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Progress Toward Global Eradication of Dracunculiasis, January 2010--June 2011

Weekly
Oct o be r 28, 20 11 / 6 0 (4 2);14 5 0 -14 5 3 In 19 8 6 , the Wo rld Health Assembly (WHA) called fo r the eliminatio n o f dracunculiasis (Guinea wo rm disease), a parasitic infectio n in humans caused by Dracunculus medinensis (1). At the time, an estimated 3.5 millio n cases were o ccurring annually in 20 co untries in Africa and Asia, and 120 millio n perso ns were at risk fo r the disease ( 1,2). Because o f slo w mo bilizatio n in co untries with endemic disease, the 19 9 1 WHA go al to eradicate dracunculiasis glo bally by 19 9 5 was no t achieved (3). In 20 0 4, WHA established a new target date o f 20 0 9 fo r glo bal eradicatio n*; despite co nsiderable pro gress, that target date also was no t met. This repo rt updates published (4-- 6) and previo usly unpublished data and describes pro gress to wards glo bal eradicatio n o f dracunculiasis since January 20 10 . The number o f indigeno us cases o f dracunculiasis wo rldwide decreased 44%, fro m 3,18 5 cases in 20 0 9 to 1,79 3 in 20 10 . As o f June 20 11, dracunculiasis remained endemic in three co untries (Ethio pia, Mali, and So uth Sudan). Of the 8 14 cases that o ccurred during January--June 20 11, a to tal o f 8 0 1 (9 8 %) were repo rted fro m 358 villages in So uth Sudan. By Octo ber 20 10 , Ghana had go ne 12 mo nths witho ut an indigeno us case, thereby interrupting transmissio n; Ethio pia and Mali are clo se to interrupting transmissio n, as indicated by the small and declining numbers o f cases in these two co untries. An o utbreak o f 10 cases was disco vered in Chad in 20 10 . The current target is to interrupt transmissio n in the remaining co untries as so o n as po ssible. Insecurity (e.g., spo radic vio lence o r civil unrest) in areas o f So uth Sudan and Mali, where dracunculiasis is endemic, po ses the greatest threat to the success o f the glo bal dracunculiasis eradicatio n campaign. Perso ns beco me infected with the parasite by drinking water fro m stagnant so urces (e.g., po nds) co ntaining co pepo ds (water fleas) that harbo r D. medinensis larvae. Currently, no effective drug to treat o r vaccine to prevent the disease is available, and perso ns who co ntract D. medinensis infectio ns do no t beco me immune. After a 1-year incubatio n perio d, adult female wo rms 24--40 inches (6 0 --10 0 centimeters) lo ng migrate under the skin to partially emerge, usually thro ugh the skin o f the fo o t o r lo wer leg. On co ntact with water, these wo rms release larvae that can then be ingested by co pepo ds and infect perso ns who drink the water. The emerging wo rm can be remo ved by manual tractio n and ro lling it up o n a stick o r gauze a few centimeters each day. Co mplete remo val requires an average o f appro ximately 4 weeks. Disabilities caused by dracunculiasis are seco ndary to bacterial infectio ns that frequently develo p in the skin, causing pain and swelling (7,8). Dracunculiasis can be prevented by 1) educating perso ns fro m who m wo rms are emerging to avo id immersing affected parts in so urces o f drinking water, 2) filtering po tentially co ntaminated drinking water thro ugh a clo th filter, 3) treating po tentially co ntaminated surface water with the larvicide temepho s (Abate), and 4) pro viding safe drinking water fro m bo re-ho le o r hand-dug wells (3). Co ntainment o f transmissio n, achieved thro ugh 1) vo luntary iso latio n o f each patient to prevent co ntaminatio n o f drinking water so urces, 2) pro visio n o f first aid, 3) manual extractio n o f the wo rm, and 4) applicatio n o f o cclusive bandages, is co mplementary to the fo ur main interventio ns.
