1 The Guinea Worm and the Campaign to Eradicate It: An Overview 1.

Overview of the organism and its pathogenesis The Guinea worm, Dracunculus medinensis, is a filarial nematode native to northern Africa and the Mideast (Roberts and Janovy, 2009). It causes dracunculiasis, also known as Guinea Worm Disease (GWD)(Centers For Disease Control and Prevention, 2009). The disease appears extensively in the historical record, documented in the Old Testament as the fiery serpents that afflicted the Israelites (Barry, 2007), and calcified specimens have been recovered from Egyptian mummies dating to 1000 b.c.e. (Cockburn et al., 1998). The organism's binomial name and common name reflect its historic geographic distribution from Medina, near the Red Sea, to the Guinea Coast of west Africa, though its current distribution is significantly smaller (Roberts and Janovy, 2009). Adults are white, threadlike in appearance and exhibit significant sexual dimorphism, with females recorded up to 800 mm in length compared to 40 mm in the largest males (Roberts and Janovy, 2009). Guinea worms have a two-host life cycle (Roberts and Janovy, 2009). Juveniles (J1) infect water-dwelling clopoid crustaceans (copepods), the intermediate host, via ingestion (Roberts and Janovy, 2009). The definitive host, humans, consume stagnant water containing the copepods, which now harbor J3s (Roberts and Janovy, 2009). The J3s excyst in the gut, migrate to connective tissues, mature, and mate (Roberts and Janovy, 2009). Males die after mating and are either enclosed in a calcified cyst or absorbed by the host. Females migrate through soft tissue to an extremity, normally the leg or foot but also to the arm, buttocks, genitalia, head or torso (Roberts and Janovy, 2009). The female's uterus bursts, or rarely, is expelled through its mouth, releasing juveniles that trigger an acute allergic reaction accompanied by a blister and

2 intense burning pain (Roberts and Janovy, 2009). Hosts seek relief by dipping the blister in water. The blister ruptures on contact with cool water, and the juveniles begin a new cycle of infection (Roberts and Janovy, 2009). The Guinea worm life cycle is complete in 10-14 months (Roberts and Janovy, 2009).

2. The decision to eradicate the Guinea worm In 1981 the World Health Organization (WHO) and the U.S. Centers for Disease Control (CDC) identified GWD eradication as a benchmark for success in the Drinking Water Supply and Sanitation Decade (DWSSD). This was a United Nations Children's Fund (UNICEF) initiative lasting from 1981 to 1990 (World Health Organization, 2011a). The Carter Foundation joined the initiative in 1986, and the Guinea worm was formally targeted for eradication at that year's World Health Assembly (WHA) (World Health Organization, 2011a). The program was designated the Guinea Worm Eradication Program (GWEP) (The Carter Center, 2011). At the time of the 1986 announcement, 3.5 million cases of GWD were reported annually, principally in poor, agrarian regions of Africa, though actual incidence was estimated between 5 and 15 million cases (Hopkins, 1993) with the at-risk population totaling 120 million individuals (Watts, 1987). GWD is rarely fatal, but causes temporary incapacitation in infected individuals. Secondary infection through the open wound is the most common complication (Hopkins, 1993), and permanent disability occurs in 0.5% of cases (Hunter, 1996). These effects are cumulative at a community level; a region with active infections loses 20-50% of its workforce during critical periods of agricultural activity (Hopkins et al., 2005). This in turn causes food shortages and economic hardship to such an extent that GWD is known as the disease of the empty granary

3 in Mali (World Health Organization, 2011b). Transmission is interrupted through water filtration, sanitary reservoir construction, case containment, and larvicidal extermination of the copepod host (Hopkins et al., 2005). These methods fall under the umbrella of the DWSSD (Hopkins et al., 2005). Humans are the only definitive host of the Guinea worm, and no reservoir exists beyond the short-lived copepods (Roberts and Janovy, 2009). Consequently, under ideal conditions the parasite can be eliminated from an entire region in a single year (Hopkins et al., 2005). Collectively, the prevalence of the disease, its economic and agricultural impact, and the debilitating effects of secondary infection provided strong incentive to eradicate the Guinea worm. Total eradication is still considered an attainable end-state that will demonstrate the effectiveness of the DWSSD and the programs that have followed it (Hopkins et al., 2005).

3. Can the Guinea worm be completely eradicated? Since inception of the GWEP, the parasite has gone into sustained decline (Hopkins et al., 2005). Sudan, with a long-running civil war, has presented the largest obstacle to eradication, but it showed progress even before formal peace accords (the Guinea Worm Cease Fire) were signed in 2005 (Hopkins et al., 2005). At that time, 98% of documented cases occurred in Ghana and Sudan, with the remaining 2% distributed (in descending order of total cases) across Nigeria, Mali, Niger, Togo, Burkina Faso, Ivory Coast, Benin, Ethiopia, Mauritania, and Uganda (Hopkins et al., 2005). Only Sudan, Ghana, Mali and Ethiopia remain endemic, with a total of 1797 cases reported in 2010 (World Health Organization, 2011a). In total, GWD cases are now down to less than 0.01% of 1986 levels.

