GUINEA WORM ERADICATION IN NIGERIA: WHY THE

DISEASE STILL PERSISTS.

INTRODUCTION/BACKGROUND

Nigeria with an estimated population of over 150 million was in

2010 regarded as the country with the highest endemicity for

drancunculiasis (Guinea worm disease) in the world as at the time of

initiation of the global eradication program. The name guinea

worm was given to the parasite Dracunculus mendinensis by a Swiss

traveler after a visit to West Africa in the 16th century; he was

basically referring to what he had seen visiting the Gulf of

Guinea where Nigeria is located. It dates back to the slave trade

era (1501-1888). It was first noticed in the south eastern part

of Nigeria then later the northern part and was later followed by

the south western part of Nigeria. Guinea worm is a waterborne

helminthes disease transmitted by consuming water from a pond or

stagnant water which host small crustaceans or Cyclops even after

a year of water consumption from that source, the larvae find

their way to body cavity where male and female then mate. The

male dies after mating and it is then consumed in the body cavity

but the female continues to migrate in the connective tissues

especially to the long bones of the extremities. It then creates

a blister in the human host extremities and ruptures about 72 hrs

exposing the worm. Because of the pain encountered and which is

relieved by immersing the affected limb in water, more larvae are

released into water when infected individuals enters the water

source which contaminates it again and consumed by a copepod

until another round of mating starts (new cycle). (1, 2) Symptoms

like pruritus, pain especially on the lower limb and inflammation

are common features in this disease. (3) Below is the lifecycle

of guinea worm according to the CDC.

It is noticed that drancontiasis is seasonal in variation which is

closely associated with the mode of transmission and the life

cycle of the causative organism, the Drancunculus mendinensis. The

infection is common mostly in the tropical and subtropical

regions because the larvae develops best in temperature range of

between 25-30 degrees and the disease is more common during the

rainy season of the year when the contaminated water source is

expected to have risen. (3) The major social determinants of the

disease shows it is more among people of low socio-economic

status, the rural poor especially those without good source of

water supply. (9)

Aims and Objectives

(1) To evaluate the impact of globalization on the ability

of the Nigerian government and other international agencies

to reduce the incidence of guinea worm in Nigeria with

effective policy statement and implementation.

(2) To identify the major determinants of guinea worm in

Nigeria as well as policies and programmatic responses to

combat the disease or reduce its incidence.

METHODS

To meet the objectives of this paper, multiple literature

searches were conducted. The following databases were used:

Google Scholar

Medline (Ovid; 2000 – date)

Pub med

EBSCO host

WHO Bulletins/Reports

Keywords: Guinea worm; Drancunculiasis; Eradication; Surveillance;

Health education; Community participation; Deadline;

Disease; Certification of eradication; water supply;

Globalization, Nigeria, Africa, rural areas.

Apart from the keywords stated above, no specific criteria were

considered for eligibility. However only studies conducted in

Nigeria were considered.

WHO Bulletin reports, Carter foundation reports, UNICEF, UN, JICA

and policy documents from the national guinea worm eradication

program in Nigeria.

All journals and articles in English language were also

considered. Journals from the year 1995 till date were

considered.

FINDINGS

I will be discussing the findings, using the objectives of this

paper as a guide. Literature search shows, a lot still need to be

done despite several intervention statistics. “Globalization is

defined as the global relationships of people, culture and

economic issues or activities. In some aspects it also includes

mass migration and movement of people and even communication”.

It was noticed that the disease was of major risk as at 1993, it

was reported in 23,000 villages in 18 countries of the world with

more than 100 million people at risk of the Drancunculus

infection, even though there were several cases of under

reporting because a lot of those mostly infected are in the

impoverished population who are mostly based in the rural areas

of the community and access to proper healthcare difficult so

also proper documentation of the disease in some situations. (14)

In the late 1980’s, governments and international agencies

started the fight to eradicate the disease from our society, and

since then there has been a great decline in incidence worldwide.

