Professional Documents
Culture Documents
Guinea Worm
Sharon Roy, MD MPH
Centers for Disease Control and Prevention
&
Ernesto Ruiz-Tiben, PhD
The Carter Center
February 2009
Prepared as part of an education project of the
Global Health Education Consortium
and collaborating partners
Learning objectives
1.
2.
3.
4.
5.
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Dracunculiasis
Guinea Worm Disease (GWD)
Ancient parasitic infection
Referred to in ancient texts
Found in Egyptian mummies
Waterborne disease
Caused by the roundworm
Dracunculus medinensis
There is no vaccine, nor
medical cure, and no
immunity to infection.
Latin name means little
dragon from Medina
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Intermediate
Host,
Copepod:
2 Weeks
Final
Host,
Human:
1 Year
Free-living:
3 Days
Maximum
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Infection
Generally infected with a
single worm but infection
with multiple worms
simultaneously is possible
No immunity conferred by
infection
Annual re-infection
commonly occurs in highlyendemic areas
Guinea worm emerging from a foot
(Benin). Photo credit: WHO
Collaborating Center at CDC archives.
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Clinical Course
Asymptomatic for about 1 year
after infection
1-year incubation period
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Clinical Course
Pain relief sought by immersion
in water
Blister breaks exposing worm
Worm emerges most commonly
from lower limb
However, worms can emerge
anywhere on the body
Clinical Course of GWD
People infected with Guinea worm are unaware of their infection for 10-14 months
(average, 1-year incubation period). When the pregnant adult worm is ready to
emerge, acute systemic symptoms develop (e.g., slight fever, an urticarial rash with
intense itching, nausea, vomiting, diarrhea, dizziness), which are related to the
formation of a blister. The blister induces a burning pain that causes the patient to
seek relief by immersing the affected body part in water. Water immersion also helps
to slough off the skin over the blister and expose the worm. When the blister
ruptures, the worm emerges and releases her larvae into the water. In 80-90% of the
cases, the worm emerges from the lower extremities. However, a Guinea worm can
emerge anywhere on the body.
References. Greenaway C. Dracunculiasis (guinea worm disease). CMAJ.
2004:170(4):495500.
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Morbidity
Pain
Wound complications
Wound infections
Cellulitis
Abscesses
Sepsis
Septic arthritis
Joint deformities
Tetanus
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Disability
Functional disability
Impaired mobility
Inability to work or attend school
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References
Hopkins DR, Hopkins EM. Guinea Worm: The End in Sight. In: Medical and Health Annual, E. Bernstein
ed. Encyclopedia Britanica Inc., Chicago 1991:1027.
Hopkins DR, Ruiz-Tiben E, Ruebush TK, et al. Dracunculiasis Eradication: Delayed, Not Denied. Am J
Trop Med Hyg. 2000;62(2):1638.
Ruiz-Tiben E, Hopkins DR. Dracunculiasis (Guinea worm disease) eradication. Adv Parasitol.
2006;61:275309.
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Management
Worm extraction
Water immersion
Wound cleaning
Worm coiling around rolled gauze
or stick
Topical antibiotics
Bandaging
Analgesics
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Treatment
Worm extraction
General wound care
No specific treatment for GWD
No drug
No vaccine
Epidemiology
Epidemiology of GWD Part 1. Because D. medinensis larvae need a period of 12-14 days to develop inside the copepods and
become infective, GWD is not normally caught from drinking flowing water, like rivers and streams. Instead, infection occurs by drinking
stagnant untreated water such as ponds, cisterns, pools in drying riverbeds, and shallow unprotected wells. Anyone who drinks from
these water sources can become infected.
References
Cairncross S, Muller R, Zagaria N. Dracunculiasis (Guinea Worm Disease) and the Eradication Initiative. Clin Micro Reviews.
2002;15(2):23346.
Greenaway C. Dracunculiasis (guinea worm disease). CMAJ. 2004:170(4):495500.
Ruiz-Tiben E, Hopkins DR. Dracunculiasis (Guinea worm disease) eradication. Adv Parasitol. 2006;61:275309.
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Epidemiology
Risks for disease vary and reflect how and where
people get drinking water
Sex
Roughly equal risk for male and females
Age
Can affect any age group but more common in young adults
Occupation
Farmers and those who fetch water at greater risk
Ethnicity
Some groups at higher risk
Epidemiology of GWD Part 2 . The risk for GWD varies by sex, age, occupation, and ethnicity. These differences reflect how and where
people get their drinking water in different areas, countries, and cultures. For the most part, GWD is distributed roughly equally between males
and females and occurs in all age groups although, in general, it is more common among young adults (ages 15-45 years). This may be a
reflection of the types of work persons in this age range perform. Farmers and those fetching drinking water for the household generally become
infected more frequently, perhaps because they are more likely to drink from stagnant potentially-contaminated water sources while away from
the household. In certain endemic areas, GWD disproportionally burdens particular ethnic groups.
References. Cairncross S, Muller R, Zagaria N. Dracunculiasis (Guinea Worm Disease) and the Eradication Initiative. Clin Micro Reviews.