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Co untries enter the Wo rld Health Organizatio n (WHO) precertificatio n stage o f eradicatio n appro ximately 1 year (i.e., o ne incubatio n perio d fo r D. medinensis) after repo rting o f their last indigeno us case. A case o f dracunculiasis is defined as o ccurring in a perso n exhibiting a skin lesio n o r lesio ns with emergence o f o ne o r mo re Guinea wo rms. Each perso n is co unted o nly o nce during a calendar year. An impo rted case is an infectio n acquired in a place (ano ther co untry o r village within the same co untry) o ther than the co mmunity where it is detected and repo rted. Eight co untries where transmissio n o f dracunculiasis previo usly was endemic (Burkina Faso , Co te d'Ivo ire, Ghana, Kenya, Niger, Nigeria, Sudan, and To go ) are in the precertificatio n stage o f eradicatio n. In each co untry affected by dracunculiasis, a natio nal eradicatio n pro gram receives mo nthly repo rts o f cases fro m each village that has endemic transmissio n. Repo rting rates are calculated by dividing the number o f villages with endemic dracunculiasis that repo rt each mo nth by the to tal number o f villages with endemic disease. All villages with endemic dracunculiasis are kept under active surveillance, with daily searches o f ho useho lds fo r perso ns with signs and sympto ms suggestive o f dracunculiasis. This is do ne to ensure that detectio n o ccurs within 24 ho urs o f wo rm emergence so that patient management can begin to prevent co ntaminatio n o f water. Villages where endemic transmissio n o f dracunculiasis is interrupted (i.e., zero cases repo rted fo r 12 co nsecutive mo nths) also are kept under active surveillance fo r 3 co nsecutive years. WHO certifies a co untry free fro m dracunculiasis after it maintains adequate natio nwide surveillance fo r 3 co nsecutive years and demo nstrates that no cases o f indigeno us dracunculiasis o ccurred during that perio d. As o f the end o f 20 10 , WHO had certified 18 7 co untries and territo ries as free fro m dracunculiasis (4); 18 African co untries, including three with endemic disease and o ne with an o utbreak o f dracunculiasis, remained to be certified. Co unt ry Re po rt s So ut h Sudan. After a referendum held in January 20 11, the 10 so uthern states o f Sudan became the independent Republic o f So uth Sudan o n July 9 , 20 11. Since 20 0 2, all indigeno us cases o f dracunculiasis in Sudan were repo rted fro m the states that are no w in the Republic o f So uth Sudan, making the no rthern states the newest dracunculiasisfree co untry (Sudan), which is awaiting certificatio n. The So uth Sudan Guinea Wo rm Eradicatio n Pro gram (SSGWEP) repo rted 1,6 9 8 cases o f dracunculiasis in 20 10 , o f which 1,26 4 (74%) were co ntained (Table 1). In January--June 20 11, SSGWEP repo rted a pro visio nal to tal o f 8 0 1 cases (77% co ntained, co mpared with 72% co ntained during January--June 20 10 ), an increase o f 8 % co mpared with the 745 cases repo rted fo r the same perio d in 20 10 (Table 2). All o f So uth Sudan's increase in cases o ccurred in the state o f Eastern Equato ria, which had 27% mo re cases than the same perio d a year befo re. Endemic areas o utside o f Eastern Equato ria repo rted 72% fewer cases during January--June 20 11. In June 20 11, So uth Sudan's cases were fewer than the same mo nth the previo us year fo r the first time this year (171 cases in June 20 11 co mpared with 241 cases in June 20 10 , a reductio n o f 29 %). During 