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Cite this article: Biswas G, Sankara DP, Agua-Agum J, Maiga A. 2013 Dracunculiasis (guinea worm disease): 
eradication without a drug or a vaccine. Phil Trans R Soc B 368: 20120146. 
http://dx.doi.org/10.1098/rstb.2012.0146 
One contribution of 15 to a Theme Issue ‘Towards the endgame and beyond: complexities and challenges for the 
elimination of infectious diseases’. 
Subject Areas: health and disease and epidemiology 
Keywords: dracunculiasis, guinea worm, eradication, water supply 
Author for correspondence: Gautam Biswas e-mail: biswasg@who.int 
on February 25, 2018 http://rstb.royalsocietypublishing.org/ Downloaded from 

Dracunculiasis (guinea worm disease): 

eradication without a drug or a vaccine 
Gautam Biswas1, Dieudonne P. Sankara1, Junerlyn Agua-Agum1 and Alhousseini 
Maiga2 
1Department of Control of Neglected Tropical Diseases, World Health Organization, Avenue Appia 20, 1211 Geneva 27, 
Switzerland 2Intercountry Support Team-West Africa, WHO Regional Office for Africa, Avenue de l’Indépendance No. 158, 03 
BP 7019 Ouagadougou 03, Burkina Faso 
Dracunculiasis,  commonly  known  as  guinea  worm  disease,  is  a  nematode  infection  transmitted  to  humans  exclusively  via 
contaminated  drinking  water.  The  disease  prevails  in  the  most  deprived  areas  of  the  world.  No vaccine or medicine is available 
against  the  disease:  eradication  is  being  achieved  by  implementing  preventive  measures.  These  include  behavioural  change  in 
patients  and  communities—such  as  self-reporting  suspected  cases  to  health  workers  or  volunteers,  filtering  drinking  water  and 
accessing  water  from  improved  sources  and  preventing  infected  individuals  from  wading  or  swim-  ming  in  drinking-water 
sources—supplemented  by  active  surveillance  and  case  containment,  vector  control  and  provision  of  improved  water  sources. 
Efforts  to  eradicate  dracunculiasis  began  in  the  early  1980s.  By  the  end  of  2012,  the  disease  had reached its lowest levels ever. 
This  paper  reviews  the  progress  made in eradicating dracunculiasis since the eradication campaign began, the factors influencing 
progress  and  the  difficulties  in  controlling  the  pathogen  that  requires  behavioural  change,  especially  when  the  threat  becomes 
rare.  The  challenges  of  intensifying  surveillance  are  discussed,  particularly  in  insecure  areas  containing  the  last  foci  of  the 
disease. It also summarizes the broader benefits uniquely linked to interventions against dracunculiasis. 

1. Introduction 
Dracunculiasis,  commonly  known  as  guinea  worm  disease,  is  caused  by  a  60–100cm  long  nematode  worm,  Dracunculus 
medinensis.  The  disease has been known to humankind since antiquity. The ‘fiery serpents’ of the Israelites were possibly guinea 
worms.  The  first known mention of the disease was in the Turin Papyrus in the fifteenth century BC by the Egyptians; it has been 
since  described  by  ancient  Greek,  Roman,  Arab,  Persian  and  Indian  physicians  [1].  Guinea  worm  disease  derived  its  common 
name  from  its  prevalence  on  the  Gulf  of Guinea [2]. It is known to cause temporary incapacitation and some- times is associated 
with  permanent  disability  [3,4],  resulting  in  loss  of  income  and  reduced  school  attendance  among  the  already-deprived 
communities  and  households  associated  with  the  disease. The Dogon people of Mali refer to dracunculiasis as ‘the disease of the 
empty  granary’  [3].  Significant  progress  has  been  made  in  reducing  the  incidence  of  the  disease  by more than 99 per cent. This 
paper reviews the progress made during the eradication campaign, the lessons learnt and the remaining challenges. 
2. Biology of the parasite Dracunculiasis is transmitted exclusively to humans via drinking water contami- nated with infected 
copepod Cyclops, the intermediate host of D. medinensis. Following ingestion, the Cyclops die and release D. medinensis larvae, 
which pene- trate the host stomach and intestinal wall, and enter the abdominal cavity and retroperitoneal space. The larvae 
develop and mature into adults; after copu- lation, the male worms die and females grow to a length of 60–100 cm and 
© 2013 The Author(s) Published by the Royal Society. All rights reserved. 
 
migrate  in  the  subcutaneous  tissues  towards  the  surface  of  the  skin.  About  10–14  months  after  infection,  the  female  worm 
induces  a  painful  blister  on  the  skin,  mostly  from  the  lower  limbs;  the  blister  ruptures,  and  larvae  are  released  on  contact  with 
water  by  the  adult  female  worm  as  it  emerges.  The  larvae  are  ingested  by  a  Cyclop  and  after  two  moults  (in about two weeks) 
develop  into  infective  larvae.  Drinking  unfiltered  water  from stagnant water sources containing the infected Cyclops perpetuates 
the  transmission  cycle  [5].  Although  no  vac-  cine  is  available  for  prevention  or  medicine  for  mass  treatment  [5–8],  the 
transmission  cycle  can  be  broken  at  different  points  by  avoiding  contaminated  sources  of  drinking  water, filtering unsafe water 
with  cloth  and  fine-mesh  strainers  before  consum-  ing,  drinking  water  from  improved  sources  and  controlling  the  vectors  of 
transmission (figure 1). 

