ERADICATION OF GUINEA WORM DISEASE

ERADICATION OF
GUINEA WORM DISEASE
Case Statement

Since The Carter Center began leading global Guinea worm disease eradication efforts in 1986 together with
endemic countries and the World Health Organization, as well as other trusted partners such as UNICEF, the
campaign has reduced the number of cases 99.99 percent, from 3.5 million cases annually in Africa and Asia to
22 cases in 2015.
Guinea worm eradication is drawing ever closer to the finish line. The campaign demonstrates what remarkable
change can occur with full engagement — from national ministries of health and each individual in affected
villages — even though there is no drug to cure Guinea worm disease or a vaccine to prevent it.
Each country that triumphs over Guinea worm disease serves as a reminder to the world that the greatest
challenges can be overcome with hard work, political commitment, and support of the international community.
However, success in global eradication will require stronger commitment of the four endemic countries fighting
the remaining cases, as well as of international partners in this public health initiative.
Everyone has a stake in these efforts. The entire world stands to gain from the eradication of Guinea worm disease,
not only because an age-old affliction will have been wiped off the surface of the planet, but also as proof that
eradication can be achieved with willpower, political involvement, local perseverance, and financial investment.
It was done with smallpox, and we can do it again.
We urge development partners — governments, foundations, and corporations — to generously contribute financial
support in a united demonstration that, together, we can ensure the eradication of Guinea worm disease by 2020.
With best wishes,
Jimmy Carter
Former U.S. President
Co-founder, The Carter Center
Margaret Chan
Director-General
World Health Organization
Boys with Guinea worm disease receive treatment at a case containment center in South Sudan.
On the cover: A South Sudanese boy examines a cloth filter. Filtration of drinking water prevents Guinea worm disease.

ABOUT GUINEA
WORM DISEASE
Guinea worm disease is an affliction of
2011
poverty, debilitating residents of remote
COTE GHANA
D’IVOIRE 2015
and marginalized communities in sub-
2013
Saharan Africa. A painful and incapacitating
TOGO BENIN 2009
waterborne disease, it negatively affects health,
2011
agricultural productivity, school attendance, and
overall quality of life in the communities where
it is found. 1 Guinea worm disease is caused by
the parasitic worm Dracunculus medinensis, which
infects people who drink water from stagnant
sources containing microscopic infective larvae
harbored by tiny copepods (“water fleas”). During
the yearlong incubation period, individuals do
not know they are infected and become unwitting
carriers of the parasite until the adult female worms,
measuring up to one meter in length, emerge. An
emerging worm causes a blister on the victim’s skin,
accompanied by a severe burning sensation and
pain, followed by an open lesion with a protruding
Guinea worm. When a patient cools the wound in
a stagnant water source, the worm releases hundreds
1989
1990
of thousands of larvae, which are readily ingested
1991
by copepods, contaminating the water source and
1992
continuing the transmission cycle.
There is no drug to cure Guinea worm
disease or vaccine to prevent it, humans do
not develop immunity to the disease, and
there is no known wild animal reservoir from
which the disease can return to humans once
transmission is interrupted. However, disease
transmission can be prevented. The Carter
Center — in partnership with the national Guinea
worm eradication programs of the ministries of
health of affected countries, the World Health
Organization (WHO), and strategic partners such
as the Centers for Disease Control and Prevention
and UNICEF — have pioneered community-based
responses to prevent transmission, and ultimately
eradicate Guinea worm disease by 2020.
MAURITANIA
2009 MALI
NIGER
5
CHAD SUDAN
SENEGAL
2013
9
YEMEN
2002
2004
2004
BURKINA FASO
NIGERIA
CENTRAL AFRICAN
2013 REPUBLIC SOUTH ETHIOPIA
2007 SUDAN 3
CAMEROON
5
2007
UGANDA
2009 KENYA
1994
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
77,863
78,557
164,977
129,852
96,293
75,223
63,718
54,638
32,193
16,026
10,674
25,217
9,585
4,619
3,190
1,797
1,058
542
148
126
22
152,814
229,773
374,202
543,585
623,579
PAKISTAN
1996
Progress on Guinea
worm eradication since
1986, by country
Year Certified by
WHO as Free of
Guinea Worm Disease
Year Guinea Worm
Transmission Halted
Cases Remaining
at End of 2015
(provisional count)
Annual number of cases of Guinea worm disease worldwide since 1989
892,055
INDIA
2000
3

