Perspective
The Tail End of Guinea Worm — Global Eradication without a Drug or a Vaccine
N Engl J Med 2007; 356:2561-2564June 21, 2007
- Article
Guinea worm disease, or dracunculiasis — Latin for “affliction with little dragons” — is a plague so ancient that it has been found in Egyptian mummies and has been proposed by some to have been the “fiery serpent” described in the Old Testament as torturing the Israelites in the desert. The global Dracunculiasis Eradication Program spearheaded by former President Jimmy Carter and the Carter Center has now reached its final stages (see graph
Number of Reported Cases of Dracunculiasis Worldwide, 1989–2006.). This accomplishment is unprecedented — the only disease previously eradicated was smallpox, not a parasitic disease — and it has been achieved through grassroots public health initiatives involving thousands of village volunteers.Thanks to the two-decade campaign against guinea worm disease, the global incidence has fallen from an estimated 3.5 million cases in 1986 to 25,217 in 2006.1 A slight increase in the reported incidence during 2006 is attributable to improved detection in newly accessible areas of southern Sudan.1 The eradication program has reduced the number of countries with endemic dracunculiasis from 20 in 1986 to 9 in 2006 (with 5 of the 9 having reported fewer than 30 cases each). The World Health Organization (WHO) has now certified 180 countries as free of guinea worm disease, and all countries where the disease was endemic have signed a WHO Geneva declaration pledging to wipe out the parasite by 2009.2 Whereas massive funding is funneled into campaigns to eradicate poliovirus, to control malaria and tuberculosis, and to prevent the spread of human immunodeficiency virus, guinea worm disease is about to be eradicated without any drug therapy or vaccine. Its demise will be proof that people can be persuaded to change their behavior through innovative health education.
Dracunculiasis is transmitted to humans through drinking water contaminated with microscopic copepods (water fleas) that are infected with larvae of the worm. About a year after a person has become infected, adult female worms emerge from the skin (usually 1 to 3 emerge simultaneously, but as many as 40 have been documented to emerge from a given person in a season). If the emerging worms make contact with water, they expel larvae into the water, which copepods ingest, beginning the cycle anew.2 The emergence of the worms, which can be more than 2 ft (0.6 m) long, is painful and often incapacitates people for 2 to 3 months. Humans are the only reservoir, and there is no effective anthelmintic agent or vaccine. Infection can be prevented by filtering drinking water through finely woven cloth, which removes the copepods; by killing copepods and larvae with temephos applied to open ponds; by educating villagers about not entering sources of drinking water; or by providing clean drinking water from safe sources such as borehole wells or hand-dug wells. In areas where guinea worm is endemic, the parasite often predominantly infects women, who tend to do most of the washing and the gathering of water for households. During planting or harvest season, dracunculiasis has sometimes been reported in more than half the population of a given village.
The global eradication campaign began at the Centers for Disease Control (CDC) in 1980 and was then adopted as a subgoal of the United Nations International Drinking-Water Supply and Sanitation Decade (1981–1990).3 Since 1986, the Carter Center has led the effort with the help of the CDC, the WHO, the United Nations Children's Fund (UNICEF), the Bill and Melinda Gates Foundation, and many other donors and nongovernmental organizations, as well as governments of the countries where guinea worms are endemic and thousands of village volunteers. Working with this public–private coalition, the Carter Center has been able to initiate village-based surveillance, health education, and distribution of cloth filters and to provide larvicides and solicit operational support for the digging of wells.
The Carter Center provides financial and technical assistance to national guinea worm programs that include participants from ministries and from nongovernmental organizations, traditional leadership, political leadership, and village volunteers; these programs put eradication activities and surveillance into motion and empower communities to provide clean drinking water. When the eradication program encounters an impasse, those involved often deploy unusual tactics. At a 1989 lunch with Edgar Bronfman, the Seagram's liquor heir, President Carter explained the technique of filtering copepods out of water, demonstrating with a damask napkin. Bronfman, who held a major stake in the DuPont chemical company, had DuPont scientists develop the tough fine mesh that is now used to filter water. In Uganda, the eradication program has employed elderly men as “pond caretakers” to guard ponds against contamination by worms emerging from people.4 When infected people are identified at a pond, the caretakers assist them with water gathering, preventing contamination of the water, and distribute nylon filters for ongoing prevention. Cash rewards are sometimes offered to those who report cases or to infected villagers who agree to be quarantined while the worm is emerging; often such persons receive free care and food during that period.4
Manual Extraction of Guinea Worm. Water sources are monitored, and the level of coverage by control measures is reported monthly or quarterly to heads of state, who are also given documentation listing areas free of guinea worm. The WHO has convened an International Commission for the Certification of Dracunculiasis Eradication to certify countries that have eradicated the parasite.
