The last bastions of guinea-worm disease.

Abstract

A terrible itchiness is the first symptom of guinea-worm disease or dracunculiasis. Next, explains Adama Guindo, a village chief in eastern Mali, an agonizing blister appears on an ankle or foot. You don't see the worm to begin with, he says. When the creature's head emerges several days later, the pain is unbearable. Nausea, vomiting, diarrhoea and dizziness follow. You can't work or sleep, and if you can walk at all--it's with a crutch, he says. Extracting the worm takes on average between 30 and 60 days, as it must be done manually, by making an incision and twisting the worm slowing out around a stick. Secondary infection from the wound can lead to tetanus, permanent disability or septicaemia, which can be fatal. Guindo's home village of Tele, at the foot of the Bandiagara escarpment, a sandstone massif close to the border with Burkina Faso, is one of thousands of communities in Mali that were once ravaged by guinea-worm disease. We had guinea worm so badly here that women from other villages were frightened of marrying our men, recalls Ata Lougue. Only 30 years ago, a large proportion of the population was stricken with this debilitating disease and the granaries were empty, says Professor Ogobara Doumbo, a parasitologist at the University of Mali, who grew up in the area. [ILLUSTRATION OMITTED] Today guinea-worm disease stands on the brink of eradication--the goal is to wipe it out globally by December 2015--a year from now. Although the eradication goal was revised after an earlier goal to stop human transmission of the disease globally by 2009 was missed, few public health campaigns have made such rapid progress. In the mid-1980s, 3.5 million new cases were estimated to occur annually, but in 2013, as a result of the intensive efforts to halt transmission, only 148 cases were reported--a reduction of more than 99% since 1989--and the disease has been confined to four countries: Chad, Ethiopia, Mali and South Sudan. This year, the pattern has been similar. From January to September, 101 cases have been reported, with 11 of those in Chad, two in Ethiopia, 19 in Mali and 69 in South Sudan. So far, the World Health Organization (WHO) has certified 197 countries, areas and territories, including 185 WHO Member States, as being free of the disease. Efforts to wipe out guinea-worm disease date back to the years after smallpox was declared the first disease to be eradicated in 1979. In May 1981, the Interagency Steering Committee for Cooperative Action for the International Drinking Water Supply and Sanitation Decade (1981-1990) proposed the eradication of guinea-worm disease as an indicator of success for the 10-year clean water campaign. In the same year, WHO's decision-making body, the World Health Assembly (WHA), adopted resolution WHA 34.25 reinforcing the idea that the International Drinking Water Supply and Sanitation Decade presented an opportunity to wipe out the disease. As a result, WHO and the United States Centers for Disease Control and Prevention developed a strategy and a set of technical guidelines for a global eradication campaign. To give it a final push in 2011, the WHA called on the countries where the disease was still endemic to step up efforts to stop transmission and strengthen nation-wide surveillance to achieve their goal. Although the disease is still endemic in Mali, some parts of the country have been transformed by the global eradication campaign. In Tele, children stood giggling shyly when asked about the disease that once ravaged their parents' communities. They are too young to know what guinea worm is, says Lougue, explaining that it has been years since anyone in Tele contracted the disease. In those days, people blamed sorcerers for poisoning their wells--they knew that people got infected from drinking water, but did not know how, she says. A key part of efforts to eradicate the disease has been educating people in the communities affected on how the disease is transmitted. …