20 10 , a to tal o f 732 villages repo rted o ne o r mo re indigeno us cases; during January--June 20 11, a to tal o f 36 6 villages repo rted indigeno us cases. During January--June 20 11, three security incidents (e.g., civil diso rder, banditry, and o ther vio lence) disrupted Guinea wo rm pro gram o peratio ns in So uth Sudan, co mpared with 14 such incidents during January--June 20 10 . The peak transmissio n seaso n in So uth Sudan is March thro ugh Octo ber. Mali. Mali's Guinea Wo rm Eradicatio n Pro gram repo rted 57 indigeno us cases in 20 10 , which was a reductio n o f 6 9 % fro m the 18 6 indigeno us cases repo rted in 20 0 9 . Of the 57 cases repo rted fo r 20 10 , 45 (79 %) were co ntained. Mali repo rted three cases, o f which o ne was co ntained, during January--June 20 11, co mpared with o ne case repo rted during January--June 20 10 . The two unco ntained cases were detected mo re than 24 ho urs after the wo rms began to emerge, but neither patient appears to have co ntaminated water. Insecurity attributed to Al Qaeda--asso ciated gro ups is an increasing pro blem in the areas o f Mali that are endemic o r previo usly endemic. Mali's peak Guinea wo rm transmissio n seaso n is June thro ugh Octo ber. Et hio pia. Ethio pia repo rted 20 indigeno us cases and o ne impo rted case fro m So uth Sudan in 20 10 , o f which 19 (9 0 %) were co ntained. This was a reductio n o f 17% fro m the 24 indigeno us cases repo rted in 20 0 9 . During January--June 20 11, Ethio pia repo rted six indigeno us cases and two cases impo rted fro m So uth Sudan, o f which seven cases (8 8 %) were co ntained, fo r a reductio n o f 54% fro m the 13 indigeno us cases repo rted during January--June 20 10 . All o f the indigeno us cases in 20 10 and so far in 20 11 were fro m Go g District in the Gambella Regio n. The pro gram extended surveillance to all 71 kno wn inhabited settlements in Go g District beginning in January 20 10 . The peak transmissio n seaso n in Ethio pia is March thro ugh May. Ghana. Ghana repo rted eight indigeno us cases in 20 10 , all o f which were co ntained. Ghana has repo rted no case o f dracunculiasis since May 20 10 . The peak transmissio n seaso n in Ghana was Octo ber thro ugh March. Chad. After a decade with no repo rted cases and three assessments by WHO teams in 20 0 1, 20 0 6 , and 20 0 8 , a visiting WHO team in 20 10 investigated rumo rs o f cases and co nfirmed an o utbreak that invo lved a to tal o f 10 kno wn indigeno us cases in eight villages during 20 10 . No ne o f the cases were co ntained. Wo rm specimens taken fro m several patients in 20 10 were co nfirmed at CDC as D. medinensis. Two cases were repo rted during January--June 20 11 (co mpared with two cases during January--June 20 10 ),
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o f which o ne was co ntained, in two additio nal villages. A to tal o f 36 villages are asso ciated (i.e., visited by o r the residence o f a patient 10 --14 mo nths befo re the emergence o f the wo rm) with the 12 cases repo rted during January 20 10 --June 20 11. WHO staff members and two CDC Epidemic Intelligence Service o fficers co nducted an investigatio n during January--February 20 11, the o utco mes o f which were repo rted in June 20 11 (9). The Carter Center o pened an o ffice in Chad in March 20 11, and has pro vided a resident technical adviso r and two expatriate technical adviso rs to assist the pro gram. Active surveillance and o utbreak co ntro l measures are being taken to help ensure rapid detectio n and co ntainment o f cases. The peak transmissio n seaso n in Chad appears to be June thro ugh August.

