Guinea Worm Eradication: The Last Frontier
Human Biology 153: Parasites and Pestilence
February 26, 2010
“Hopefully Guinea worm will be the first parasitic disease ever eradicated. If and when that happens, we will have done it without a drug and without a vaccine to treat or prevent the disease. If we can do that, it will be one of the greatest achievements in public health."
—Dr. Ernesto Ruiz-Tiben, Director, Guinea Worm Eradication Program
From as early as the 17th century, Dracunculiasis, the “fiery serpent” or Guinea Worm as it is commonly known has been plaguing human populations. Now, in the absence of vaccines, in the midst of political instabilities, and a host of new parasites and pestilences, mankind may be saying its last good bye to Guinea Worm disease. The near global eradication of Guinea Worm will mark the first eradication of a parasitic disease. Eradication of Guinea Worm is more than just another feat in public health but a symbol of the power of collective action, unity and behavioral change.
Guinea Worm Disease – the What and the How?
Dracunculiasis or Guinea Worm Disease (GWD) is a preventable water-borne disease caused by the parasitic nematode Dracunculus medinesis (Control 1). GWD is a disease of poverty, particularly affecting those that live in remote rural areas, where there exists little if any access to safe drinking water. Once world-wide, the debilitating disease is now confined to less than 6 countries world-wide (Center).
GWD is transmitted via water through water-borne fleas or copepods. Often-times the water is from stagnant sources of drinking water such as “ponds, cisterns, pools in dried-up riverbeds, and shallow unprotected hand-dug wells” (Ruiz-Tiben and Hopkins 279). Persons become infected by drinking water containing the copepods with infective larvae of the parasite. Once ingested, stomach acids digest the copepods but not the larvae which migrate to the small intestine, penetrate its walls, pass into body cavity and grow into full size adults (2- 3 feet) (Control 2). Symptoms do not begin to appear in the person until about ten to fourteen months later when the female adult worms migrate and emerge from the skin. A painful lesion where the female Guinea Worm will eventually emerge is formed in the skin; contact with fresh water relieves the pain of the individual but causes the female worm to release millions of larvae into the water and upon ingestion by copepods begins the cycle again (Ruiz-Tiben and Hopkins 279). Often times when the worm emerges from the skin, a gauze or small stick is used to twist the worm out, a few centimeters a day; however the process ranges from a few days to several weeks (Control 2).
Currently there exists no known drug to treat Guinea Worm Disease or vaccine to prevent infection (Control 2) despite studies done to develop vaccines or targets for drug therapy (Bloch, Lund and Vennervald 140 Control 2). Consequently infected people receive no immunity against future infections of Guinea Worm. Antibiotics can be used to prevent bacterial infection as well as analgesics to help reduce pain and swelling.
A detailed life-cycle of Guinea Worm is pictured below. (Figure 1 )
Guinea Worm Disease – the Why and the Who?
“In southeastern Nigeria, rice farmers in a single county lost $20 million in just one year due to outbreaks of Guinea Worm disease.” (Center)
While the long painful process of removing a worm may take a month, its effects are felt long after. Guinea Worm outbreaks leave many unable to work. Because the disease is often found in poor agriculture areas, many affected are farmers and are left unable to work. When adults are unable to work, children are often expected to take up the workload, which sometimes leads to infection in the children, as well as absences in school (Control 2 and Ruiz-Tiben and Hopkins 286).
Although Guinea Worm disease has been documented since the ancient times, eradication efforts did not begin to develop for the disease until the late 1980s. The beginnings of Guinea Worm disease eradication begins with The International Drinking Water Supply and Sanitation Decade (IDWSSD) (1981- 1990), a lofty program that was dedicated to providing safe and sanitary water to every country (Group). Due to Dracunculiasis spread confined only to unclean drinking water—eradication of the disease was proposed as a good indicator of IDWSSD’s progress in providing clean water worldwide and thus was officially adopted as a sub-goal of the IDWSSD (Ruiz-Tiben and Hopkins 287). Following adoption, the first international meeting devoted to Dracunculiasis meet in Washington D.C. , with participants from among the United States, Nigeria, Togo, United Kingdom, United States Agency for International Development (USAID), World Health Organization (WHO), to review current knowledge of Dracunculiasis, its transmission, and countries that were endemic with the disease. (Group 1 and Ruiz-Tiben and Hopkins 288). Eradication programs were soon set up in several countries.
The eradication strategy adopted and still followed for eradication today, includes three phases, the first of which, calls on “nationwide or area wide conducted searches to determine location of villages with endemic transmission, and the number of cases (Ruiz-Tiben and Hopkins 291)”. Utilizing this information, program structures’ are targeted to identify needs and develop a plan of action. During phase two, program staff, and village- based health workers are trained to implement interventions, conduct active surveillance and education to villagers. Phase three only occurrs after a dramatic reduction in Guinea Worm prevalence and consists of intensified surveillance to detect all persons with emerging worms, and to contain transmission when eradication was most imminent (Ruiz-Tiben and Hopkins 292).
The Carter Center
The Carter Center, founded by former U.S. president, Jimmy Carter and his wife, Rosalyn Carter is currently the main agency pushing for eradication (lodge). Since its role in leading the eradication efforts in 1992, the number of cases has dropped from 3.5 million cases to less than 5,000 (Center). The Carter Center’s role in eradication extends beyond providing financial assistant but also mobilizing manpower in the form of tens of thousands of villagers, providing technical and financial assistance, as well as logistics and tools, such as donated filter cloth material, larvicide and medical kits and providing a tenacious spirit to continue eradication efforts far after the beginning initial efforts The International Drinking Water Supply and Sanitation Decade (IDWSSD) in the early 1980s (Center).
