anosike et al. 2003a; Anosike et al. 2003b). After the outcome in Nigeria, there is a recent involvement of President Amadou Toumani Toure of Mali with passionate advocacy, which is believed, will help in the reduction in the number of indigenous cases in Mali and probably the francophone endemic West African countries with his influence. In Uganda, a monetary cash reward system was initiated in mid-1997 to help check indigenous cases of dracunculiasis. Both the reporter and the patient him/herself were beneficiaries of 10,000 Ugandan shillings, and the village volunteer who treated the case received 4,000 Ugandan shillings (Rwakimari et al. 2006). The amounts were later increased to 20,000 Ugandan shillings in 2000, 50,000 shillings in 2001 and 100,000 shillings in 2002, where it remains till today. In 2000, all suspected cases in villages were

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urged to stay in a local public health clinic where they were managed till blister. The patients received free food and cash reward upon completion of the containment programme. They also recruited elderly men to guard ponds against contamination by infected individuals. Infected individuals were assisted with gathering water and distribution of filters thereby preventing contamination. The issue of a vertical or horizontal implementation strategy was earlier resolved with the determined purpose of eradicating dracunculiasis notwithstanding what obstacle and the sustained support by the Government of Uganda. This is worth emulating by the remaining endemic African countries. The Sudanese Guinea Worm Eradication Programme distributed several million pipe filters for personal protection to travellers and displaced persons in 2001. Sudan also ended indigenous cases in northern Sudan in 2002 except for the war-torn southern Sudan (Hopkins et al. 2005). Three countries with high numbers of cases (Sudan, Ghana and Mali) are continuing in their combined effort towards Guinea worm eradication (WHO 2006). WHO has certified 180 countries free of Guinea worm disease (Barry 2007), and with the ‘Geneva Declaration’ to finish eradication by 2009 (WHO 2004), the battle is almost over. If achieved, Guinea worm will be the second disease after small pox to be eradicated and the first parasitic disease to be eradicated (Barry 2006) without any drug therapy or a vaccine (Barry 2007). Already, the eradication programme has drastically reduced the number of indigenous cases from 20 countries in 1986 to nine countries in 2006 by more than 99% (with five out of nine countries reporting less than 30 cases a year; Barry 2007; Hopkins et al. 2007). By 2015, the set target of Millennium Development Goals towards integrated control of Neglected Tropical Diseases, waterborne/ vector-borne diseases, schistosomiasis, lymphatic filariasis, onchocerciasis and especially Guinea worm may be ready to be consigned to history if resolute efforts are implemented from all stakeholders (Fenwick 2006). There is no effective treatment for dracunculiasis or a vaccine. Patients acquire no immunity, and half of the village can be infected within a short period of time. Infection can only be prevented by community-based education aimed at equipping the local populace with the needed information: prevention of infected individuals from entering sources of water supply, filtration of drinking water through a fine woven cloth, boiling of drinking water, treatment of open ponds or stagnant water with Abate larvicide® (temephos; BASF, Mount Olive, NJ) and provision of clean drinking water through a bore hole or hand-dug wells. With concerted efforts both from the endemic hamlet, international community, national dracunculiasis eradication programmes and the affected national governments, Guinea Worm is likely to be the first human parasitic infection that will soon go into extinction.

Parasitol Res (2008) 102:343–347 Acknowledgement The authors wish to thank Dr Gawa Bidla for proof appraisal of the manuscript. We apologise to authors whose articles were not cited in this review.

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