4 Despite the ongoing success of the eradication program, it has not met predicted goals. Guinea worm eradication was a stated WHO objective as a subprogram of the UNICEF clean water project ending in 1990, and at the 1991 WHA summit the WHO designated 1995 as the target year for eradication (World Health Organization, 1991). Revised WHO projections in 1997 and 2004 were also missed (World Health Organization, 2011b). At present, a major obstacle to complete eradication of the Guinea worm is surveillance and case containment. As GWD cases become increasingly isolated, it becomes more challenging and expensive to track and identify outbreaks (Staub, 2008). In response to these difficulties, the Bill and Melinda Gates Foundation and the U.K. government donated $8 million directly and an additional $32 million in challenge funds to the Carter Center to assist in the completion of the program (Staub, 2008). Ongoing civil war in the Darfur region of Southern Sudan has killed over 200,000 people and displaced another 2 million, posing significant risks and obstacles for GWEP workers (United Nations Department Of Public Information, 2007). Instability in Ivory Coast and Ethiopia also continues to impede detection and treatment, as does the discovery of new endemic minority populations who previously have been overlooked (Hopkins et al., 2005). Nomadism has been implicated in new outbreaks in Chad, previously certified worm-free by the WHO in 2000, so displacement of populations remains a concern in attempting to track, isolate, and monitor transmission (Djidina et al., 2011). Sustained peace and stability in southern Sudan is currently viewed as the most important requirement for total eradication of the Guinea worm (Hopkins et al., 2011). Continued vigilance for new outbreaks, isolation and case containment, and improvement of water sanitation are also essential to complete the program (Hopkins et al., 2011). If these requirements continue to be

5 fulfilled, eradication is likely to be complete by the end of 2012 (Hopkins et al., 2011).

4. Potential consequences of containment failure and species recovery To understand the potential costs of GWEP failure, we must look back to a time when GWD was endemic, which was the case for most of human history (Hopkins, 1993). As previously mentioned, the disease causes individual hardship, temporary incapacitation, high incidence of secondary infection, and in some cases permanent disability or death. The preeradication campaign incidence of 3.5 million cases annually is a stark reminder of the raw human suffering inflicted by this organism every year. In 1997 the World Bank estimated that 12.5% of a work-year was lost for every individual afflicted with GWD, and that eradication repays 29% of its cost (in 1997 stable dollars) to a country for every year that country remains worm-free (Kim et al., 1997). Guinea worm eradication pays for itself, and economic recovery was a major justification for the eradication program. A return to widespread annual infections would reverse these trends, causing severe loss of productivity in regions already suffering financial hardship. Another WHO, UNICEF and CDC program, the Polio Global Eradication Initiative (PGEI), provides insight into the risk of broken containment in a disease on the course to eradication. In 2003, clerics and community leaders in northern Nigeria began to spread rumors that the polio vaccine was part of an American plot to sterilize women (Zaracostas, 2006). For more than a year, the vaccination campaign was interrupted, leading directly to resurgence of the virus through importation to various countries in Africa, Asia and the Middle East (Zaracostas, 2006). Afghanistan, Pakistan, Nigeria and India are the only countries still endemic for polio

6 (World Health Organization, 2011c). Like GWD, overall incidence of poliomyelitis has been reduced by over 99% since the 1980s (World Health Organization, 2011c). Polio's rapid resurgence following interruption of the vaccine campaign echoes the importation of GWD into countries that previously had been certified free of Guinea worm.

5. Ethical and ecological considerations is eradication the right choice? By all indications, the GWEP is likely to achieve complete success in the near future. If so, Guinea worm will be the second species deliberately eradicated by humans in the name of public health, the first being Variola (smallpox) (Preston, 2002). The justifications considered in 1986 remain valid today; GWD is no less debilitating to the individual or the community than it was a generation ago. There is no evidence that Guinea worm eradication will have any significant effect on biodiversity. Genus Dracunculus includes non-human parasites such as D. insignis, found in raccoons and dogs (Crichton and Beverly-Burton, 1977) and D. ophidae, found in reptiles (Brackett, 1938). These close relatives of the Guinea worm have the same life cycle, only substituting a different definitive host. Numerous other filarial nematodes remain endemic in Africa and Asia, including Onchocerca volvulus, Loa loa, Wuchereria bancrofti, and others. Eradicating the Guinea worm has broad philosophical implications. As mentioned, deliberate eradication has previously been accomplished with smallpox and is being attempted with polio. Humans have unintentionally caused the extinction of many species, and many more have been lost to the blind machinations of a universe that is inherently inhospitable to life. The overwhelming majority of species that have existed are now extinct, so why should we worry