Such a transnational global campaign for improving health requires a nuanced understanding of global health diplomacy. Faced with one of the most imposing barriers to eradication of guinea worm — the civil war in southern Sudan — Carter negotiated a 4-month “guinea worm ceasefire” in 1995, which also allowed public health officials to kick-start Sudan's onchocerciasis control program.3 Inadequate security in other countries where guinea worm disease is endemic, inadequate political will on the part of national leaders, and the absence of a “magic bullet” treatment have all presented challenges to the eradication program. Health care initiatives have had to be linked with diplomatic efforts to overcome these challenges.
Much has been written about the inadequacy of “vertical,” single-disease programs that fail to focus on widespread reductions in poverty, on infrastructure development, and on the broad-based provision of primary care. But the Dracunculiasis Eradication Program is leaving a legacy of development in sync with the United Nations Millennium Development Goals. It has helped to improve the quality of water sources for communities that previously lacked access to clean and safe water, created jobs for the (often elderly) unemployed, and empowered volunteers, frequently inspiring them to pursue health-related employment. In communities where guinea worm was endemic, networks of women have been created for education campaigns; Ghana alone has 6500 female Red Cross volunteers assisting in the program, and in Benin newly created women's clubs have helped to stop transmission of the disease.3 School absenteeism has decreased as fewer children have become infected. Research in Mali had linked a 5% decrease in production of two food crops to guinea worm disease, and the annual economic losses due to guinea worm in three rice-growing Nigerian states was estimated to be over $20 million, but now agricultural productivity has improved.5 Thus, this vertical program has been shown to combat poverty, hunger, and even illiteracy (by decreasing school absenteeism), as well as to empower women — all Millennium Development Goals.
In an era when unprecedented global health funding is being directed toward vaccines and drug therapy, guinea worm eradication has been successful on a modest budget of about $225 million for the entire 20-year campaign. It has done so, according to Dr. Donald Hopkins, vice president for health programs at the Carter Center, by relying on the old-fashioned public health tactic of educating people about changing their behavior. With its charismatic leader practicing global health diplomacy, a public–private coalition has been able to empower a marginalized, infected population to slay its not-so-little dragons.
An interview with Jimmy Carter and Donald Hopkins is available at www.nejm.org.
Source Information
Dr. Barry is a professor of medicine and global health at Yale University School of Medicine, New Haven, CT.
- References
References
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Dracunculiasis eradication: global surveillance summary, 2006. Wkly Epidemiol Rec 2007;82:133-140
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Dracunculiasis eradication: Geneva declaration on guinea-worm eradication. Wkly Epidemiol Rec 2004;79:234-235
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Hopkins DR ,Ruiz-Tiben E ,Downs P ,Withers PC Jr ,Maguire JH . Dracunculiasis eradication: the final inch. Am J Trop Med Hyg 2005;73:669-675
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Rwakimari JB ,Hopkins DR ,Ruiz-Tiben E . Uganda's successful Guinea Worm Eradication Program. Am J Trop Med Hyg 2006;75:3-8
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The Carter Center home page. (Accessed June 1, 2007, at http://www.cartercenter.org.)
- Citing Articles (8)
Citing Articles
1
T.N. Petney, H. Taraschewski. 2011. Waterborne Parasitic Diseases: Hydrology, Regional Development, and Control. , 303-366.
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F. Vega-López, R. J. Hay. 2010. Parasitic Worms and Protozoa. , 1-44.
CrossRef3
Bernhard Liese, Mark Rosenberg, Alexander Schratz. (2010) Programmes, partnerships, and governance for elimination and control of neglected tropical diseases. The Lancet 375:9708, 67-76
CrossRef4
Tim Ford, Steve Hamner. 2009. Control of Waterborne Pathogens in Developing Countries. , 33-56.
CrossRef5
Andrea Rinaldi. (2009) Free, at last! The progress of new disease eradication campaigns for Guinea worm disease and polio, and the prospect of tackling other diseases. EMBO reports 10:3, 215-221
CrossRef6
David H. Molyneux. (2008) Combating the “other diseases” of MDG 6: changing the paradigm to achieve equity and poverty reduction?. Transactions of the Royal Society of Tropical Medicine and Hygiene 102:6, 509-519
CrossRef7
Donald R. Hopkins, Frank O. Richards Jr, Ernesto Ruiz-Tiben, Paul Emerson, P. Craig Withers Jr. (2008) Dracunculiasis, Onchocerciasis, Schistosomiasis, and Trachoma. Annals of the New York Academy of Sciences 1136:1, 45-52
CrossRef8
Nnaemeka C. Iriemenam, Wellington A. Oyibo, Adetayo F. Fagbenro-Beyioku. (2008) Dracunculiasis—the saddle is virtually ended. Parasitology Research 102:3, 343-347
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