3. Decision to eradicate 
The  adoption  in  1986  of  resolution  WHA39.21  acknowledged  the  special  opportunity  afforded  by  the  International  Drinking 
Water  Supply  and  Sanitation  Decade  (1981–1990)  for  combat-  ing  dracunculiasis.  The  resolution  noted  the  importance  of 
maximizing  the  benefits  to  health  of  an  intersectoral  approach  in the context of primary healthcare; the progress achieved by the 
National  Guinea  Worm  Eradication  Programme  of  India;  and  the  increasing  awareness  and  actions  being  taken  against  the 
disease  in  Africa  and  its  successful  elimination in several countries. Furthermore, the resolution endorsed efforts to eliminate the 
infection  country  by  country  and  to  provide  through  a  combined strategy safe drinking water sources, active surveillance, health 
education,  vector control and per- sonal prophylaxis; it called on all Member States affected by dracunculiasis to establish, within 
the context of primary 
case containment 
2. Cyclops die and release 3. the larvae into stomach. Larvae develop, mature 
surveillance health education 
vector control 
access to improved water source use of filters 
Infected man enters water ponds. Larvae are released into the water and reproduce. after 10–14 months, female worms emerge 
1. Individual drinks unfiltered water containing Cyclops with ingested larve 
Figure 1. Guinea worm life cycle and interventions to interrupt transmission [9]. 
2. Cyclops swallow the larvae and undergo two moults to become infective 
5. Individual collects water containing infected Cyclops 
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healthcare,  plans  of  action  to  eliminate  dracunculiasis  [10].  The  45th  World  Health  Assembly  in  1991  further  resolved  to 
eradicate dracunculiasis by 1995 [11]. This decision had evolved based on various discussions and several factors. 
(a) The disease burden In 1947, more than 48 million people were estimated to be affected by the disease in Africa, India and the 
Middle East [12]. During the 1970s, the disease was reported to be distrib- uted in the rural areas of India, the Islamic Republic of 
Iran, Pakistan, Saudi Arabia, Yemen, and East and West Africa [13–15]. In 1976, the World Health Organization (WHO) esti- 
mated a prevalence of 10 million dracunculiasis cases globally [15]. By the 1980s, the disease was known to be endemic in 20 
countries in Africa, the Middle East and Asia. 
(b) Emerging opportunities After the successful conclusion of the smallpox eradication campaign in 1979, public-health experts, 
notably at India’s National Institute of Communicable Diseases [16] and the United States Centers for Disease Control and 
Prevention, sought other potential disease candidates for eradication [17]. Dracunculiasis was considered a suitable candidate 
because its geographical distribution is limited to tropical or subtropical areas, transmission is seasonal [13,18], diagnosis is 
unambigu- ous by visual recognition of the emerging worm through a painful blister or ulcer [19], the intermediate host is non- 
airborne and there is no known animal reservoir [6]. Moreover, there is no further multiplication of the parasite in the vector, 
unlike that of malaria. Based on the understanding of its local epidemiology, occurrence of the disease can be forecasted by 
geographical area and time period, permitting advance 
2 
 
 planning for focused and effective implementation of interven- tions for interrupting transmission. Its potential for eradication 
was asserted in 1993 by the International Task Force for Disease Eradication, which after reviewing 94 infectious diseases con- 
cluded that dracunculiasis is one of six eradicable diseases [20]. The launch of the International Drinking Water Supply and 
Sanitation Decade of 1981–1990 encouraged the World Health Assembly to note in resolution WHA34.25 that the decade 
presented an opportunity to eliminate dracunculiasis as a public-health problem in affected areas, where the preva- lence of the 
disease could serve as a uniquely visible and measurable indicator of progress during that period [13]. 
Following  the  momentum generated by the resolution, the first international meeting (‘Workshop on opportunities for control 
of  Dracunculiasis’)  was  held  in  June  1982  [21,22].  In  1983,  India  officially  launched  its  National  Guinea  Worm  Era-  dication 
Programme  as  a  centrally  sponsored  programme  after  assessing  the  extent  of  the  disease’s  distribution  since  1980  and 
formulating  a  strategy  for  eradication  through  a  National  Task  Force  set  up  in  1980 [23]. In 1984, the United States Centers for 
Disease  Control  and  Prevention  was  designated  as  a  WHO  Collaborating  Centre  for  Research,  Training  and  Control  of 
Dracunculiasis  [24].  Since  then,  it  has  developed  operational  guidelines  in  collaboration  with  The  Carter Center’s Global 2000, 
the  United  Nations  Children’s  Fund  (UNICEF)  and  WHO  and  continues  to  provide  technical  assistance  to  the  programme, 
including laboratory support. 
(c) Cost-benefit Another aspect influencing the decision to eradicate was the important socioeconomic toll of the disease on 
affected com- munities and countries and the cost-benefit of public-health interventions. The cost in lost school attendance and 
revenue from decreased agricultural productivity for individuals and the community can be very high. The economic loss of 
dracunculiasis in India alone was estimated to be 11.7 million man-days annually among 4 per cent of the 12.2 million people 
living in endemic villages [25]. In 1985, researchers noted that dracunculiasis has an impact on school attendance in Benin and 
Nigeria, and on agriculture in Benin and Burkina Faso 
Table 1. World Health Assembly resolutions on dracunculiasis. 
World Health Assembly year main focus 
WHA 34.25 1981 International Drinking Water Supply and Sanitation Decade: dracunculiasis as indicator of 
progress [32] WHA 39.21 1986 endorsed combined strategy: safe water provision, active surveillance, health 
education, community mobilization, 
vector control personal prophylaxis [10] WHA 42.29 1989 declared goal for eliminating dracunculiasis in the 1990s, 
invited other development agencies, organizations, foundation to support the country and ensured funding [33] 
WHA 44.5 1991 country by country certification of elimination of dracunculiasis, certification by WHO. National 
goals to interrupt 
transmission by 1995 [11] WHA 50.35 1997 political support and availability of resources for completion of 
dracunculiasis and support the work of 
International Commission for the Certification of Dracunculiasis Eradication 
(ICCDE) [34] WHA 57.9 2004 Geneva Declaration for the Eradication of Dracunculiasis by 2009 [35] WHA 64.16 
2011 provision of adequate resources for interrupting transmission and certification of eradication of disease, 
supporting 
surveillance in dracunculiasis-free areas, annual reporting of the progress to WHA [36] 
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[26,27].  In  1987,  a  study  in  Nigeria  estimated  an  annual  loss  of  US$  20  million  per  single  crop  (rice,  yam  and  cassava)  from 
farmers incapacitated by the disease for an average dur- ation of five weeks [3,4,28,29]. 
In  1956,  referring  to  the  eradication  of  yaws  in  Haiti,  it  was  concluded  that  interventions  for  disease  eradication  pro- 
grammes  should  be  considered  as  a  capital  investment  rather  than  as  a  recurrent  expense  once  the  disease  is  eradicated  [30]. 
Using  a  project  horizon  of  1987–1998,  the  World  Bank  estimated  an economic rate of return under conservative assumptions of 
29 per cent [31]. 
(d) Support for eradication Since the inception of the global eradication campaign, there has been continuous support from 
countries and commu- nities affected by the disease as well as partners in the public and private sectors. 
The  World  Health  Assembly  has adopted a total of seven res- olutions on dracunculiasis eradication (table 1), compared with 
27  resolutions  on  smallpox  eradication  and  four  resolutions  on  eradication  of  poliomyelitis.  Similar  resolve  was  echoed  at  the 
regional  level  of  WHO  during  the  first African regional confer- ence on dracunculiasis eradication held in Niamey, Niger in July 
1986, shortly after WHA39.21 was adopted. 
These  regional  conferences  brought  together  ministries  of  health  and  partners  and  were  sometimes  attended  by  current  or 
former  Heads  of  State  to  advocate  dracunculiasis  eradica-  tion.  Following  the  adoption  in  1988  of  resolution  RC38/R13  by the 
African  Regional  Committee  [37],  Cameroon,  Ghana  and  Nigeria  took  action  to  eradicate  dracunculiasis  with  national  case 
searches  conducted  during  1988–1989;  most  countries  carried  out  national  case  searches  between  1990  and 1992 and scaled up 
interventions  from  1991  to  1993.  A  total  of  eight  African  regional  conferences  on  dracunculia-  sis  have  been  held;  the  last 
conference took place in Abuja, Nigeria, in April 2008. 
In  1986,  The  Carter  Center  began  its  involvement  in  dracun-  culiasis  eradication  [3]  and  has  played  a  crucial  role  in  the 
global campaign since then, tirelessly advocating, fund-raising and assisting endemic countries to interrupt transmission. 
3 
 