2002;15(2):23346. --- Greenaway C. Dracunculiasis (guinea worm disease). CMAJ. 2004:170(4):495500. --- Ruiz-Tiben E, Hopkins DR.
Dracunculiasis (Guinea worm disease) eradication. Adv Parasitol. 2006;61:275309.
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Epidemiology
Greatest risk for GWD is having had GWD in the
previous year
Recurrent contamination of water supply?
Host susceptibility?
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Epidemiology
Seasonality of Transmission in Africa
Arid regions
Ethiopia, Mali, Niger, northern Nigeria, and Sudan
Transmission occurs in rainy season when stagnant surface water is
available
Wet Regions
Ghana and southern Nigeria
Transmission occurs in dry season when surface water is drying up
and becoming stagnant
Seasonality ---- GWD occurs mostly in the dry savannah areas of countries in the Sahel region of Africa.
NovemberApril, the dry season, are the peak transmission months in countries in the southern Sahel, e.g.,
Ghana. JuneOctober, the rainy season, are the peak transmission months in countries on the northern fringe of
the Sahel, e.g., Sudan.
References ---- Ruiz-Tiben E, Hopkins DR. Dracunculiasis (Guinea worm disease) eradication. Adv Parasitol.
2006;61:275309. ---- Greenaway C. Dracunculiasis (guinea worm disease). CMAJ. 2004:170(4):495500.
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Intangible benefits
Culture of disease prevention
Social equity
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GWEP Interventions
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Safe Water
Borehole well
Protected deep
well/spring
Has surrounding wall and
cap to prevent people
from entering water
Stream/river
Flowing water
Borehole well in Sierra Leone.
Photo credit: Sharon Roy, 2006, CDC.
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Safe Water
GWEP advocates for
provision and
rehabilitation of safe
water supplies
GWEP monitors status
of safe water in each
endemic village
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Guinea worm filter cloths. Photo credit: WHO Collaborating Center at CDC archives.
Pipe filters provided for drinking water while away from household
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Case Containment
Patient is prevented from
contaminating water and
transmitting GWD
4 criteria for successful
containment
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Vector Control
Abate larvicide (temephos) applied to
selected unsafe (contaminated) sources of
drinking water to kill copepods
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Inform communities
about Abate and its use
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900
900
89
29
26
Cases
800
800
700
700
GWD-Endemic Villages
62
38
54
GWD-Endemic Countries
600
600
400
400
300
300
200
200
100
100
4,643
(1986)
(2008*)
23,735
1,021
(1993)
(2008*)
20
(1986)
(2008*)
22
97
73
16
49
77
12
98
15 52
28
14
77
86
78 3
55
96 7
29
75 3
22
63 3
71
54 7
63
32 8
19
16 3
02
10 6
67
25 4
21
10 7
67
45 4
73
500
500
~3,500,000
42
33
26
37
42
02
1000
1000
00
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008*
* Provisional data
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1,000
2,000
3,000
4,000
3,642
Sudan
501
Ghana
417
Mali
Ethiopia
39
Nigeria
38
Niger
Togo
2006^
Burkina Faso
2006^
Cote d'Ivoire
2006^
Benin
2004^
Mauritania
2004^
Uganda
2003^
2001^
Chad
1998^
Cameroon
1997^
Yemen
1997^
Senegal
1997^
India
1996^
Kenya
1994^
Pakistan
1993^
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1) The country must demonstrate that transmission of GWD has been halted by meeting the criteria
described on the previous slide.
2) An International Certification Team (ICT) must visit the country, assess the sensitivity of the surveillance
system, review the historical records, visit the most likely places where GWD might be occurring and conduct
case searches, and write a report for consideration by the International Commission for Certification of
Dracunculiasis Eradication (ICCDE).
3) In addition to the ICT report, the country must also submit a report to the ICCDE detailing the history of the
national GWD eradication campaign.
4) If the ICCDE determines that the first three steps have been successfully completed, it recommends to the
WHO Director General that the country be certified as being free of GWD.
5) The WHO Director General then makes a formal announcement of GWD eradication certification for that
country.
Once certification is achieved, GWEP interventions and preventive measures can be reduced to a minimum.
Reference
World Health Organization. Criteria for the Certification of Dracunculiasis Eradication. WHO/FIL/96.187
Rev.1.
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Of the remaining 14 countries originally in the GWEP, eight are under pre-certification
surveillance and six remained endemic (Ethiopia, Ghana, Mali, Niger, Nigeria, Sudan) as of
January 2009. Ethiopia suffered an outbreak of GWD in 2008 and is again considered to be an
endemic country.
Reference
Al-Awadi AR, Karam MV, Molyneux DH, Breman JG. The other neglected eradication
programme: achieving the final mile for Guinea worm disease eradication? Trans Royal Soc
Trop Med Hyg. 2007;101:7412.
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Credits
Sharon Roy, MD MPH
Director, WHO Collaborating Center for Research,
Training, and Eradication of Dracunculiasis
Centers for Disease Control and Prevention
Sponsors