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Health condition: Before the start of the campaign in 1986, an estimated 3.5 million people in 18 endem-
ic countries in Africa and Asia were infected with guinea worm, and 120 million were at risk.
Global importance of the health condition today: In 2005, fewer than 11,000 cases of guinea worm were
reported in the nine remaining endemic countries. Just three countries have reported more than 1,000
cases—and the vast majority of the cases are in Sudan, where civil war has impeded progress.
Intervention or program: With the technical and financial support of a global coalition of organizations led
by the Carter Center, the United Nations Children’s Fund, the US Centers for Disease Control and Preven-
tion, and the World Health Organization, 20 countries implemented national guinea worm eradication
programs, run through their ministries of health. The primary interventions of the campaign include the pro-
vision of safe water (through deep well digging, applying larvicide, and purifying water through cloth filters);
health education; and case containment, management, and surveillance.
Cost and cost-effectiveness: The total cost of the program between 1986 and 1998 was $87.4 million.
The estimated cost per case was $5 to $8. The World Bank determined that the campaign has been highly
cost-effective and cost-beneficial. The economic rate of return based on agricultural productivity alone has
been estimated at 29 percent. The estimated cumulative cost of the campaign as of 2004 was approxi-
mately $125 million.
Impact: The eradication efforts have led to a 99.7 percent drop in guinea worm prevalence. In 2005, fewer
than 11,000 cases were reported, compared with an estimated 3.5 million infected people in 1986. By
1998, the campaign prevented between 9 million and 13 million cases of guinea worm. As of 2005, the
campaign has prevented more than 63 million cases of guinea worm disease, reduced the number of
endemic villages by 91 percent, and stopped the transmission of the disease in 11 of the 20 endemic
countries.
D
racunculiasis, or guinea worm disease, is an of the most preventable of all parasitic diseases, guinea
ancient scourge that once afflicted much of worm disease has vanished from developed countries
the world, including parts of the Americas. since the introduction of safe drinking water. Today it
Documented in Egyptian medical texts as is truly a disease of the poor, debilitating many of the
early as the 15th century BC, it is thought to be the most remote and disadvantaged communities in Africa,
“fiery serpent” referenced in the Old Testament. One where access to potable water is limited and health care
and education are lacking. In 1986, an estimated 3.2 mil-
Case drafted by Molly Kinder. lion people in 20 endemic countries in Africa and Asia
How the Worm Turns Guinea worm disease takes its toll not through death, as
the disease is rarely fatal, but rather through devastating
Guinea worm disease is contracted when a person disability, pain, and infection. Two studies in Nigeria,
drinks stagnant water from a well or pond that is for example, reported that 58 percent to 76 percent of
contaminated with tiny freshwater copepods carry- patients were bedridden for at least one month follow-
ing guinea worm larvae. Once inside the human, the ing the worm’s emergence. The pain is also long lasting,
stomach acid kills the copepods allowing the larvae to evidenced by the fact that in one study 28 percent of
migrate into the small intestine, where they penetrate infected individuals in Ghana experienced pain 12 to
the intestinal wall into the abdominal cavity. After 60 to 18 months later.2 The disease’s other symptoms, includ-
90 days, male and female larvae mate and, unbeknownst ing nausea, vomiting, diarrhea, and dizziness, further
to their host, grow to an average of two to three feet in exacerbate this burden. Secondary bacterial infections
length. A year later, the fully grown female worm rises occur in about half of all cases and can lead to arthritis,
to the skin in search of a water source to lay her larvae. “locked” joints, tetanus, and permanent crippling.3
A painful blister forms, usually in the person’s lower
limbs, although the worms can emerge from any part of Although the disease afflicts all age groups, it particu-
the body. To ease the burning pain, infected individuals larly harms children. The likelihood of a child under the
frequently submerge the blister in cool water, causing age of 6 years in Sudan being malnourished is more than
the blister’s rupture and the release of hundreds of thou- three times higher when the adults in the household are
sands of larvae into the water. A vicious cycle of reinfec- infected with the disease. School absenteeism rises when
tion occurs when sufferers inadvertently contaminate the debilitating symptoms render children incapable
sources of drinking water and set the stage for them- of walking the often long distance to school and when