4. The eradication strategy 
Evidence  from  various  studies  on  the  natural  history  of  the  dis- ease, proven interventions and experiences in countries [22] and 
lessons  learnt  from  the  successful  smallpox  eradication  programme  and  the  not  so  successful  malaria  eradication  pro-  gramme 
have  shaped  the  dracunculiasis  eradication  strategy  [6,38–40].  The  eradication  strategy,  based on the following interventions (i) 
surveillance  (including  case  management and containment); (ii) provision of safe drinking-water sources; (iii) vector control; (iv) 
health  education  (personal  prophy-  laxis);  and  (v)  certification  of  eradication,  was  endorsed  by  the  World  Health  Assembly 
[10,11]. 
(a) Surveillance Surveillance is a key element of disease control programmes, but it is the most crucial element in the final stage 
of the dracunculiasis eradication programme. The objective of sur- veillance and reporting is to promptly detect all cases until the 
last case of the disease is contained and the absence of transmission is confirmed. Endemic countries pass through three different 
stages: endemic; pre-certification; and post- certification. After interrupting transmission of the disease, the country enters a 
pre-certification stage of at least 3 years. During this stage, a country must show evidence of sustained absence of transmission 
through nationwide surveillance in order to be eligible for certification as dracunculiasis-free. Once WHO has certified a country 
free of dracunculiasis transmission, it enters the post-certification surveillance stage, which is continued until eradication of 
dracunculiasis is declared globally. 
Where the disease occurred in the remotest and difficult to access areas of endemic countries, with limited access to pri- mary 
healthcare  services,  surveillance  involved  the  community  in  detecting,  containing  and  reporting  dracunculiasis  cases  [41,42]. 
Active  house-to-house  case  searches  were  carried  out:  communities  were  shown  a  guinea  worm  photo  identifica-  tion  card  to 
assess  whether  anyone  had  seen  a  person  with  an  emerging  worm,  as  was  carried  out in the smallpox eradica- tion campaign of 
the  1970s  [43,44].  However,  because community-based surveillance (CBS) relied on a supportive infrastructure of supervisors to 
train,  monitor  and  collect  monthly  reports  from  health  workers,  implementation  was  restricted  to  known  endemic  and  at-risk 
villages  until  zero  cases  had  been  reported  for 3 years or transmission was no longer a risk. Dracunculiasis was reported through 
the  national  health  information  systems  of  affected  countries  [26,45,46].  Today, a case of dracunculiasis is immediately notified 
for  prompt  investigation  and  containment,  and  cases  are  repor-  ted  monthly  to  the  national  level  even if zero cases are detected 
[47]. 
With  the  decline  in  the  number  of  cases  and  to  increase the sensitivity of surveillance, eradication programmes announced a 
reward  for  notifying  cases  that  are  subsequently  confirmed  as  dracunculiasis.  A  similar  strategy  was  used  during  the  smallpox 
eradication  campaign  [48].  The  International  Com-  mission  for the Certification of Dracunculiasis Eradication also recommends 
that  national  dracunculiasis  eradication  pro-  grammes  announce a suitable reward for individuals reporting cases and for patients 
[49]. The amount of the reward in ende- mic countries and countries in the pre-certification stage ranges from US$ 40 to US$ 160 
[47]. 
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(b) Case management and containment Every case that is detected should be treated to prevent further transmission. The 
tried-and-tested treatment is to roll the worm gradually from the body using a stick or a match [6]. In some parts of Ghana and 
India, guinea worms were extracted surgically [50,51] with varying results. The Indian Guinea Worm Disease Eradication 
Programme expressed concerns about this practice and its clinical seque- lae and recommended against surgical extraction [52]. 
The practice was withdrawn from the Ghana Guinea Worm Era- dication Programme in 2000. In the absence of any effective 
drug to kill the parasite, development of drug resistance is not a concern for the programme. 
A  dracunculiasis  case  is  reported  to  be  contained  if  all  of the following criteria are met: the case is detected before or within 
24 h of the worm’s emergence; the patient did not contaminate any water source after the worm’s emergence; the patient received 
proper  care  by  cleaning  and  bandaging  the wound until all the worms are fully expelled; the patient received health education on 
not  entering  any  water  source;  and  a  supervisor  verified  the  case  as  dracunculiasis  within  7  days  [53].  Case-containment 
strategies have been implemented in all endemic countries since 1995 [54]. 
To  further  ensure  proper  case  containment,  especially  when  numbers  of  cases  are  reduced  and  localized,  national 
programmes  have  established  case-containment  centres  in  existing  health  facilities  or  temporary  camps  where  patients  are 
admitted  and  treated;  health  education  is  provided until the worm has been completely expelled, and any contact of patients with 
unsafe drinking water sources is prevented. 
(c) Access to improved drinking water The link between the prevalence of dracunculiasis and the lack of access to improved 
drinking-water sources is well recognized [55–57]. Communities identified by the Guinea Worm Eradication Programme as 
endemic for dracunculiasis are prioritized for access to improved water supplies. Methods to improve drinking-water supplies for 
affected communities include: protecting hand-dug wells and sinking deep-bore wells, improving existing surface drinking-water 
sources by constructing barriers to prevent humans from entering the water; and filtering surface water through sand filters 
[56,58]. Ministries of water and sanitation with the support of UNICEF and other partners such as Japan International 
Cooperation Agency (JICA) played a key role. Access to improved drinking-water supplies in affected communities provides a 
sustainable solution for eradica- tion. However, insufficient resources, difficulties in sinking deep-bore wells resulting from 
complex hydrogeological structures [59], and unsuitable water quality in certain areas [60] led to the goal of providing universal 
access to improved drinking water in all villages (including dracunculiasis-endemic communities) not met by the end of the 
International Safe Drinking Water and Sanitation Decade. Dracunculiasis eradication programmes have contin- ued leveraging 
access for improved water sources [61] in remote communities. 
(d) Vector control Vector control consists of killing the Cyclops (intermediate host) by applying a chemical called temephos. 
When applied 
4 
 