Reported by
Donald R. Hopkins, MD, Ernesto Ruiz-Tiben, PhD, The Carter Center, Atlanta, Georgia. World Health Organization Collaborating Center for Research, Training, and Eradication of Dracunculiasis. Mark L. Eberhard, Div of Parasitic Diseases and Malaria, Center for Global Health; Sharon L. Roy, Div of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC. Corresponding contributor: Sharon L. Roy, slroy@cdc.gov, 404-718-4698.

Editorial Note
With fewer than 1,8 0 0 cases repo rted in 20 10 (the lo west annual to tal ever), o nly three endemic co untries remaining, and 9 8 % o f cases in shrinking endemic areas o f So uth Sudan, the glo bal Guinea Wo rm Eradicatio n Pro gram is clo ser than ever to the go al o f sto pping transmissio n by the end o f 20 12. Since last year's update, Guinea wo rm disease transmissio n has ended in Ghana, o nce the co untry with the seco nd highest dracunculiasis prevalence in the wo rld. Unfo rtunately, Chad experienced an o utbreak after mo re than 10 years in the precertificatio n stage. The so urce o f that o utbreak, whether it o riginated fro m an externally impo rted case o r was the result o f undetected endemic transmissio n, is still unkno wn and likely will never be kno wn. The o utbreak in Chad fo llo ws the previo us setback in Ethio pia in 20 0 8 , after 20 co nsecutive mo nths with no repo rted indigeno us cases there. The setbacks in Chad and Ethio pia (10) undersco re the perils o f inadequate vigilance after transmissio n o f dracunculiasis is believed to have been interrupted, as well as the impo rtance o f adequate surveillance and respo nse to suspected cases in Guinea wo rm--free areas o f endemic co untries. Other remaining challenges include the pro blem o f insecurity in Guinea wo rm--endemic areas o f So uth Sudan and Mali, and the need to fo cus impro vements in safe water supplies o n prio rity endemic villages. In May 20 11, the WHA ado pted a reso lutio n (WHA6 4.16 ) o n eradicatio n o f dracunculiasis, its first since 20 0 4. This reso lutio n requires the secretariat o f WHO to repo rt o n the status o f Guinea wo rm eradicatio n to the WHA annually until the disease is eradicated.

Ref erences
1. Wo rld Health Assembly. Reso lutio n WHA 39 .21. Eliminatio n o f dracunculiasis: reso lutio n o f the 39 th Wo rld Health Assembly. Geneva, Switzerland: Wo rld Health Organizatio n; 19 8 6 . 2. Watts SJ. Dracunculiasis in Africa: its geo graphic extent, incidence, and at-risk po pulatio n. Am J Tro p Med Hyg 19 8 7;37:119 --25. 3. Ruiz-Tiben E, Ho pkins DR. Dracunculiasis (Guinea wo rm disease) eradicatio n. Adv Parasito l 20 0 6 ;6 1:275--30 9 . 4. Wo rld Health Organizatio n. Dracunculiasis eradicatio n: glo bal surveillance summary, 20 10 . Wkly Epidemio l Rec 20 11;8 6 :18 9 --9 8 . 5. Wo rld Health Organizatio n. Mo nthly repo rt o n dracunculiasis cases, January--December 20 10 . Wkly Epidemio l Rec 20 11;8 6 :9 1--2. 6 . CDC. Pro gress to wards dracunculiasis eradicatio n Jan 20 0 9 --June 20 10 . MMWR 20 10 ;59 :1239 --42. 7. Imtiaz R, Ho pkins DR, Ruiz-Tiben E. Permanent disability fro m dracunculiasis. Lancet 19 9 0 ;336 :6 30 . 8 . Ruiz-Tiben E, Ho pkins DR. Dracunculiasis. In: Guerrant RL, Walker DH, Weller PF, eds. Tro pical infectio us diseases: principles, patho gens, and practice. 2nd ed. New Yo rk, NY: Elsevier; 20 0 6 :120 4--7. 9 . CDC. Renewed transmissio n o f dracunculiasis---Chad, 20 10 . MMWR 20 11;6 0 :744--8 . 10 . Wo rld Health Organizatio n. Dracunculiasis eradicatio n---glo bal surveillance summary, 20 0 8 . Wkly Epidemio l Rec 20 0 9 ; 8 4:16 2--71. * Additio nal info rmatio n available at http://www.who .int/gb/ebwha/pdf_files/wha57/a57_r9 -en.pdf .
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 Transmissio n fro m a patient with dracunculiasis is co ntained if all o f the fo llo wing co nditio ns are met: 1) the disease is detected <24 ho urs after wo rm emergence; 2) the

patient has no t entered any water so urce since the wo rm emerged; 3) a vo lunteer has managed the patient pro perly, by cleaning and bandaging the lesio n until the wo rm has been fully remo ved manually and by pro viding health educatio n to disco urage the patient fro m co ntaminating any water so urce (if two o r mo re emerging wo rms are present, transmissio n is no t co ntained until the last wo rm is remo ved); and 4) the co ntainment pro cess, including verificatio n o f dracunculiasis, is validated by a superviso r within 7 days o f emergence o f the wo rm.
On July 9 , 20 11, the fo rmer co untry o f Sudan o fficially separated into two co untries: the Republic o f the Sudan and the Republic o f So uth Sudan. Currently, So uth Sudan is

endemic fo r dracunculiasis. The area co mprising the new co untry o f Sudan, lo cated no rth o f So uth Sudan, has been free fro m dracunculiasis since 20 0 2.
Additio nal info rmatio n available at http://apps.who .int/gb/ebwha/pdf_files/wha6 4/a6 4_r16 -en.pdf