The year 1995 was then declared as the deadline for total

eradication of Drancunculiasis but there have been a lot of

obstacles like logistics, political and cultural issues making it

unrealistic. (12) The forty-fourth World Health Assembly in 1991

endorsed the goal of eradicating guinea worm disease by the end

of 1995 so earlier in 1988 the WHO regional committees for Africa

had set a target deadline for the eradication of Drancunculus

medinensis in the remaining 17 countries still left with the

disease in Africa, however some countries in Asia like India and

Pakistan still had the disease around the period of the deadline

which according to the WHO was of public health importance. (8)

Collaborations

It is also worthy to mention efforts by some international

agencies and the national government of Nigeria toward the

eradication of the disease. The national government of Nigeria

through its program called National Eradication Program has

contributed a lot to the eradication and international agencies

like UNICEF, WHO, Carter Center, Centers for Disease Control and

Prevention (CDC), Global 2000 and Japan International Cooperation

Agency (JICA) have all supported the eradication of Drancunculiasis

in different ways either in terms of prevention or interventions.

(4, 7, 1, 12)

Economic Impact

It is however difficult to determine the economic impact on

disabled self employed farmer in a community affected with

Drancunculiasis especially considering the seasonal nature of the

disease and crop production which overall will affect the total

outcome of agricultural output for the year under review with the

endemicity of the disease in the community. A country like

Nigeria where majority of the work force in the rural setting

among farmers is between ages 15 to 40 years with incapacitation

for at least minimum of 10 weeks can have a great toll on the

economy of such a community. And the cost involved in the

recovery of infected person must be put into perspective, with

attention of family members now diverted to take care of the

sick. This affect the economy of the family as a whole, so also

that of the community at large. (3) The World Bank estimated the

importance of the disease eradication to the economy of a nation

like Nigeria and other affected countries as increment in the

economic rate of return by about 29% per year once the disease is

eradicated. This figure according to the world bank is based on a

conservative estimate considering the duration of time the farmer

will be unable to work or perform his/her agricultural task as

the case may be. (6)

However it was estimated by the World Health Organization that

about $30 million has been spent on the eradication of guinea

worm excluding the amount spent on water supply which is a key

factor in the eradication program as at 1989 but with the

inclusion of community based surveillance and health education,

the cost is estimated to be around US$100-200 per village.(7) The

total estimate cost of guinea worm eradication globally was put

at a moderate cost of US$75 million, however it is agreed in some

quarters that it is way above this cost especially if portable

water supply which is a core part of guinea worm eradication is

considered.(8) The cost of the targeted cost of water supply in

guinea worm endemic area in Nigeria was estimated at US$35.6

million.(1) There were also several financial contributions from

foreign national governments like the Canadian, Netherlands and

the United Kingdom running into several millions of dollars. (1)

Political Impact

The political impact in the eradication of guinea worm is the

role politicians play in the eradication program especially to

score political point. So guinea worm campaign has reiterated the

importance of political mobilization, which includes mobilization

of local and national leaders. For example General Yakubu Gowon,

the former head of state of the Federal Republic of Nigeria with

encouragement and support from President Jimmy Carter through his

Non Governmental Organizations (NGO), The Yakubu Gowon Center,

contributed a great deal to the eradication of guinea worm in

Nigeria. We also have similar experience in neighboring African

country Mali where the former head of state of Republic of Mali

also with support from President Carter too in 1992. He also was

passionate about the eradication of guinea worm in nine other

French-speaking countries in West Africa were his contributions

made eradication a reality in these countries at least a great

decline in the rate of infection, he made it his personal mission

and because of that he is highly regarded as a respected

statesman and a supporter of the poor who are mostly affected

with Drancunculiasis.(6) Other past head of states like President

Ibrahim Babangida in Nigeria did contribute financially about

US$1 million to the national eradication program through the

Carter foundation on behalf of Global 2000 program in 1988.(1)