to  unsafe  drinking-water  sources  at  monthly  intervals  during  the  transmission  season,  temephos  is  effective  in  killing  the 
Cyclops,  thus  reducing  the  likelihood  of  individuals  contracting  the  infection  [62,63].  The  challenges  of  treating  ponds  with 
temephos  include  calculating  the  appropriate  quantity  for  application,  the  intensity  of  labour  [6]  and  the  difficulty  in  reaching 
remote  areas.  In  addition,  there  may  be  difficulties  in identifying which surface water sources are potentially con- taminated and 
which  need  to  be  treated.  Without  a  complete  census  of  potentially  unsafe  drinking-water  sources  in  use  by  communities, 
contaminated water sources continue to be used and transmission is perpetuated. 
To  supplement  vector  control  by  treatment  of  water sources with temephos, the adult Cyclops measuring about 1 mm can be 
removed simply by filtering drinking water through an ordinary nylon cloth or steel mesh. 
(e) Health education The objective of health education is to ensure that greater numbers of individuals and communities adopt 
behavioural practices aimed at preventing and interrupting transmission. Practices include voluntary reporting of dracunculiasis 
cases and knowledge of the reward scheme, prevention of patients from entering drinking-water bodies, regular use of drinking 
water from improved water sources and, in the absence of such sources, filtering water before drinking. The required know-how 
is transferred by health staff and volunteers using simple and professionally crafted messages [6] to individuals and communities. 
Although  filtration  appears  to  be  easy  and  effective,  chal-  lenges  remain  in  individual  and  household  compliance  with 
straining  all  unsafe  drinking  water  before  consumption  and,  more  importantly,  in  the  agricultural  fields  or  when travel- ling. In 
many  endemic  communities,  challenges  have  been  overcome  by  sustained  behavioural  change  communication  supported  by 
community  empowerment  and  mobilization  campaigns.  To  address  particular  issues,  such  as  filtering  unsafe water for nomadic 
communities  and cattle herders, innovative methods include designing portable water filters (‘pipe filters’) for use in the field and 
funnel filters for filtering water through plastic containers (used to carry water to and from the field). 
Advocacy  and  information,  education  and  communi-  cation  materials  have  been  prepared  and  disseminated  through poster, 
radio  and  television  broadcasts,  town  criers  and  markets.  In  resource-poor  situations,  face-to-face  com-  munication  (social 
mobilization  and  house-to-house  visits)  appeared  to  have  been  the  most  significant  strategy  for  disse-  minating  messages  [64]. 
Behavioural  changes  have  to  be  brought  about  in  the  community  to  achieve  the  required  impact,  which  remains  a  challenge. 
Ownership by all com- munities and commitment to the programme have made a remarkable difference. 
A  series  of  films  for  advocacy  and  creating  community  awareness  were  produced,  ‘Avicenna’s  Thread  Dracunculo-  sis’  in 
1977,  ‘Guinea  worm:  the  Fiery  Serpent’,  ‘The  Waters  of  Ayole’  in  1988,  ‘Dracunculiasis:  A  Forgotten  Disease  of  Forgotten 
People’  in 1991, ‘Yoro-Empty Granary’ in 1995, ‘The Final Sprint’ in 2005, ‘Foul Water Fiery Serpent’ in 2010 and ‘Heightened 
Surveillance’ in 2012 [58,65–73]. 
All national programmes implement a combination of all the above-listed interventions to interrupt transmission. 
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Surveillance  remains  the  crucial  overarching  intervention  to  detect  each  worm  emergence  at  the  earliest  to effectively con- tain 
any  subsequent  transmission.  Programmes  have  given  varying  emphasis  within  this  overall  mix  of  interventions  depending  on 
local  conditions.  For  example,  the  Indian  Guinea Worm Eradication Programme considered the vector control as a cost-effective 
strategy  and  emphasized  identification  of  all  potential  unsafe  drinking  water  sources  and  their  aggressive  treatment  with 
temephos  monthly  [23].  However,  in  areas  and countries where application of teme- phos in the very large surface water sources 
was  difficult,  alternative approaches were adopted such as preventing entry of humans into the water, providing the surface water 
after  pumping  through  sand  filters  and  making it potable. Countries in Africa such as South Sudan and Ghana accorded a greater 
emphasis in the provision of filters and health education to prevent transmission. 
Based  on  experience  in  Ghana,  Nigeria  and  Pakistan,  the  recommended  strategies  were  summarized  and  the  following 
operational  phases  were  described:  (i)  the  first  phase  consist-  ing  of establishment of the national programme office, conducting 
baseline  surveys  and  preparing  a  national  plan;  (ii)  the  second  phase  including  the  interventions  to  interrupt  transmission  by 
implementing  training,  village-based  surveil-  lance,  health  education,  filter  distribution, providing safe drinking water suppliers, 
vector control and monitoring; and (iii) the last phase involving case containment followed by a post-eradication phase [74]. 
(f) Certification of eradication The need for certification of attainment is inherent in the goal of an eradication programme. WHO 
established the Inter- national Commission for the Certification of Dracunculiasis Eradication (ICCDE) in 1995 [33] as requested 
by resolution WHA44.5 [10]. The Commission is made up of 12 inde- pendent public-health experts, and recommends to the 
Director-General of WHO the certification of countries as free of dracunculiasis transmission. At its first meeting in 1996, the 
ICCDE finalized the criteria against which dis- ease-endemic and non-endemic countries are assessed for certification [49]. All 
countries have to be certified, irrespec- tive of their endemicity status. The ICCDE categorized countries into groups: endemic, in 
pre-certification and those with more than 3 years without cases. Once trans- mission is interrupted, the ICCDE recommends a 
minimum 3-year pre-certification stage, during which a country must show evidence of absence of transmission to be eligible for 
certification. The process for certification is based on the epi- demiological group of the country and is based on a thorough 
review of the declaration, and a report submitted by the country followed by field evaluation carried out by an independent 
International Certification Team. 

5. Progress towards eradication 

In  1986,  there  were  an  estimated  3.5  million  dracunculiasis  cases  [75,76].  Following  the  launch  of  national  eradication 
programmes,  more  accurate  reporting  of  the  annual  incidence  of  cases  was  obtained  through  national  case searches, initiated in 
India  in  1980.  National  case  searches  began  in  sev-  eral  other  countries:  Pakistan  (1987), Cameroon and Nigeria (1988), Ghana 
(1989); Benin, Burkina Faso, Central African 
5 
 