Because Guinea worm is a
waterborne disease, water
filtration can prevent its spread.
THE NEEDS
In 1986, an estimated 3.5 million cases of the disease
could be found in 21 countries in Africa and Asia,
where 120 million residents were at risk of the
infection. 2 Since then, cases have been reduced by
more than 99.9 percent. At the end of 2015, there
were only 22 cases in 20 villages in four countries:
South Sudan, Ethiopia, Mali, and Chad. To date, the
World Health Organization has certified 15 formerly
endemic countries and 183 other countries and
territories and areas as free of Guinea worm disease.
Guinea worm is poised to be the second human
disease and the first parasitic disease ever
eradicated. The Carter Center and its partners assist
the national Guinea worm eradication programs to
halt transmission of the disease through:
Education: Communities learn about the disease
and how to prevent it. For example,
people learn never to enter a source
of drinking water if a Guinea worm is
emerging, never to allow anyone else
in the community with an emerging
Guinea worm to do so, and to report
anyone with Guinea worm.
Surveillance: A comprehensive
community-based surveillance
network aims to detect and report
cases of Guinea worm disease
promptly (before or within 24 hours
of worm emergence).
Case containment: Individual
cases are promptly managed
(contained) to prevent infected
people from contaminating sources of
drinking water.
Water treatment: Contaminated, stagnant
sources of drinking water are treated with Abate ®
(temephos), a safe chemical larvicide donated by
BASF Corporation.
Water filtration: Community members are taught to
filter all unsafe drinking water to sieve out copepods
and prevent infection. Cloth filters and pipe filters
are donated by Vestergaard.
As the lead agency over the last 30 years of the
global Guinea worm eradication campaign, The
Carter Center has raised $332.9 million in financial
and in-kind contributions. Sources of support are
illustrated in the chart below.
An estimated $214 million is needed between 2015
and 2020 to fully eradicate Guinea worm disease
and to certify that the disease has been eradicated.
As with any eradication campaign, the last cases
will be the most expensive, but the ultimate reward
is a world free of Guinea worm disease for future
generations.
Contributions and pledges for Guinea worm
eradication by donor type, 1986–2014
4%
13%
41%
4%
FPO
38%
Foundations
Governments
Organizations
Corporations
Individuals
4

THE INTERVENTIONS
The campaign will be successful when all
countries are certified as free of Guinea worm
disease. The following phases outline the work
remaining to reach that goal. Ministries of health,
national Guinea worm eradication programs and
governments of affected countries are key partners
in these efforts.
Phase 1 Interruption of transmission in
remaining endemic countries, led by endemic
countries with support from The Carter
Center: 2016
• Ensure 100 percent coverage of active
surveillance in remaining endemic areas,
including regular case searches, investigation,
documentation and response (within 24 hours) of
rumored cases of Guinea worm disease.
• Maintain surveillance and response capacity in
areas of endemic countries where transmission
has already been stopped.
• Continue health education and mobilization,
including distribution of cloth and pipe water
filters, application of Abate larvicide to treat
contaminated sources of drinking water, provision
of safe drinking water, and promotion of cash
rewards for reporting cases.
• Conduct ongoing advocacy at national and
international levels for continued support and
funding to reach eradication.
• Maintain cross-border surveillance and response
capacity to prevent importation of cases and
ensure that eradication status is maintained in all
countries that have already been certified as free
of Guinea worm disease. (WHO)
Because many families in South Sudan, such as this child and her parents,
move from place to place to care for their cattle, disease surveillance must
cover a wide geographical area.
Phase 2 Pre-certification, led by
concerned countries with support
from The Carter Center and WHO:
2016–2019
• Continue active surveillance in last
group of endemic areas and immediate
reporting and investigation of rumored
cases. (The Carter Center)
• Conduct ongoing advocacy at
national and international levels for
continued support and funding to
reach eradication. (The Carter Center
and WHO)
• Facilitate external assessments to
verify national claim that transmission has been
interrupted. (WHO)
• Implement a global reward for Guinea worm disease
cases. (WHO)
• Maintain cross-border surveillance and response
capacity to prevent importation of cases and ensure
that eradication status is maintained in all countries
that have already been certified as free of Guinea
worm disease. 3 (WHO)
Phase 3 Certification, led by WHO: 2016–2020
• Continue dissemination of information about
rewards for Guinea worm disease cases.
• Assist countries in preparing report for the
International Commission for Certification of
Dracunculiaisis Eradication (ICCDE).
• Certify eight countries remaining, based on ICCDE
assessment: Chad, Ethiopia, Mali, South Sudan,
Kenya, Sudan, Angola, and Democratic Republic of
the Congo.
An Ethiopian
community
learns how to
prevent Guinea
worm disease.
5