As part of the political will to eradicate guinea worm

(Drancunculiasis) the World Health Organization (WHO) regional

offices for Africa including Nigeria resolved in the year 1988 to

set a deadline to eradication of guinea worm by 1995 even though

there are still some countries with recurrence even after

eradication.(8)

Cultural Impact

The literature search did not reveal any significant cultural

beliefs about the disease unlike disease like HIV/AIDS. However,

as previously described stagnant water like ponds have been

implicated in the disease. I will be describing some possible

cultural beliefs related to the disease based on my acculturation

experience. In some parts of Nigeria especially in the south-east

and south western part there are beliefs by some communities that

a water source even though contaminated and not fit for drinking

is a source of worship which has been in existence from the time

of their ancestors, and those water sources are used for

spiritual purposes as well as for bath and consumption. In

situations like this it is difficult to convince the locals to

desist from consumption of water like that because of the belief

they hold on to and that itself is a cause for guinea worm

infection. There is also need for cultural competence from health

educators and donor groups, even between community population and

migrant population who come in as settlers to the host

communities. This enables them learn about the cultures of the

host community and this enhances good communication and trust

between the rural population and agencies concerned with the

eradication program. (4) For example in some local communities in

Africa including Nigeria at the end of each session of regional

competition a good local song is chosen in a traditional style

about guinea worm and response from local officials indicated the

response has been phenomenal and has attracted the largest crowd

they had seen in the past three decades.(4) In a multi-ethnic

nation like Nigeria it is a common site to see people of

different ethnic divide co-exist even in the smallest units of

local administration. A typical example is the co-existence that

exists in Ifelodun Local Government Area (LGA) in Oyo State,

Nigeria. This is a good example of ethnic mix. A typical example

of this mix is that between the Fulani’s who are known to be

cattle rearers and move around (migrants) with herds of cattle

and settle wherever they feel is comfortable for their

cattle/livestock to graze. Their migration from one location to

another allows for the goal of eradication of guinea worm

difficult to achieve. So in order to achieve the set goal of

eradication their cultural status must be a factor to communicate

effectively and pass on health education to the minority groups

like the Fulani’s. So with this situation cultural aspect appears

a very important aspect that enhances guinea worm eradication in

Nigeria and other part of the world where they still exist. (12)

Efforts of International Agencies

As mentioned earlier the efforts of international agencies and

foreign national government have been well documented and

appreciated. However the eradication of guinea worm now appears

realistic. The World Health Organization did set up program

procedure for complete eradication or interrupted cases of

transmission of Drancunculiasis, so after eradication has been

achieved through all the programs of health education, improving

water supply and use of chemicals for water treatment, the next

step is the certification of Drancunculiasis eradication .(11)

Certification of drancunculiasis eradication: The procedure will

require at least about three extra years of active surveillance

after the drancunculiasis transmission interruption in the last

endemic country, on the long run the three extra years is to be

sure the eradication is indeed a reality and it does extend the

time before the certification is declared. The certification of

drancunculiasis eradication from one country to the other is of

utmost importance especially during the final stage of global

eradication. As at 2009 two-thirds of the formerly endemic

countries (14 of 20) still needed the certification. However, it

is part of the goals of the world body on eradication (WHO) to

ensure that countries certified have interrupted the disease

transmission and surveillance system on ground is able to detect

new and existing cases of guinea worm if any. The present

certification though complex but efforts are going on to simplify

them through series of reviews while ensuring re-occurrence

remains at the minimum level. Countries where divided into three

groups based on certification of drancunculiasis eradication as

defined by the commission namely:

(i) Countries with drancunculisis transmission after 1980 in

which Nigeria happens to be one of the 20 countries.

These countries after reporting no cases of drancunculiasis

need three year surveillance period and a visitation by

the International Certification Team (ICT) to declare

that the country is drancunculiasis-free. The report is

later presented to the Commission.

(ii) Countries where information obtained was not sufficient

to declare them transmission-free. These concerned

countries which Nigeria is not part of (8 in all) needs a

verification team to take a tour around the country to

ascertain interruption of the transmission of

drancunculiasis.