What is alre ady kno wn o n t his t o pic? The number o f new cases o f dracunculiasis (Guinea wo rm disease) o ccurring wo rldwide each year has decreased fro m 3.5 millio n to fewer than 1,8 0 0 since the 19 8 6 Wo rld Health Assembly pro claimed glo bal eliminatio n as a go al. What is adde d by t his re po rt ? The to tal number o f dracunculiasis cases repo rted wo rldwide in 20 10 declined by 44% co mpared with 20 0 9 but increased by 6 % fro m January--June 20 10 to January--June 20 11. Transmissio n remains endemic in o nly three co untries, with just o ne, So uth Sudan, acco unting fo r 9 8 % o f all repo rted cases. An o utbreak with 12 repo rted cases o ccurred in a fo urth African co untry, Chad, during January 20 10 --June 20 11. What are t he im plicat io ns f o r public he alt h pract ice ? Altho ugh earlier target dates fo r glo bal dracunculiasis eradicatio n were missed, pro gress co ntinues, and eradicatio n within the next few years is likely if disruptio ns o f pro gram o peratio ns can be minimized, particularly in So uth Sudan and Mali.

TAB LE 1. N umb e r o f re p o rt e d d racunculiasis case s, b y co unt ry and lo cal int e rve nt io ns - - - wo rld wid e , 2010 N o . o f re p o rt e d case s* C o unt ry Ind ig e no us Imp o rt e d % o f case s re p o rt e d t hat we re co nt aine d Villag e s/Lo calit ie s re p o rt ing case s No. No. N o . re p o rt ing re p o rt ing re p o rt ing o nly imp o rt e d ind ig e no us 1 case s case s case s 732 4 22 9 3 505 0 3 4 3 227 4 19 5 0 End e mic villag e s ( 2009- 2010) Villag e s/Lo calit ie s and int e rve nt io ns % wit h 1 % p ro vid e d % using so urce s o f wit h he alt h t e me p ho s* saf e e d ucat io n* wat e r* 60 100 93 100 --22 84 17 78 --90 100 100 100 --PDFmyURL.com

% % wit h clo t h re p o rt ing f ilt e rs in all mo nt hly* ho use ho ld s* 99 100 100 100 --98 95 100 100 ---

Sudan Ghana Mali

1,698 8 57

0 0 0 1 3

74 100 79 90 66

676 19 53 9 0

Ethiopia 20 Niger 0

Chad To t al

10 1,793

--4

0 76

7 777

0 515

7 26 2

--757

--98

--98

--63

--23

--90

* Definitio ns o f indigeno us and impo rted cases as they relate to villages/lo calities are available at http://www.cartercenter.o rg/health/guineawo rm/pro gram_definitio n.html
Interventio ns included distributio n o f filters, use o f temepho s (Abate) larvicide, pro visio n o f o ne o r mo re so urces o f safe water, and pro visio n o f health educatio n. All cases repo rted in these villages/lo calities were traced to so urces o f transmissio n elsewhere, usually fro m within the same co untry. The case impo rted into Ethio pia was fro m So uth Sudan; the three cases impo rted into Niger were fro m Mali.

TABLE 2. Num be r o f re po rt e d indige no us dracunculiasis case s, by co unt ry --- wo rldwide , J anuary 20 10 --J une 20 11* Co unt ry Sudan Ghana Mali Ethio pia Chad To t al 20 0 9 2,733 242 18 6 24 0 3,185 20 10 1,6 9 8 8 57 20 10 1,7 9 3 % change -38 -9 7 -6 9 -17 ---4 4 J anuary--J une 20 10 745 8 1 12 2 768 J anuary--J une 20 11 801 0 3 6 2 812 % change 8 -10 0 20 0 -50 0 6 % o f case s co nt aine d during J anuary--J une 20 11 77 --33 10 0 50 77

* Excludes fo ur cases impo rted fro m o ne co untry to ano ther in 20 10 .

Pro visio nal case co unts; excludes two cases impo rted into Ethio pia fro m So uth Sudan.

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