Guinea Worm Disease - Prevention and Eradication
“ In the village of Ogi, Nigeria, Guinea worm is endemic and villagers describe the copepods that give way to the fiery serpent with the words ‘ fire”, and describe it as a pain so deep “ you feel it even unto your heart” . Field officers from The Carter Center have attempted to treat ponds and streams surrounding the village of Ogi with Abate, a mild pesticide that kills the fleas but allows the water to remain portable – yet there is one pond, that villagers refused to show to workers, even going as far as to pay the worker to not treat this pond, The sacred pond of Ogi, , a pond where villagers believed their ancestors lived, a pond to sacred to be touched, a pond where the “fiery serpent” resides. “ (McNeil Jr.)
The tale of the village of Ogi, fictionalized from actual events represents only one of the barriers to eradication that The Carter Center has faced in its effort to halt transmission of Guinea Worm Disease. Dispensing knowledge of the disease and importance of safe drinking water, and according to studies done in Mali, the use of woven mesh nets to fliter water and larvacide are key in stopping transmission (Etard, Kodio and Traoré 295). Dispelling myths and beliefs and gaining trust of those infected, lack of funding and lack of security and governmental involvement are challenges faced in Guinea Worm eradication.
Age Old Beliefs
In many villages in Africa, the last continent with Guinea Worm disease, there are many that still may refuse the help of workers coming to help in the name eradication. Ancestral spirits, “juju”, folklore stories are some of the obstacles facing workers coming to give aid. Education has been the primary key in helping to dispel these beliefs, but even still sometimes success may come through working around the belief system of the villages. For example, in a village where villagers refused to put Abate in the pond, workers paid a villager to kill a dog and throw it in the pond. The dog, a cursed animal , caused the villagers refused to drink or use the pond and consequently, incidence of Guinea Worm went down (McNeil Jr.). Additionally, because of the absence of a vaccine or medication, a “magic bullet” to end the pain and infection, villagers are often reluctant to adopt the changes proposed and instead are more willing to rely on their healers and native medicines and remedies rather than trained doctors or workers. Continued surveillance as well as relentlessness on the part of trained village workers accounts for much if not all of the success of the ability to rid infection in many rural and remote areas of endemic communities (Peries and Cairncross 436) .
Political Power and Security
Conflict and lack of political structure in some countries has posed challenges in getting access to those that need it most. In Sudan for example, an area where more than seventy percent of Guinea Worm infection remains (Center) a long civil war in its southern region, prevented many health workers from entering the country due to the extreme violence (Rinaldi 218) In 1995, however the longest cease-fire was achieved through negations’ with Jimmy Carter to allow for aid to come to region, which allowed health workers to begin Guinea Worm eradication programs among other interventions (Center). Although the civil war is officially over, conflict can easily be ignited, and with a government with a weak hold on its people, leaves the beginnings of eradication in Sudan in a very precarious position. In the poor remote areas that remain in Sudan, delivery of the goods remains high on barriers to eradication, especially due to the lack of governmental support and coinciding of rainy season with peak transmission rates. The Carter center along with other organizations thus relies on trained workers and quick control of new infections to combat the unsteady stability of government and society.
And then there were Six: Moving Forward…Eradication’s Final Stages?
In less than 30 years, Guinea Worm Disease prevalence has decreased from 20 countries in Africa and Asia to only 6 countries in Africa, Sudan, Ghana, Mali, Ethiopia, Niger, and Nigeria (Center) (See Figure 2). And as of 2008, Nigeria and Niger have thus reported transmission ceasing in their countries. As the final stages of eradication near, the challenges are still the same but the scope has become much smaller. In Mali eradication efforts have been threatened by the presence of rebels in the country inching toward a civil war whereas in Ghana, the sudden presence of the government in eradication has helped achieved large strides in removing eradication from several regions in the country.
Eradication still follows the same three phase strategy, proposed decades ago when the eradication efforts were first begun. However, the remaining countries possess unique challenges in carrying out these phases. Sudan’s vast size and lack of technology and government infrastructure do not allow for the same possibilities in Ghana but rest on intensified surveillance, especially in its remote areas, especially as to prevent cross-border transmission into countries that have eradicated Guinea Worm (Wakabi). In 2008, “Ghana reduced cases by 85 percent, the greatest single-year reduction of any moderately endemic country in the history of the campaign” (Center). The success of Ghana lies in large part to government efforts and using public awareness programs as well as the role of national peoples, such as Miss Ghana pledging to take up the cause of Guinea Worm eradication (Center) and in Mali, the country with the third highest prevalence of Guinea Worm, hope lies in partnering with the Mali’s minister of Health.
As eradication nears, funding has consequently dried up. However the continued surveillance and spotlight on the progress of eradication through The Carter center has enabled funding through various sources, including a recent 40 million matching grant from The Bill and Melinda Gates Foundation (Center) providing a new rigor and vitality in pushing forward in the last steps to eradication.
The Tenacious Will
To think or believe that by 2015 eradication of Guinea Worm is possible is to understand the tenacity of the human spirit. The collective nature of the eradication program and its success relies on those that started its beginnings in the 1980s the villager who is willing to endure the ridicule and sometimes violence from fellow villagers in order to bring the “fiery serpent” to its final end. Eradication would not only be a public health triumph, but a triumph of human spirit and will.
Taken from Morbidity and Mortality Weekly Report, August 17, 2007
All pictures taken from The Carter Center unless noted
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