The extraction of
a Guinea worm
is a slow and
painful process
that can take up
to two weeks
or more for a
single worm; if a
worm is coaxed
out forcefully, it
can break and
cause infection
or permanent
disability.
6
A health worker in Mali applies the
safe larvicide Abate to a pond where
people get their drinking water.
SOCIAL AND ECONOMIC CASE
FOR ERADICATION
The burden of Guinea worm disease on individuals,
communities, and societies extends beyond
physical suffering to significant economic and
social consequences, hampering development and
perpetuating a cycle of poverty and disease. 4 Due
to its significant economic burden, Guinea worm
disease is both a symptom of and contributor to
poverty. The disease burden impacts adults and
children alike, resulting in decreased agricultural
and household productivity, as well as impinging
on children’s school attendance.
The economic burden on poor rural communities
is particularly severe and aggravated by the
seasonality of transmission, which coincides with
peak agricultural activities. Agricultural laborers
infected with Guinea worm disease are unable to
harvest and farm crops (average duration of Guinea
worm disability is eight weeks), affecting income
and nutrition for families and the wider community. 5
Additionally, children may be forced to take on
work of their sick family members in the fields or
in the home, causing absences at school. Children’s
malnourishment or their own emerging Guinea
worms that disable them from walking to school can
further exacerbate the impact of the disease.
The effort to eradicate Guinea worm disease is
considered one of the most cost-effective health
interventions available. Over 80 million cases have
been averted since The Carter Center began working
on the campaign in 1986, resulting in improved
health status (including childcare and immunization
coverage), agricultural productivity, and school
attendance for millions of people in some of the most
remote areas of the world at an estimated financial
cost of $3.47 per case averted. Through communitybased
health education, filtration of drinking water,
application of Abate, and prompt detection of
cases, Guinea worm disease can be affordably and
effectively prevented.
However, the costs per case of treatment and
containment do increase toward the end of each
national campaign and the end of the global
campaign for the following reasons:
Long incubation: The one-year-long incubation
period makes it impossible to pre-identify infected
carriers of the disease and ascertain who will develop
infection. An extensive and intensive surveillance
system must be maintained for at least one year
beyond the report of the last indigenous case.
Thus, the surveillance footprint of Guinea worm
eradication programs must not only be maintained
but must encompass all places where infected persons
may be when they develop the disease.
Prompt detection and containment: Interrupting
transmission requires intensified operations during
the last phase of each national eradication effort
in order to detect all cases within 24 hours of
worm emergence, to manage all patients promptly
by case containment and to prevent transmission
effectively, through treatment of contaminated
sources of drinking water and ongoing community
education about the need to consistently filter all
drinking water.

Isolation and marginalization of affected
communities: The dearth of public health
infrastructure in Guinea worm endemic areas requires
establishment and operation of case containment
centers where patients with cases voluntarily
admit themselves for health care and prevention
of transmission. In addition, the last communities
affected by Guinea worm disease are frequently the
most marginalized by local society and distrustful
of government programs and anyone of authority
outside their communities. This often results in
community reluctance to cooperate and likelihood to
hide cases or withhold information about population
movements or sources of drinking water, thus
increasing the chances of missing cases. Community
mobilization and trust are therefore essential.
SUCCESS STORY: HUBEIDA IDDIRISU
Above: In Ghana in 2007, volunteer Sulley Zakaria visits Hubeida Iddirisu at home to treat her three painful wounds where Guinea
worms are emerging from her body. Right: Six years later Hubeida is a smiling teenager, and no one in her family, village, or country is
at risk of the parasitic disease.
In 2007, 11-year-old Hubeida Iddirisu faced
long days of pain as three Guinea worms
began to emerge from blisters on her body.
Hubeida was the victim of a particularly severe
Guinea worm disease outbreak in her town of
Savelugu, Ghana.
“I probably caught the worms when
accepting a drink from a neighbor during my
rounds of charcoal selling,” she said.
Every day for two weeks, a volunteer
came to Hubeida’s home to extract the
worms. Often people suffer from more
than one worm at a time, as Hubeida did,
and the incapacitating wounds caused by
the worms typically take up to two months
to heal. While the worms were emerging,
Hubeida was unable to attend school, handle
her household tasks, or work at her afterschool
job.
During the outbreak, the Ghana Guinea
Worm Eradication Program, assisted by The
Carter Center and its partners, stepped up
efforts to halt the disease in Savelugu by
providing all households with cloth filters to
strain out the Guinea worm larvae in drinking
water. Community members with emerging
worms were told not to enter sources of
drinking water, such as the local dam, because
doing so would allow the worms to release
larvae into the water and continue the
parasite’s life cycle. Stagnant ponds were also
treated with a safe larvicide.
One year later, Hubeida was free of Guinea
worm disease. She was able to carry out her
daily chores as well as her job selling charcoal
to help support her family and pay for school
fees.
Today, Hubeida Iddirisu is a smiling young
woman, and she has never had another
Guinea worm. Ghana saw its last case of the
disease in 2010 and was certified as free of
Guinea worm disease in 2015.
7