Republic,  Coˆte  d’Ivoire  and  Togo  (1990);  Niger,  Mauritania,  Mali,  Senegal,  Uganda  and  Yemen  (1991);  Ethiopia  and  Sudan 
(1992); and Chad and Kenya (1993) [58,77–79]. 
To  supplement  national  case  searches,  CBS  was  initiated  in  Cameroon,  Ghana  and  Nigeria.  In 1989, a total of 883 640 dra- 
cunculiasis  cases  were  reported  to  WHO  by  15  countries: Nigeria reported 640008 cases and Ghana reported 179556 cases [78]. 
The  total  did  not  include  cases  from  other  known  endemic  countries  such  as Chad, Senegal and Sudan (figure 2) [24]. By 1995, 
the  first  target  year  for  eradication,  the  annual  inci-  dence  of  dracunculiasis  had reduced significantly to 152814 cases. Pakistan 
interrupted  the  transmission  in  1993  and  Kenya  reported  its  last  indigenous  case  in  1994. India inter- rupted the transmission in 
1996, followed by Cameroon, Senegal and Yemen in 1997 (figure 3). 
In  2004,  the  12  remaining  endemic  countries  pledged  to  era- dicate the disease by 2009, which was endorsed by WHA50.29 
[35].  South  Sudan,  then  part  of  undivided  Sudan  and  in  the  grip of a 20-year-old civil war, implemented full-scale pro- gramme 
activities  only  in  2006,  thanks  to  the  Comprehensive  Peace Agreement of 2005. By the end of 2009, eight of these 12 remaining 
endemic  countries  claimed  to  have interrupted transmission (figure 3), bringing the total number of countries that had interrupted 
transmission  to  16.  The  number  of  cases  declined  to  3190  (a  99%  reduction  since  the  start  of  the  global  campaign)  during  the 
same year; 80 per cent of the cases were reported in South Sudan [81]. 
By  2012,  the  number  of  cases  reported  to  WHO  worldwide  had  dwindled  to  a  historic  low  of  542  cases  reported  in  272 
villages.  Dracunculiasis  was  limited  to  four  countries  (Chad,  Ethiopia,  Mali  and  South  Sudan),  a  49  per  cent  reduction  com- 
pared  with  the  1058  cases  reported  in  2011  (figure  3).  South  Sudan  reported  521  cases,  contributing  96  per  cent  of  the  total 
number of cases in 2012; the 21 remaining cases were 
national case searches in Nigeria, Ghana, other countries with subseqent implementation 1 000 000 
of interventions 
800 000 
three of 15 countries reported annually, 
s e s a 
most cases were from India 
Nigeria 
global case count 
c . o n 
600 000 
WHA calling for 
Guinea disease 
worm 
in ceasefire 1995 in intesification of surveillance 
improved Sudan resulting accessibility 
in 
and case finding Burkina Faso 
Sudan 
other countries 
1981 
year 
Figure 2. Dracunculiasis cases reported worldwide, 1981–2011 [80]. 
400 000 
 Comprehensive Peace Agreement in 2005 resulted in full-scale programme implementation in South Sudan Guinea Worm 
Eradication Programme 
0 
Ghana 
200 000 
Uganda India 
1986 1991 1996 2001 2006 2011 
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reported by Chad (10 cases), Ethiopia (four cases), Mali (four cases) and Niger (three imported cases from Mali) [82]. 
The  eradication  target  was  not  achieved  in  1995  or  2009.  The  target  might  have  been  unrealistic  [83].  During  the  1990s, 
insufficient  resources,  operational  challenges  lar-  gely  owing  to  conflicts  and  security  concerns,  and  ensuing  inaccessibility 
prevented  programme  interventions  from  being  comprehensively  rolled  out  for  some  time;  these  fac-  tors  certainly  delayed  the 
eradication  process  in  Mali  and  South  Sudan.  Nevertheless,  setting  targets  might  have  accelerated  the  course  of  eradication  by 
energizing  and  intensifying  global  efforts,  and  contributed  to  significantly  reducing  the  number  of  cases during 1991–1996 and 
inter- rupting transmission in 75 per cent of endemic countries by 2009. 
Between  1995  and  2011,  the  ICCDE  met  eight  times  and,  on  its  recommendations,  WHO  has  certified 192 countries, areas 
and  territories  free  from  dracunculiasis,  either  by  having  inter-  rupted  transmission  or  by  being  an  entity  where  transmission is 
never  known  to have occurred. As of 2012, a total of 14 countries remain to be certified. There are four endemic countries (Chad, 
Ethiopia,  Mali  and  South  Sudan)  six  pre-  viously endemic countries in the pre-certification stage (Coˆte d’Ivoire, Ghana, Kenya, 
Niger,  Nigeria  and  Sudan)  and  four  countries  with  no-known  history  of  dracunculiasis  pending  verification  (Angola,  the 
Democratic Republic of the Congo, Somalia and South Africa) (figure 4) [47]. 
Countries  have  taken  varying  periods  of  time  to  interrupt  transmission  and  achieve  zero  reported  indigenous  cases. Among 
possible  determinants  are  the  burden  of  the  disease  (figure  5)  and  country-specific  operational  implementation.  Transmission 
dynamics  are  complex,  at  the  individual  and  community  level;  interrupting transmission relies on the inten- sity and accuracy of 
control interventions. Future predictions 
6 
 
based  on  previous  trends  may  not  always  be  accurate.  On the basis of the past trend in the number of cases, it was predicted that 
Ghana was unlikely to achieve interruption of trans- mission by 2015 [84]. However, Ghana interrupted the 
2010 1980 1985 1990 1995 
2000 2005 
2015 
establishment of International Commission for The Certification Dracunculiasis Eradication (1995) 
Figure 3. Dracunculiasis eradication timeline. The shaded box indicates the respective years (in parenthesis) in 
which countries interrupted transmission. (Online version in colour.) 
countries currently endemic for dracunculiasis countries at precertification stage previously endemic countries certified free of 
dracunculiasis other countries and territories certified free of dracunculiasis 
countries and territories not known to have dracunculiasis but yet to be certified not applicable 
data source: World Health Organization map production: Guinea Worm Eradication Programme World Health Organization 
WHO 2013, all rights reserved 
Figure 4. Endemicity status of certification. (Online version in colour.) 
WHA 34.25 dracunculias as indicator of progress during the International Drinking Water Supply and Sanitation Decade 
(1981–1990) 
launching of National Guinea Worm Eradication Programmes (1983–1993) 
WHA 39.21 elimination of dracunculiasis (1986) 
WHA 42.29 elimination of dracunculiasis (1989) 
WHA 44.5 eradication of dracunculiasis by 1995 (1991) 
Kenya (1994) 
Cameroon (1997) Pakistan (1993) 
Senegal India 
(1997) 
20 endemic countries in early 1980s 
(1996) 
Yemen (1997) 
WHA 50.35 dracunculiasis eradication (1997) 
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CAR (2001) 
transmission  in  2010  and  has  reported  zero  cases  since  May  2010.  After  having  almost  no  decline  in  cases  between  2001  and 
2007, apparently due to not so effective programme implementation, Ghana achieved an unprecedented record of 
certified 192 countries, areas and territories 
Benin (2004) 
Mauritania (2004) 
WHA 64.13 eradication WHA 57.9 Geneva declaration eradication of dracunculiasis 
of dracunculiasis annual reporting to WHA (2011) by 2009 (2004) 
Uganda 
Burkina Faso (2004) 
(2006) 
Togo (2006) 
Nigera 
Cote 
(2008) 
Ghana D’ (2006) 
Ivoire 
(2008) Niger 
(2010) 
four remaining endemic countries Chad, Ethiopia, Mali and South Sudan 
7 
 