7 about a parasitic worm? Unintentional anthropogenic extinctions have occurred many times as a consequence of humans' technological development and territorial expansion. Deliberate eradication stands in sharp contrast to global conservation efforts designed to preserve species, sometimes at great expenditure of money and labor. In a sense, we have chosen to play god and decide which species will live and which will die. These decisions illuminate humanity's ever-growing influence on the global ecosystem. The benefits Guinea worm eradication are numerous and easily quantified, and it is an extensively researched species, but can we be certain that the extinction of this organism will not have unforeseen consequences? We risk establishing a dangerous precedent with the GWEP. If the WHO, a non-state entity, can decide that the Guinea worm must be eradicated, who else can choose to begin an extinction campaign? What standards must be used? Could a theocratic nation decide to exterminate unclean animals? Would countries go to war over such a decision? The potential for far-reaching ecological and sociopolitical consequences should not be underestimated in this case. Considering the known benefits against the hypothetical consequences, I support the eradication of the Guinea worm. Completing the program will make Africa a better place, aid economic growth in some of the most impoverished nations on Earth, and free resources and workers to fight polio, malaria, filariasis, shistosomiasis, AIDS, and numerous other diseases currently endemic throughout the world. GWEP success will serve as an example to the world of the good that science and medicine can accomplish.

8 References Barry, M. 2007. The Tail End of Guinea Worm Global Eradication Without a Drug Or Vaccine. The New England Journal of Medicine. 356, pp 2561-2564 Brackett, S. 1938. Description and Life History of the Nematode Dracunculus ophidensis n. sp., with a Redescription of the Genus. The Journal of Parasitology. 24, pp 353-361 The Carter Center. Guinea Worm Facts. 2011. http://www.cartercenter.org/health/guinea_worm/mini_site/facts.html Centers for Disease Control and Prevention. Parasites: Dracunculiasis [Dracunculus medinensis]. Laboratory Identification of Parasites of Public Health Concern. 2009. http://dpd.cdc.gov/dpdx/html/Dracunculiasis.htm Crichton, V. and Beverly-Burton, M. 1977. Observations on the seasonal prevalence, pathology and transmission of Dracunculus insignis (Nematoda: Dracunculoidea) in the raccoon (Procyon lotor) in Ontario. Journal of Wildlife Diseases. 13, pp 273-280 Cockburn, T., Cockburn, E., and Reyman, T. 1998. Mummies, Disease and Ancient Cultures, 2nd Edition. Cambridge, England. Cambridge University Press. Djidina, M., Guialongou, H., Dono, B., Ngarhor, N., Biswas, G. Sankara, D., Maiga, A., Djimrassengar, H., Roy, S., Bcheraoui, C. and Walldorff, J. 6/10/2011. Morbidity and Mortality Weekly Report. Centers For Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6022a4.htm?s_cid=mm6022a4_w Hopkins, D. 1993. Dracunculiasis. The Cambridge World History Of Human Disease. Cambridge, England. Hopkins, D., Ruiz-Tiben, E., Downs, P., Withers, C. Jr. and Maguire, J. 2005. Dracunculiasis Eradication: The Final Itch. American Society Of Tropical Medicine And Hygiene. 72, 4, pp 660675. Hopkins, D., Ruiz-Tiben, E., Eberhard, M., Roy, S. 2011. Morbidity and Mortality Weekly Report. Centers For Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6042a2.htm?s_cid=mm6042a2_w Hunter, J. 1996. An Introduction To Guinea Worm On The Eve Of Its Departure: Dracunculiasis Transmission, Health Effects, Ecology and Control. Social Science and Medicine. 43, 9, pp 1399-1425 Kim, A., Tandon, A. and Ruiz-Tiben, E. 1997. Cost-Benefit Analysis of the Global Dracunculiasis Eradication Campaign. The World Bank Africa Human Development Program.

9 Preston, R. 2002. The Demon In The Freezer. New York. Random House. Roberts, J. and Janovy, L. 2009. Foundations of Parasitology, Eighth Edition. New York. McGraw-Hill. Staub, E. Guinea Worm Cases Hit All Time Low: , WHO, Gates Foundation, and U.K. Government Commit $55 Million Toward Ultimate Eradication Goal. Modified 2008. The Carter Center: Press Releases . http://www.cartercenter.org/news/pr/gates_120508.html United Nations Department of Public Information. The United Nations and Darfur Fact Sheet.. 2007. http://www.un.org/News/dh/infocus/sudan/fact_sheet.pdf Watts, S. 1997. Population Mobility and Disease Transmission: The Example Of The Guinea Worm. Social Science and Medicine. Volume 25, Issue 10, pp 1073-1081. World Health Organization. Dracunculiasis: Current Situation, Global Eradication Campaign. 2011a. http://www.who.int/dracunculiasis/en/ World Health Organization. Eradication of dracunculiasis, Agenda Item 17.2, Fifty-Fourth World Health Assembly. 1991. World Health Organization. Eradication of dracunculiasis Report by secretariat. 2011b. Sixtyfourth World Health Assembly, Provisional Agenda Item 13.11. http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_20-en.pdf World Health Organization. Poliomyelitis Fact Sheet N114. 2011c. http://www.who.int/mediacentre/factsheets/fs114/en/index.html Zarcostas, J. 2006. Failed Vaccine Campaigns May Lead To Polio Resurgence, Experts Warn. British Medical Journal. 333, 7573, pp 823