(iii) Countries known to have no transmission for many

decades or even no history of the guinea worm disease.

The concerned countries are asked to sign a declaration

stating the absence of transmission and they also need to

complete a questionnaire which shows satisfactory

surveillance which can detect the guinea worm disease if

it occurs. Both documents are then presented to the

Commission. (11)

Challenges in certification: The major challenge faced is

certifying countries known to be highly endemic and continue to

be endemic which also face some challenges reducing occurrence of

drancunculiasis for example countries such as Ghana, Nigeria, Mali

and Sudan. Nigeria started its eradication about 22 years ago

while countries like Sudan had security issues in endemic areas

so accessibility has been a problem especially during the civil

war. (11)

Access to health care has been a challenge according to the

findings in the literature search done for most of the affected

countries especially since most of the guinea worm infection

occurs in the rural areas of the affected countries. We also have

the issue of political unrest in some countries which prevented

health education from getting to the affected population. (3, 4,

7, 8, 11)

Drancunculiasis was widely during the early years of the eradication

of the program in Nigeria and affected every part of the nation.

The 36 states accounted for more than 75% of the reported cases,

but Enugu state in Nigeria was confirmed and kept its reputation

as the world capital of guinea worm disease.(1)

DISCUSSION

Appreciation must be extended to past ministers of health in

Nigeria who have put in a lot of efforts in ensuring that Nigeria

is drancunculiasis-free. People like the late Professor Olikoye

Ransome-Kuti and his disease control team led by the director Dr.

Gabi Williams, the then UNICEF representative in Nigeria Richard

Reid. So many efforts have been put together by international

agencies in the eradication program for Nigeria to attain the

status of a disease free country (guinea worm). (1)

However, there have been several setbacks in achieving this goal

since the World Health Organization (WHO) set a deadline to

eradicating drancunculiasis by the end of 1995. There were

questionable doubts as to the reality of achieving the global

eradication that year, so other deadlines were set until the year

2004 when the World Health Organization (WHO) put the target for

the global eradication to 2009 since there were still a good

number of countries still left behind in the disease eradication.

(15) There are questions that still remain unanswered, just like

in the past when target dates have been set for many goals of the

UN, WHO and many international agencies. Is it appropriate to set

target date/deadline for achieving eradication of guinea worm?

Judging by the commitments of leaders in different countries,

colleagues in the health education field, so the feasibility will

still be in doubt as to achieving the set goal. The donor

agencies were attracted to the deadline date set for the

eradication program, but with global eradication becoming a

challenge, donor agencies become impatient and start to lose

interest after deadline had passed and eradication has not been

achieved.

Another drawback is recruitment and training of Village Based

Health Workers (VBHW) for endemic rural setting and the mobility

of the population has always been a challenge as well. Another

potential drawback is the poor relationships that exist between

the Local Government Area (LGA) staff and the indigenes, efforts

must be made to improve the relationship between them to

facilitate the trust between the LGA staffs and the local

population, and this will make dissemination of their

information/health education far reaching.

CONCLUSION

Results from my literature reviews indicate that prevention

strategies, eradication program efforts, certifications after

confirmed eradication should be given much more attention in

keeping the eradication permanent and those countries still left

with cases are still making efforts to make Drancunculiasis history

but a lot of logistics ranging from political will of the

national leaders, wars and civil unrest in some countries are

still obstacles that needs to be overcome. (3) A lot has been

done and achieved on the prevention and intervention strategies

at eradicating guinea worm infection in Nigeria with help from

various arms of national government, local groups and

international agencies part of which was mentioned above. (4)

Some treatment measures were also tried but yielded little result

with the use of medications like niridazole (given in doses of 25

mg/kg body weight daily for 10 days), metronidazole (400 mg for

an adult daily for 10 days) and tiabendazole (50 mg/kg body

weight daily for 3 days). So symptomatic treatment at a time was

the other of the day.