reducing  the  number  of  dracunculiasis  cases  from  3358  cases  in  2007  to  only  501  cases  in  2008, 242 cases in 2009 and the last 
eight  cases  in  2010  owing to a significant increase in the proportion of cases (above 84%) that were contained since 2007. Figure 
6  compares  the  impact  of  interventions  in  Ghana  with the percentage change in the number of cases reported the following year. 
A  similar  comparison  between  the  number  of  reported  cases  and  the  operational  indicators  (figure  7) for South Sudan indicates 
that  while  the  proportion  of  cases  reported  to  have  been  contained  rose  from  49  per  cent  in  2006–2008  to  74  per  cent  in 
2010–2011, and the percentage 
100 000 
s e s a c . o n 
10 000 
1000 
100 
10 
0 5 10 
15 20 25 no. years untill zero indigenous case 
Figure 5. Duration of years from the highest number of guinea worm cases until zero indigenous cases [80]. 
10 000 
9027 
7402(–18%) 
4739 (–36%) 
5611(+18%) 
8290(+48%) 
7275(–12%) 
4136 (+4%) 
100% 
100 
83% 
3981(–45%) 
85% 
3358(–19%) 
93% 
86% 
84% 
85% 
73% 
80 1000 
80% 
72% 
68% 
75% 
501(–85%) 
63% 
68% 
65% 
242(–52%) 
s e s a c 
100 
61% 
66% 
66% 
60% 
56% 
58% 
60 
57% 
44% 
42% 
39% 33% 41% 
cases (per cent change from previous year) 
per cent of cases contained 
8 (–97%) 
per cent of endemic villages with treated water source 
per cent of endemic villages with 0(–100%) 
at least one safe water source 0 
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 
Figure 6. Impact of interventions in Ghana [80]. Data Source: Ghana Guinea Worm Eradication Programme. 
% . o n 
47% 47% 46% 
40 
10 
20 
1 
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 
refers to the intervention for the year 
2011 
refers to the cases for the year 
1 000 000 
Uganda 13 
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India 14 Pakistan 14 
Togo Senegal 
14 7 
Cameroon 
Yemen 
9 
4 
the nos below the country indicate the no. years taken to reach zero indigenous cases since its highest no. cases 
of  endemic  villages  with  temephos-treated  water  sources gradually increased from 7 to 85 per cent in 2011, the rate of decline in 
cases varied between 24 per cent and 49 per cent during 2007–2012. 

6. Lessons learnt from the global 

eradication programme 
It has been 22 years since the 45th World Health Assembly resolved to eradicate dracunculiasis. During the course of 
Nigeria 21 
R2 linear = 0.801 
Ghana 22 
Benin 15 
Niger 16 
Burkina Faso 18 
Mauritania 15 
Cote d′Ivoire 16 
8 
 
the  global programme’s implementation, certain lessons can be drawn that affect the course of an eradication campaign and could 
inform future eradication initiatives, in particular, and public-health practice, in general. 
(a) Sustain political commitment Any effort to eradicate a disease requires sustained commitment from decision-makers at the 
highest level of government, minis- tries of health of affected countries and supporting partners. The dracunculiasis eradication 
initiative benefited from the personal commitment of former and current Heads of State, secured largely through advocacy by 
President Carter. The ‘guinea worm ceasefire’ of 1996, which allowed active case searches to be carried out in conflict zones of 
Sudan, demonstrates that with political will even difficult situations can be overcome. Resolutions calling for dracunculiasis 
eradication and annual reporting to the World Health Assembly maintain the required commitment of ministries of health of 
affected countries and partners. Key partners—The Carter Center, UNICEF, WHO and its Collaborating Centre at the United 
States Centers for Dis- ease Control and Prevention—have continued to provide support and assistance to the programme and to 
the endemic countries. Advocacy and commitment at the highest levels resulted in a continued funding for the programme 
starting with the United Nations Development Programme, a coordina- tor of the International Drinking Water Supply and 
Sanitation Decade, as one of the first funding sources [85]. This funding was crucial to initiate national case searches and 
establish national eradication programmes. As the cases decline or trans- mission is interrupted, multiple health challenges 
compete for scarce resources and the programme may no longer be con- sidered a priority for decision-makers. However, with 
the unstinted support of governments, UN and international devel- opmental agencies and private foundations, funding for the 
eradication initiative has now been secured until 2015 [86]. Still, unlike the poliomyelitis eradication initiative, the dracun- 
culiasis eradication campaign has a limited budget and comparatively limited publicity [87,88]. The governments of Austria, the 
United Kingdom of Great Britain and Northern 
100 000 
100 
20 582(+270%) 
85% 
10 000 
5569 
5815(–72%) 
80 3618(–38%) 
2733(–24%) 
78% 
1698(–38%) 
74% 
74% 
s e s a c . 
1000 
1028(–39%) 
60% 
60 
% 
o n 
100 
45% 49% 49% 
49% 
521(–49%) 
cases (per cent change from previous 
34% 
40 
year) 
per cent of cases contained 27% 
22% 
25% 
per cent of endemic villages with 
10 
16% 
16% 
15% 
16% 
20 
treated water source 
11% 
per cent of endemic villages with at least 
4% 
6% 
one safe water source 
1 
2% 
2005 2006 2007 2008 2009 2010 2011 
0 
refers to the intervention for the year 2005 2006 
2007 2008 2009 2010 2011 
2012 
refers to the cases for the year 
Figure 7. Impact of interventions in South Sudan [80]. Data source: South Sudan Guinea Worm Eradication 
Programme. 
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Ireland,  and  the  United  Arab  Emirates,  the  JICA,  the  Kuwait  Fund,  the  OPEC  Fund  for  International  Development,  the United 
States  Agency  for  International  Development,  the  Bill–  Melinda  Gates  Foundation,  the  Children’s Investment Fund Foundation 
and  UNICEF  have  been the major donors during the course of the programme. These contributions have sup- plemented intrinsic 
funding  to  endemic  countries.  Eradication  relies  on  public  –  private  sector  partnerships  to  fund  and  support  community-level 
interventions and innovative incentives to empower exceptional community involvement [89,90]. 