selves and other residents to contract the infection. children forgo school to take on the agricultural and
household work of sick adults. As a result, schools in
The worm, about the width of spaghetti, gradually endemic areas frequently shut their doors for a month
emerges from the blister in a painful process that can each year.2
last 8 to 12 weeks. Numerous worms can emerge simul-
taneously or may emerge sequentially over a period of Guinea worm disease is not only a symptom of poverty
many weeks. Lesions caused by guinea worms invariably but also a perpetrator. The economic burden inflicted on
develop secondary bacterial infections, which exacer- poor rural communities is severe and is compounded by
the seasonal nature of the disease and its high preva-
The 20 endemic countries included Benin, Burkina Faso, Cameroon, lence in affected communities. Cyclical weather pat-
Chad, Côte d’Ivoire, Central African Republic, Ethiopia, Ghana, India,
Kenya, Mali, Mauritania, Niger, Nigeria, Pakistan, Senegal, Sudan,
terns and harvesting and planting seasons lead to peak
Togo, Uganda, and Yemen. periods when water in contaminated ponds and wells is
100
A popular communications tool has been “worm
weeks”—weeks of intensive health education and
community mobilization in the most highly endemic 10
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and demonstrate how to use cloth filters and prevent the Year
disease.6 Research in Ghana demonstrated the success of Source: Cairncross S, Muller R, Zagaria N. Dracunculiasis
the worm weeks: The communities that had participated (guinea worm disease) and the eradication initiative. Clin
Microbiol Rev. 2002;15(2):223–246.
in worm weeks showed an 80 percent decrease in cases
Despite the constraints, some progress has been made. In 1995, President Carter negotiated a 4-month
“guinea worm cease-fire,” which allowed health workers to distribute more than 200,000 cloth filters to
nearly 2,000 villages. (The cease-fire also provided a precious window for providing other life-saving health
interventions: 100,000 people at risk of river blindness were treated; 41,000 children were vaccinated for
measles; 35,000 received a polio vaccine; 35,000 doses of vitamin A were distributed; and 9,000 chil-
dren were treated with oral rehydration therapy.4) Since the cease-fire, government authorities, the United
Nations, the Carter Center, and more than 20 NGOs have focused on combating the disease in the south.
An estimated 600,000 cloth filters have been distributed each year, and in 2001, nearly 8 million pipe
filters—a strawlike tube with a nylon filter cloth that can be worn around the neck and used when farming
or traveling—were distributed. These efforts have been assisted by political commitment from the highest
levels of Sudan’s government and from the advocacy of President Carter, who visited parts of the rebel-
controlled region in 2002.6,9 Success in Sudan is not believed possible without an end to the conflict. Until
then, the persistence of guinea worm there jeopardizes the residents, the populations of the neighboring
countries, and the success that the national eradication programs have worked so hard to achieve.
the start of the campaign, is now considered a model of the disease would have presumably occurred annu-
for the surveillance of other diseases such as tetanus, ally. Therefore, the eradication campaign can be said to
lymphatic filariasis, and leprosy.5 have prevented at least 63 million cases of guinea worm
disease since 1987.
A 99 Percent Drop in Guinea Worm
Prevalence Cost and Economic Returns
The result of the campaign’s efforts has been a 99 percent The estimated cost of the global campaign between 1987
drop in the prevalence of guinea worm. In 2005, only and 1998 is $87.5 million.3 The effort received major
10,674 cases of the disease were reported, compared financial support and donor support from the govern-
with an estimated 3.5 million infected people in 1986. ments of Canada, Denmark, Finland, Japan, the Neth-
All three countries in Asia are now free of guinea worm: erlands, Norway, Qatar, Saudi Arabia, Spain, Sweden,
Pakistan (1993), India (1996), and Yemen (1997). As United Arab Emirates, the United Kingdom, and the
of 2005, 11 of the original 20 endemic countries halted United States.8 The private sector also contributed to the
transmission of the disease; 4 reported fewer than 100 campaign: BASF (formerly American Home Products)
cases each, and just 2 had more than 1,000 each. The donated more than $2 million worth of insecticide to
vast majority (89 percent) of the cases reported in 2005 the campaign, and E.I. DuPont Corporation donated
were from Sudan (5,569 cases) and from Ghana (3,981 more than $14 million worth of cloth for filters. The an-
cases) (see Box 11–1). In the absence of the eradication nouncements of a grant from the Bill & Melinda Gates
campaign begun in 1986, a total of 3.5 million cases Foundation in 2000 worth $28.5 million and, more re-