Guinea worm eradication campaign
funding requirements, 2015–2020
CALL TO ACTION
Global eradication of Guinea worm disease requires
unrelenting daily acts of courage by field workers in
the four remaining endemic countries to break the
transmission cycle. In spite of numerous challenges
(including, but not limited to, insecurity and difficult
access to endemic areas), the national Guinea worm
eradication programs, assisted by The Carter Center
and WHO, continue to deliver on their goals,
steadily reducing cases, stopping transmission in
endemic villages, and ensuring optimal surveillance
and reporting. Continued perseverance and adequate
funding will certainly ensure victory.
Once transmission has been stopped globally, no
further interventions or monitoring will be needed
beyond the three-year-long precertification of
eradication stage required by WHO. 6 The impact of
success without a vaccine or curative drug will extend
to validate the principle of disease eradication, the
potential of community-based engagement and health
education, and provide an example of a successful
$156.97 million remaining
$55.95 million confirmed
$212.92 million total funding needed
program for a neglected tropical disease. The legacy
of the established health infrastructure and networks
created to fight Guinea worm disease will include
community-based surveillance and health education
delivery systems ready to deliver other essential
interventions. 7 Eradication will accrue economic
returns forever by benefiting the health, agricultural
productivity, and school attendance among some of
the world’s poorest people.
Join the global campaign. Your support is essential
to maintaining momentum in the final push to
eradicate Guinea worm disease.
1 Cairncross S, Muller R, Zagaria N (2002). Dracunculiasis (Guinea worm disease)
and the eradication initiative. Clin Microbiol Rev 15:223-246.
2 Watts SJ. (1987) Dracunculiaisis in Africa in 1986: Its Geographic Extent,
Incidence and At-Risk Population. American Journal of Tropical Medicine and
Hygiene. 37(1): 119-125.
3 See: http://apps.who.int/dracunculiasis/dradata/html/report_Countries_i1.html
4 Levine R, What Works Working Group (2007): Case 11: reducing Guinea worm
in Asia and sub-Saharan Africa. In Case studies in global health: millions saved.
Sudbury (Massachusetts): Jones & Bartlett Learning.
5 Kim A, Tandon A, and Ruiz-Tiben E. (1997). Cost-Benefit Analysis of the
Global Dracunculiasis Eradication Campaign (GDEC) Policy Research Working
Paper, No 1835. The World Bank. Available on: http://www.cartercenter.org/
documents/2101.pdf
6 WHO, Dracunculiasis Fact Sheet. May 2015. Available on: http://www.who.int/
mediacentre/factsheets/fs359/en/
7 Callahan K, Bolton B, Hopkins DR, Ruiz-Tiben E, Withers PC, et al. (2013)
Contributions of the Guinea Worm Eradication Campaign toward Achievement
of the Millennium Development Goals. PLoS Negl Trop Dis 7 (5): e2160. Doi
:10.1371/journal.pntd.0002160. Available on: http://www.cartercenter.org/
resources/pdfs/news/health_publications/guinea_worm/plos-contributions-of-gweradication-toward-achievement-of-MDG.pdf
For more details on how to support the
Guinea worm eradication campaign,
please contact:
Nicole Kruse, nicole.kruse@cartercenter.org
Kate Braband, kate.braband@cartercenter.org
Chris Maddock, maddockc@who.int
For the most up-to-date information, including
a link to the current case count, go to
www.cartercenter.org/guinea-worm.
One Copenhill
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