(b) Sustain surveillance when the disease burden is 

reduced or transmission has been interrupted When the number of cases decreases or transmission is inter- rupted, it 
becomes harder to sustain the commitment of all stakeholders as the disease is no longer perceived as a pro- blem for the 
community or the health system [88]. This phenomenon is certainly not unique for dracunculiasis, and lapses can lead to costly 
setbacks and re-emergence of the disease. In Chad, for example, an outbreak occurred in 2010 after the last reported indigenous 
case in 2000. An almost non-functional national eradication programme may have contributed to suboptimal surveillance. To 
avoid lapses in surveillance it is important to: 
— ensure that transmission has indeed been interrupted in the community by thorough evaluation before transiting previously 
endemic communities to passive surveillance; — partnering with and strengthening the Integrated Disease Surveillance and 
Response (IDSR) system, which provides a nationwide opportunity to improve surveillance of dra- cunculiasis, especially in 
formerly endemic and non- endemic areas where dracunculiasis-specific surveillance is not in place. The IDSR is still in different 
stages of evol- ution, and the reporting rate varies from country to country. To bridge the gap between communities where 
dracunculiasis is likely to occur and the facility-based IDSR reporting, the programme relies on the reward scheme and other 
programmes such as the polio 
9 
 
surveillance network, national immunization days and mass preventive chemotherapy programmes for large- scale 
house-to-house case search activities; — extending the role of community volunteers. When the disease becomes rare or is 
eliminated, extending CBS to include other diseases sustains motivation of community volunteers and maintains adequate 
surveillance for dracunculiasis. Burkina Faso, Ghana, Mali, Niger and Uganda extended the (CBS) system for other diseases, 
includ- ing poliomyelitis, neonatal tetanus, Buruli ulcer, meningitis and even census for deaths [42,91,92]. In addition, local staff 
working on dracunculiasis eradication were often made responsible for delivering other health programmes [6]; — enhance 
awareness of the reward. To be effective, the reward scheme needs to be widely publicized [47]. Awareness-raising may yield 
information on alleged cases of dracunculiasis from all sources, recorded by the programme as ‘rumours’. In areas believed to be 
free of dracunculiasis transmission, investigation of ‘rumours’ of dracunculiasis cases resulted in the detection of cases and 
isolated foci of transmission [93]. In the absence of a surrogate marker for dracunculiasis surveillance, like the acute flaccid 
paralysis for poliomyelitis, indicators for measuring dracunculiasis surveillance include aware- ness of the reward, recording and 
investigation of rumours within 24 h; and — confirm every worm. Diagnosis of dracunculiasis is normally by visual means. 
However, not every worm is D. medinensis [94,95]. In the last stage of the programme, when cases occur in isolation, worm 
specimens need to be confirmed by parasitological examination and if required by polymerase chain reaction. Excluding a lone 
dracunculia- sis case on clinical grounds and not taking any follow-up measure can result in continued transmission. On the other 
hand, continued implementation of interventions when the case is not of true dracunculiasis is equally proble- matic. Both 
situations have damaging programmatic and financial implications. 
(c) Role of primary healthcare The launch of the dracunculiasis eradication programmes in the 1980s coincided with the 
emergence of the ‘health for all’ primary healthcare initiative in many developing countries [96]. The relationship of the 
dracunculiasis eradication pro- gramme with the health services differs from one country to the other and has evolved over time. 
This relationship has been affected not only by the eradication stages (endemic, pre-certification, post-certification) of a country 
but also by the availability of the primary healthcare network and health- care reforms initiated by countries. A commonality of 
dracunculiasis eradication programmes in affected countries has been working within or in close liaison with the health- care 
system. In most endemic countries, the programme was operated with the national level providing overall strategic guidance, 
regular monitoring and evaluation, whereas all interventions were implemented and managed by the pri- mary healthcare system 
with its outreach services under the supervision of the district and state (provincial or regional) administration. However, in some 
countries, the limited capacity of the primary healthcare system and its outreach prevented the optimum implementation of the 
necessary inter- ventions to eradicate the disease. Community participation 
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was  crucial  to  success; community-based volunteers were used to strengthen implementation of activities and achieve the desired 
impact.  To  ensure  regular  supervision  and  motivation  of  volunteers  and  to  collect  information,  the  pro-  gramme  recruited 
additional  personnel  both  locally  and  internationally.  Where  healthcare  infrastructure  was  severely  limited,  CBS  networks 
directed  at  endemic  or  at-risk  commu-  nities  were  largely  controlled  and  managed  directly  by  a  secretariat  at  the national level 
with  varying  levels of inter- action and liaison at provincial and district levels. When such direct support and additional resources 
are  withdrawn  from  areas that achieve interruption of transmission, the responsibil- ity of dracunculiasis surveillance shifts to the 
district  primary  healthcare  system,  which  may  not  be  able  to  assume  this  additional  responsibility  and  needs  therefore  to  be 
oriented, trained and motivated to do so. 

(d) Local politics in the installation of improved 

water sources Endemic communities are prioritized for access to improved water sources. However, local politics and 
communities’ perceptions and values may differ and influence the choice and site of installation of improved water points in the 
area. Creating community awareness and ownership was key in many communities in the installation of the water points and their 
subsequent maintenance. It allowed more equitable access and prevented the concentration of improved water sources in one area 
only (usually in the vicinity of an influential individual such as the village head) or in areas that may not be accessible to 
communities during the rainy season due to flooding. Installation of new improved sources may not always be enough; ensuring 
that sources remain functional throughout the year continues to be a challenge. Efforts have been made to train local labourers in 
the repair and maintenance of the hand pumps, or management by the communities themselves. 
(e) Sustain and report programme effectiveness To ensure continued programme effectiveness, it is important to regularly 
measure the operational indicators and their impact. Standard operational indicators are used in all national programmes to 
monitor and regularly report to higher levels. National Task Forces set up by ministries of health review the progress of the 
programme and where necessary rec- ommend corrective measures. In addition to the intrinsic monitoring of the programmes, 
periodic in-depth evaluations are carried out by independent national or international experts at the request of the ministries of 
health. The Indian Guinea Worm Eradication Programme commissioned seven independent evaluations between 1985 and 1999. 
Soon after the independent evaluation carried out in 2007, Ghana inter- rupted the transmission within 3 years. National 
programme managers or coordinators meet annually to report on their respective programmes and share experiences. The first 
national programme managers’ meeting was held in Braza- ville, Congo, on 25–28 March 1991. By 2013, a total of 17 such 
meetings had been held; the latest meeting took place in Ouagadougou, Burkina Faso on 9–12 April 2013. 
Since  March  1982,  information  about  progress  has  been  widely  disseminated  through  an  annual  global  progress  report  on 
dracunculiasis eradication. Progress reports and, since 2009, 
10 
 
updates  on  the  monthly  status  of  the  disease  are  published  in  WHO’s  Weekly Epidemiological Record. Since January 1983, the 
WHO  Collaborating  Centre  for  Research,  Training  and  Eradica-  tion  of  Dracunculiasis  at  the  United States Centers for Disease 
Control  and  Prevention  issues  a  monthly  memo  on  the  Guinea  Worm  Wrap-Up  to  all  programme  managers  and  interested 
individuals and organizations. It analyses the dracunculiasis situation and the eradication interventions and outcomes. Since 2012, 
an annual progress report on dracunculiasis eradication is provided to the World Health Assembly. 