RECOMMENDATION

With the global eradication, dracunculiasis should be one of the

easiest diseases to prevent according to studies and findings by

international agencies since the period of infection is in weeks

and man gets infected yearly and no animal reservoir, also

transmission is limited to small and easily recognized foci.

However, the moment transmission is interrupted in a particular

community in a season the infection ceases unless the infection

is being reintroduced from outside the community in focus. The

guinea worm infection is not a stable one that stays permanent in

a local community forever; it does disappear and reoccurs in

different local communities over the years depending on factors

like migration of infected individuals and climatic conditions.

There are various ways of preventions aimed at eradicating guinea

worm which includes the individual protection; this entails

sieving drinking water through a cloth which will filter out

infected Cyclops and also the community controls which involves

two possible means of approach:

Improvement of water supplies: Provision of piped water

enhances the eradication of guinea worm disease even though

not overnight, but will rather take couple of years to

achieve total eradication. Tube-wells and bore-wells can also

be used in the provision of water to a community where

construction won’t be an issue and will be technically

feasible, this will improve water supply. Improved water

supply will go a long way in the control of guinea worm

infection and will help in the reduction of other known water

borne diseases like typhoid fever, cholera, hepatitis,

poliomyelitis and gastroenteritis.

Water treatment with chemicals: Drancontiasis control by

treating the water sources is another option for the control

of the disease but few practical control schemes have been

tried. Organophosphorous compounds are now widely used for

the control of insect larvae in portable water storage ad

have been proven to be very safe.(3)

Another important area of intervention is health education which

spans through all sectors from individuals to local, national

government and international agencies. Part of the education is

encouraging villagers to avoid drinking from surface water or

else filter with cotton cloth. Health education advocated the

following:

- Protection of sources of water from contamination,

especially prevention of individuals with the guinea worm

ulcers from going into the water sources with their open

wound;

- Protecting guinea worm ulcers or wound by covering them with

a bandage or clean cloth;

- Boiling and filtering of unsafe drinking water.

The volunteers called Villagers Health Workers (VHW) are

individuals who carry out most of the health education on guinea

worm in the villages, and they require regular motivation for

them to move from villages and field to field every month. The

motivation can be in form of material reward linked to task

performed; wrappers and tee-shirts; presentation of hats,

wrappers rather than cash. Also the importance of social status

was a good motivational factor of VHW where some programs of

eradication have offered certificates of diligence or awards to

best village health workers. Above all the important motivational

factors is regular supervision. (4)

Establishing a national program office and conducting baseline

surveys- Countries including Nigeria are expected to appoint a

program coordinator and set up a small office/secretariat to

support the national program on eradication, and conduct village

–by village survey to prepare a national action plan for guinea

worm eradication in Nigeria. This will also enable them count the

annual cases of the disease to determine the true extent of the

problem on ground.(8)

Implementing interventions- The key to implementing

interventions, evaluating program impact, mobilizing for

resources and monitoring progress is active surveillance. Health

education and community mobilization should be encouraged because

of its importance to intervention. This is a concern for each

country including Nigeria depending on the resources and the

population. There is need for safe source of water for drinking,

like hand-dug well and a bore-hole well with hand pump. Then the

control of copepod populations using Abate (temphos) which should

be used in only selected villages with the epidemic to reduce

incidence in situations where health education compliance is

difficult and safe water source is a possibility.(8)

Case containment- It refers to when cases decline as program gets

closer to eradication, when the expected case load of village-

based health worker is one case per worker. Stringent

surveillance and control will be necessary especially if

transmission is not likely to be re-established due to re-

infection from other endemic areas. (8)

Global Support- This has played a big role in the achievement so

far of eradicating drancunculiasis, but more still needs to be done,

especially with deadlines not being realistic as initially

planned. International agencies like Carter foundation, WHO,

JICA, UNICEF and a lot of other support from national and foreign

national government of countries like the Netherlands, United

Kingdom and the government of Japan.

Overall the eradication of guinea worm should be collective

efforts by all, at all level of governance starting from the

individuals, local governments, national government,

international agencies and foreign national governments.

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