7. Remaining challenges and future needs 

The  challenges  that  remain  to  be  overcome  in  order  to  reach  the  goal  of  eradication  and  its  ultimate  certification  are  (i)  to 
interrupt  transmission  at the earliest in the remaining foci and (ii) to maintain a level of optimal surveillance in the areas now free 
of  dracunculiasis  that  continue  to  be  at  risk  of  importation  of  cases  from  endemic  areas. Thus, the real challenge in interrupting 
transmission is confined to Chad, Ethiopia, Mali and South Sudan. 
Appreciable  progress  has  been  achieved  in  the  new  Republic  of  South  Sudan within a short span of time. The disease is lar- 
gely  confined  to  three  main  foci:  Kapoeta  East,  Kopoeta  North  in  Eastern  Equatoria  state  and  Gogrial  East  in  Warrap  state. 
However,  because  it  harbours  96  per  cent  of  the  worldwide  cases,  the  global  goal  of  eradiation  is  likely  to  depend  on  South 
Sudan.  South  Sudan  needs  to  significantly  improve  its case containment rate to increase the current 49 per cent rate of decline in 
annual  number  of  cases  (figure  7)  and  to  shorten  the  period  needed  to  interrupt  transmission.  The  poor  surveil-  lance  and  low 
level  of  case  containment  has  resulted  in  a  persistence of low grade transmission in Ethiopia. Of the four cases reported in 2012, 
two  were  not  contained  as  they  were  either  detected  beyond  24  hours  from  the  worm’s  emergence  or  had  reportedly  entered  a 
water  source.  It  is  not  yet  fully  understood  why  cases  occurred  in  Chad  and  certain  areas  (Macina  district  in  Segou  region and 
Djenne  in  Mopti region) of Mali as the localities where cases were reported in 2012 did not report any cases in the previous years 
nor  was  there  a  history  of  travel  of  the  cases  to  known  endemic  localities.  More-  over,  the  indigenous  cases  reported  in  2012 
could  not  recall  all  the  drinking  water  sources  after  a  year-long  incubation  period.  To  interrupt  the  transmission  effectively, all 
sources  of  trans-  mission  need to be identified and interventions implemented; each case of worm emergence requires a thorough 
and  detailed  epidemiological  investigation.  This  is  further  complicated as patients travel from place to place, especially nomadic 
popu-  lations,  cattle  herders  or  persons  displaced  due  to  conflicts.  In  some  situations,  the  source  of  infection  may  remain 
unexplained for one or more years [47]. 
Insecurity  is  another  major  challenge  faced  by  these  programmes.  Areas  affected  by  conflicts  prevent  access  by  healthcare 
workers,  thus  impacting  effective  implementation  of  surveillance  and  containment measures. In 2012, the Malian Guinea Worm 
Eradication  Programme  was  not  fully  operating  in  two provinces (Gao and Timbuktu), and was unable to carry out interventions 
in  the  region  of  Kidal.  Surveil-  lance  was  intensified  in  Burkina Faso, Mauritania and Niger in an effort to prevent the spread of 
infection  and  disease  through  the  refugees  fleeing  the  conflict  areas  into  neighbouring  states. The South Sudan programme also 
faces challenges due to 
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episodic  insecurity.  Conflicts  resulted  in  movement  of  popu-  lation  from  Pibor  to  Ethiopia.  The  Ethiopian  authorities  are 
strengthening surveillance in the border areas. 
Regular  access  to  endemic  areas  remains  a  challenge  due  to  poor  road  infrastructure and the vastness and remoteness of the 
area.  In  Chad,  the  transmission  period  coincides  with  the rainy season, and crossing the often-flooded Chari River poses a major 
hurdle  to  health  workers.  The  South  Sudan  Guinea  Worm  Eradication  Programme  is  facing  similar  con- straints when reaching 
out  to  the  endemic  areas  particularly  during  the  rainy  season.  The  collapse  of a steel bridge in Kauto in Kapoeta East County of 
Eastern  Equatoria  State  in  May  2012  broke  down  road  communication  affecting  the  movement of staff and supplies. Expensive 
transportation by air remains the only option. 
The  programmes  have  been addressing these issues by ana- lysing the epidemiological data to forecast the risk areas spatially 
and  temporally.  By  planning  well  in  advance,  resources  for  the  interventions  and  trained  volunteers  and  supervisors  are  put  in 
place  before  the  onset  of  the  transmis-  sion  season.  Mobile  and  satellite  phones  remain  the only communication channels when 
these areas are inaccessible. 
Lack of access to improved drinking water still continues to affect the endemic communities. Eighty per cent (388/483) of the 
villages  reporting  cases  in  2011  did  not  have  a  single  source  of  improved  drinking  water  [47].  Acceleration  in  the provision of 
improved  water  sources  in  the  remaining  endemic  villages  is required. Where unfavourable hydrogeological con- ditions are not 
conducive  to  bore  wells  despite  several  drilling  attempts,  innovative  solutions  are  required  to covert the water from the existing 
unsafe sources to safe water. 

8. Conclusion 
With  a  total  of  542  cases  reported  in  2012,  and  the  disease  limited  to  foci  in  South  Sudan,  Chad,  Mali  and  Ethiopia,  the 
eradication  of  dracunculiasis  is  imminent.  Challenges  remain but can be overcome with an undiluted resolve from the concerned 
govern-  ments,  partners  and health workers. There is no scope for complacency. The threat to this achievement is limited to inac- 
cessibility  of  endemic  areas  owing  to  insecurity  and  conflicts.  The  dracunculiasis  eradication  programme  will  leave a legacy of 
public-health  goods  in  terms  of  access  to  improved  drink-  ing-water  sources,  improved  surveillance  and  reduced  school 
absenteeism  or  loss  of  income owing to incapacitation from the disease. Once eradicated, dracunculiasis will be the first parasitic 
disease  of  humans  to  have  been wiped off the planet, and the first eradication campaign to have been conducted and successfully 
concluded without a vaccine or curative medicine. 
We  thank  Drs Lorenzo Savioli and Dirk Engels for their guidance and encouragement in preparing this manuscript and Ms Karen 
Ciceri  for  editing  the  text.  Thanks  are  also  due  to all the health officials and vol- unteers in the field fighting against the disease, 
interaction  with  whom  over  a period of time has resulted in much of the material for this paper. The authors are staff members of 
the  World  Health  Organization.  The  authors  alone  are  responsible  for  the  views  expressed  in  this  publication  and  they  do  not 
necessarily  represent  the  decisions,  policy  or  views of the World Health Organization. The boundaries and names shown and the 
designations  used  on  this  map  do  not  imply  the  expression  of  any  opinion  whatsoever  on  the  part  of  the  World  Health 
Organization  concerning  the  legal  status  of  any  country, territory, city or area or of its authorities, or concerning the delimitation 
of  its  frontiers  or  bound-  aries.  Dotted  and  dashed  lines  on maps represent approximate border lines for which there may not yet 
be full agreement. 
11 
 
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